Crisis intervention in the local community:
experience from Trieste, Italy
Roberto Mezzina, MH Dept of Trieste
– Director, WHO CC
Lyngby, Denmark
14 November 2011
Opportunities and risks of a crisis entering
psychiatric care
Opportunities
• Constructive and enduring change fostering growth and
learning at any stage of life
• Virtuous spiral
• Self integration
• No loss of reinforcing of social integration
• Retain negotiation and contractual power
Risks
• Induction in the perpetual career of mental patient
• Psychiatric circuit – vicious circle
• Loss of contractual power
Crisis services as alternatives to hospital?
• An individual in crisis generally enters a
psychiatric network in which psychiatric
hospitalisation is the last resort.
• Crisis interventions and home treatments are
often (always) partial alternatives to inpatient
care: even when tremendously effective, they
select their cases according to treatable
conditions tailored on their operational
limitations (e.g. safe respite places) and risk
evaluations.
• Their are time-limited and don’t provide an
ongoing project of care.
Alternatives to something else?
• Our hypothesis is that community services must be
conceived as alternatives not to a place, but to a
conception of treating illness that is based on a
reductionist psychiatry, which contain and
impoverish the individual's experience as a patient.
Therefore:
• Are services tailored on illness management or social
behavioral problems, or around the person and
his/her experience?
• Thus the need for a strategic (effective) but mostly
humane and comprehensive viewpoint
Philosophy
• The person in crisis must be enabled to pass
through the crisis with his historical and
existential continuity intact
THUS:
• The person's ties with his/her environment must
be maintained
• the links between the crisis and his/her life
history must be identified
• significant existing relationships must be
reconstructed and redefined while new ones are
formed.
The crisis can loose its characteristics of rupture
and dissolution of the existential continuity, and
acquire a dynamic value.
Today’s features of the Mental Health Department in
Trieste(245.000) are:
Facilities:
• 4 Mental Health Centres (equipped with 6/8
beds each and open around the clock) plus
the University Clinic)
• A small Unit in the General Hospital with 6
emergency beds
• A Service for Rehabilitation and Residential
Support (12 group-homes with a total of 59
beds, provided by staff at different levels and
a Day Centre including training programs and
workshops);
Partners:
-15 accredited Social Co-operatives.
-Families and users associations, clubs and
recovery homes.
Staff:
• 215 people (26 psychiatrists, 8 psychologists,
163 nurses, 9 social workers, 9 psychosocial
rehabilitation workers).
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Overarching criteria / principles
of community practice in the MH Dept.
Responsibility (accountability) for the mental health of the
community = single point of entry and reference, public
health perspective
Active presence and mobility towards the demand = low
threshold accessibility, proactive and assertive care
Therapeutic continuity = no transitions in care
Responding to crisis in the community = no acute inpatient
care in hospital beds
Comprehensiveness = social and clinical care, integrated
resources
Team work = multidisciplinarity and creativity in a whole
team approach
Whole life approach = recovery and citizenship,
person at the centre
Responsibility / accountabilty
• They aim of the MH Dept. is to shoulder the
whole burden of psychiatric morbidity within
the catchment area they serve (no institutions
behind).
• The three core activities of prevention, acute
care and rehabilitation are seamlessly
integrated.
• The CMHCs work on the basis of a shared and
collective team responsibility.
• The small scale: the size of catchment area
makes it possible for most staff to have direct
knowledge at least of the most complex cases.
Accessibility and mobility of services and the
ability to respond to a wide variety of crises
• Crisis management is not a special or separate
program but a basic function of a comprehensive
service.
• No selection criteria based on type or severity of
illness regulate access to the service, nor does illness
of a particular type or severity automatically trigger
hospital admission.
• The CMHCs are accessible and open to drop-in
referrals
• No waiting list
• Intake for problems / not for diagnosis.
Continuity of care
• This is a guiding principle and involves treating service users
within the usual care system and maintaining them in their
usual social context, thus avoiding de-socialisation and
institutionalisation.
• Follow-up is provided wherever service users are.
• Interventions take place: in the patient’s actual living
environments; within social-health institutions; in legal-penal
institutions (Courts of law, prison, forensic hospitals)
• Temporal continuity: this is defined based on the need for
care and the threefold criteria of prevention/care and
rehabilitation.
