The Psychiatry Reform Bill and the “territorialization” of the Mental Health Facilities in Italy. The Foster Family Care Project of the Mental Health University Department n°5b in Piemonte.
University of Turin, Mental Health University Dept. 5b, Collegno, S. Luigi Gonzaga Hospital, Regione Piemonte.
I wish to thank Mr Marc Godemont and the Scientific and Organizational Board for their kind invitation to this important event. Geel is at the deepest roots of any facility working in accordance with the model of Therapeutic Foster Family Care, and I’m particularly glad to be here and to share our experience with you. I would also like to point out a special coincidence which took place exactly 27 years ago in Italy, on May 13th, 1978, the Law 180 ruled the closure of all psychiatric hospitals and promoted the creation of local agencies and community facilities.
After the closure of mental hospitals and the implementation of the community based services, the following changes were registered:
Ø decline in the number of hospital beds for mentally ill patients: from 135.000 to 30.000
Ø half of them are in general hospitals, while the others are in small residences, private homes or apartments
Ø 5% only are placed in facilities for chronic patients
The principles of Community Care in Italy can be summarised as follows:
Ø integration of mental health in the general health care network
Ø the patient is the protagonist and negotiator of his own treatment
Ø the family is a resource for therapy and as a co-protagonist in the struggle against social stigmatisation
Ø the employment of multi-disciplinary care teams
Ø importance of an accurate evaluation of results and interventions
Integration of mental health in the health network:
Ø A Mental Health Department operates as a network where each single knot corresponds to a specific service and is linked to the others
Ø Care is intended to be long-term if severe impairments are present. The process of recovery is fostered by the progressive transition toward department services which require an increasing degree in the level of psychosocial functioning and autonomy
Ø Services are provided within department facilities or community settings and with the aid of social non profit organisations and volunteers
From a patient who is neither accountable nor aware of his/her illness to a protagonist and negotiator of his/her own treatment:
Ø Treatment plans, developed with the patient, are based on individual strengths and needs, hopes and desires. The plans are modified as needed through an ongoing assessment and goal setting process
Ø Care-team members are pro-active with patients, they encourage them to participate in and to continue treatment and recover from disability
Ø Employment and housing assistance (subsidised apartments, therapeutic foster family care, sheltered accommodations) and other critical services are provided to promote the individual’s ability to live successfully in the community
From the exclusion or even the stigmatisation of the patient’s family to the encouragement of their collaboration or the contextual offer of help:
Ø The involvement and the collaboration of families and milieu is a fundamental part of each treatment plan
Ø Psycho educational activity, family support and education are planned to include the patient’s natural support system in the treatment.
Ø Services promote the setting up of self-help groups for families and support them along their development process to become autonomous associations, where psychiatrists are just consultants. These associations are expected to act as interfaces between the health care system and family needs.
The team treatment approach is designed to cover as many areas as possible in the rehabilitation process:
Ø The multidisciplinary make-up (psichiatrists, psychologists, nurses, rehabilitation and social workers) of each service team leads to comprehensive treatment plans to promote community integration
Ø Each psychiatrist is in charge of a number of patients (high patient/staff ratio): some with seriuos persistent mental illness, others with mild and transient disorders
Ø Psychiatrists work as case managers and constantly exchange clinical information and take decisions about treatment plans together with the other professionals involved.
The next three slides illustrate the current situation of Mental Health Departments and Services in Italy.
The University Mental Health Dept. No. 5b in Collegno, San Luigi Gonzaga Hospital, Piemonte, has carried out the definitive closure of the “Certosa di Collegno” Mental Hospital, which was considered as being one of the largest Asylums in Italy or probably in Europe. Nowadays, after some years of activity and thanks to an ongoing quality assessment process, Mental Health Department 5b can rely on a wide service network and residential facilities as an alternative to hospitalisation. The peculiarities and the innovative spirit of these residential solutions stress the importance of the treatment of mental disorders within a normal urban context.
The Mental Health Department covers an area of 151,179 square kilometres, with about 178.000 inhabitants. Population is constantly growing in number. The Department is divided into two districts. Each district has its own Mental Health Centre and both have almost 1500 patients in charge.
Ø Psychiatric visit (urgent or booked)
Ø Psychological consultation
Ø Individual psychotherapy (limited number)
Ø Family psychotherapy (limited number)
Ø Home assistance as individually needed
Ø Scheduled therapy administration
Ø Therapy monitoring (blood test)
Ø Working and employment assistance
Ø Rehabilitation planning in other Department facilities
Other Department facilities are:
Ø Two Day Centres;
Ø Theatre and other Expressive Therapies Laboratories;
Ø One Day Residential Community (10 places);
Ø One Crisis Centre (10 beds);
Ø Supported Apartment Services (65 users);
Ø Three Sheltered Communities (60 beds);
Ø One Psychiatric Ward in “S. Luigi Gonzaga” General Hospital (10 beds);
Ø Therapeutical Foster Family Care Program.
Let’s come now to the Italian experience of Therapeutical Foster Family Care.
The results of a small research on the diffusion of Therapeutical Foster Family Care in Italy carried out by the Collegno Service at the end of 2002, show that 14 new services were added to the 11 active in 2000. From 2002 to 2005 further similar initiatives in the Italian territory were implemented. This positive trend is very encouraging and can make us think of the importance of the scientific congresses and publications carried out in Italy in these years; it also tells us that even today, when centuries have elapsed since the martyrdom of Dymphna, Therapeutical Foster Family Care can be a valid and working solution for psychiatric intervention.
From these data one can gather that, in the past few years, the interest towards Therapeutical Foster Family Care has significantly grown in Italy , particulary in the psychiatric and geriatric fields. This is mostly due to the proven efficiency of this practice which combines therapy and rehabilitation together with low costs. Actually, however, Therapeutical Foster Family Care can be a good instrument of rehabilitation only when it is properly used. In fact, we learn from its history that it can also be a bad solution, when used only for its economic advantages and if enough attention is not paid to the selection processes and to the delivery of qualified support to the parties involved.
Delving further into this matter, we can also realise how indispensable it is to give proper training to the TFFC Case Manager so that he/she can perform his/her work in the best possible way. In fact, it is possible, through thoughtful intervention, to transform the social element from a place of possible exclusion into a therapeutical place. The central element of this constellation is the family: a protected space dedicated to life, experience and growth within a more and more complex social scenerio.
By taking a person into a family, where relational dynamics and possible identification and attachment figures can be found, we can help him to reach the integration and the new possibility of development and redemption which make it possible for a patient to recover a new role and a new identity.
The patient previously hosted in a community or clinic becomes a citizen, that is someone with his private space and with his name on the doorbell label and mailbox. His/her social network is not just represented by some psychiatry professionals – that is in and of itself an unbalanced relationship - but also by so called healthy people. Parallel to the conquest of his freedom and his rights, (which the “total institutions” as Basaglia defined always tend to forget), we witness the onset of those processes of psychological growth which give the person in the Foster Family Care the ideal possibility of experimenting a second chance (we hope more successfully than the first time) a healthy separation from parenting figures.
Nowadays, the reference to the bio-psychosocial model has become quite widespread, at least theoretically, from both the etiological and therapeutical points of view.
This model clearly outlines the areas where changes occur in any healing process. Total institutions tend to give priority to only one of these three factors and to focus their actions only on the biological part of the problem. Giving their due to the residential solutions (protected communities, clinics etc.), we have however to admit that such residential possibilities carry with them a very high managing cost and often very small rehabilitation results, as well as a rest of asylum culture represented by massification and ensuing separation of the persons who suffer both from the world and from the relationship with the so-called “healthy” people.
The person who suffers is often exclusively offered drug therapy, which is often inadequate. Furthermore, this occurs in alienated and alienating contexts which ignore the importance of the psychological and social aspects of a therapeutical-rehabilitative intervention, or if they do take it into consideration, it is in an unproductive and distorted way.
It would be interesting to open a debate on the root causes of this biological bias, on the lack of a critical consideration which many operators of the psychiatric field show when confronted with this unbalanced ineffective approach and its ensuing social costs. Who profits of this all? Surely not those who suffer!
Let’s come now to the Therapeutical Foster Family Care Project of our Department.
The Project was launched at the Mental Health Department 5b ASL 5 Regione Piemonte in 1998 and represents a pilot experience both at a national and international level because of its several innovative elements which make it very different from those of other Countries. Here the Mental Health Department takes care of the organisation and implementation of this service, while in other Countries this task is left to clinics and mental hospitals.
This substantial difference shows the originality and the innovative traits of this approach, the opposite of that centred on clinics and mental hospitals, because it is integrated in a deinstitutionalised environment and operates in community settings.
There are different types of Therapeutical Foster Family Care Programs, depending on its duration and of course on each specific case: the Short Term project applies to a person who is going through a crisis, both personal or pertaining to the environment surrounding him, and lasts from a few days to one or two months.
Another type of Short Time is the Part Time: the person stays at the volunteers’ family for some hours during the day or during the whole week-end. This project is preliminary to the attainment of full time stays, or can support autonomous life in a flat for instance.
The Medium Term project usually applies to young people for which a recovery – even though partial – of the compromised functioning is hoped, towards a life characterised by a greater autonomy and responsibility. These interventions must be integrated with an efficient and articulated network of territorial services, able to operate both on a therapeutical and rehabilitative level, in synergy with the TFFC service. The maximum duration of a medium term project is 24 months.
As far as Long Term projects are concerned (more than two years), they are addressed to older people having spent long periods in a hospital, not-self-sufficient persons and to the so-called chronic patients. Their aim is to give patients the possibility of living in a quiet and protected environment, where they can peacefully spend the last part of their life. The type of intervention is more geared towards the assistance side.
Each and every project sees the active participation of the Case Managers, of the psychiatrists who selected the person ready to be inserted in a new project, the social workers and the health care facility worker. They all update, verify and structure their intervention at every step.
Their activity is regulated by detailed guidelines and by the contract which is approved and subscribed at the beginning of the trial period by the three parties involved: a) the host, b) the family; c) the Local Health Agency n° 5. Guidelines also define who qualifies for Therapeutical Foster Family Care, the management and care roles involved, the kind and extensions of the services and equipment paid by the Local Health Agency, the modalities of expense refund for hospitality, insurance for the both the patient and the family.
The caregiver families receive from the patients 1030,00 Euros every month as an refund for being hosted. If and when the patient cannot afford to pay that amount, the Local Health Agency gives a contribution by means of a health care allowance. Organisation, managinng and other running costs must be added to these. The maximum cost of such a project including all items is about 75 Euro per day even though it is only rarely reached. The TFFC Service team is made up by a co-ordinator and a number of operators - case managers varying according to the number of active treatment projects (1 case manager every 10 active projects).
The Mental Health Centre professionals who were in charge of the patients before joining the TFFC project keep following them throughout the duration of their cohabitation.
The periodical home visits of the above mentioned case managers (an average of one every two weeks or less if necessary) are combined with a Department 24/7 availability on-call.
The TFFC professional interventions aims at supporting both patients and families to cope with everyday life activities. When necessary psychological support sessions can be activated.
Apart from the staff meeting which is held once a week, clinical supervision groups meet every other week.
Professionals work to activate the social and individual resources of patients that may promote a personal growth in accordance with the empowerment principles (work support units, keeping in touch with the local associations and the neighbourhood, training programmes, leisure activities, self-help groups).
The patients while within a care giving family, may keep on attending all the activities organised in the Department Services such as the Mental Health Centre, the Day centre, which are linked to the TFFC service.
If families successfully go through the selection process, they receive specific training and their data are stored in a data base and recovered when a suitable patient is found.
Hosting families are strongly motivated by economic needs. A typical suitable family is an open, flexible environment where affective exchanges are warm and no longer mediated by professional roles. They can offer support and assistance as needed by the patients –from helping them to make plans for the day to giving good advice to face life events- and are well in touch with the surrounding social envitonment.
In brief, the families selected by the TFFC team may well represent examples of acknowledgement and maximisation of non professional interventions in psychiatry.
The family of origin is not excluded from the project, on the contrary significant efforts are made to turn it into a therapeutic resource.
Thanks to the information exchange on the project which is being developed, it becomes natural that the patients’ families get in touch with the Service to follow the course of their relatives’ treatment or to provide useful information.
30 projects were implemented in six years, 16 are still on-going, 2000 families were contacted; 110 went through the selection process, while 45 were considered adequate.
The Mental Health Centre Psychiatrists presented 35 patients as potential candidates for TFFC: 30 have been considered adequate and accepted. Patients with substance dependence and violent were excluded from the projects.
The preliminary data of a current research by our service show how a significant reduction in the number of hospital admissions per year and a smaller but also significant reduction in the use of drugs such as benzodiazepines and antipsychotics could be possible in the first 12 months. The implementation of TFFC program could also positively affect the economic conditions of several families and persons living alone by adding some more money to their monthly incomes. Moreover such a Service as the TFFC one fully meets the goals prescribed by the above mentioned Law 180/78 which promoted the definitive closure of all Mental Hospitals and stated that community services should develop treatment alternatives to those institutions to ensure that the persons previously hosted within such hospitals could benefit from living solutions with rehabilitation and treatment characteristics.