Whole team approach
• Fully multidisciplinary working is a central goal,
including integration of social care and partnerships
in care with other community services and nonprofessional and volunteer inputs.
• The aim is to formulate collective understandings of
service users’ situations and shared therapeutic
plans.
• Frequent on-site multidisciplinary training and other
joint activities underpin this comprehensive team
working.
Psychiatrists’ role
• Team leader as manager as well as clinician, but:
• Animates team meetings (intellectual and
professional guidance)
• Shares case knowledge (no ‘privatisation’)
• Involves team
• Shifts power to key-workers as informal leaders
• Positive risk-taking and “umbrella” for all team
• Covers legal issues
• Links the individual management to the wider
mission, policy and operation of the CMHC and the
MH Dept.
The CMHC as a mind
• The Service must be able to create the idea of a
therapeutic/rehabilitative “itinerary” among a
series of options from which the user himself is
able to choose or make other proposals and
engage in a therapeutic dialogue.
• In this perspective, the Mental Health Centre
becomes the planning centre, by virtue of its
being the “connecting structure” (Bateson,
1984).
The CMHC
• The Community Mental Health Services, or
“Community Mental Health Centres” (CMHC), are
responsible for a specific catchment area.
• The CMHC’s work-group is composed of about 25
nurses, 1-2 social workers, 2 psychologists, 1-2
rehabilitation specialists and 4-5 psychiatrists. The
MHC operates 24 hours a day, 7 days a week.
• During the night, the operators assist persons in crisis
who are receiving overnight hospitality.
The 24 hrs Community Mental Health
Centre
• The 24-hours community mental health centre is a
non-hospital residential facility, not conceived just as
a crisis centre.
• It is in fact multi-purpose, multi-functional: also a
day centre, an outpatient service, a base for
community teams.
• The quality of the environment (home-like, but also
a social habitat) and of the atmosphere (friendly) is
based on staff attitudes mainly focused on flexibility
and reasonable negotiation with the user’s concerns
and needs.
• The main duty is to be responsible and try to
provide a comprehensive response.
• A single multidisciplinary team acts rotating
inside and outside, for those who are “guests”
on a 24 hours scheme and for the users attending
daily or reached at home.
• Knowledge and trust are the main tools for
building up therapeutic relations.
• Users’ participation and contribution in the centre
ordinary life is seen as crucial.
• Hence crisis is addressed by ‘indirect’ strategies
of management using these peculiarities.
From hospitalisation to hospitality
• Institutional rules
• Institutionalised Time
• Institutionalised (ritualised)
relations:
among workers / and with users
Time of crisis disconnected from
ordinary life
Stay inside
A stronger patients' role
Minimum network’s inputs
• Agreed / flexible rules
• Mediated time according to
user’s needs
• Relations tend to break
rituals
• Continuity of care
before/during/after the
crisis
• Inside only for shelter
/respite
• Maximum co-presence of
SN
From hospitalisation to hospitality
Difficult to avoid:
Locked doors
• Isolation rooms
• Restraint
• Violence
Illness /symptoms /bodybrain
• Open Door System
• Crisis / life events /
experience / problems
A value based service
The services are value-driven, in that their focus
is on:
• Helping the person, not treating an illness.
• Respecting the service user as a citizen with
rights
• Maintaining social roles and networks.
• Fostering recovery and social inclusion
• Addressing practical needs that matter to
service users
• Change the attitude in the community
Pathways of care: access and
response in a crisis
• 8-20: Direct referrals to the CMHC, non formality,
real time response (mobile front line) - as a roster
(whole team)
• 20-8: access to the consultation by the casualty
dept, then overnight accomodation in the
emergency unit.
But:
• No admissions in the emergency unit as a rule.
Thus:
• The day after the CMHC team comes. The 24 hrs
rule: within 24 hrs otherwise admitted.
Usually:
• Crisis supported at home or hosted in the Centre
• Avoiding invol. treatments
• Invol. Treatments in the CMHC as a first choice
SPDC: not an acute unit but a first aid station
• The emergency psychiatric service is a part of the community service
organisation and not as a separate hospital facilty.
• It also acts as a filter for the demand arriving to General Hospital
Emergency Room, and makes referrals to the community mental health
services if necessary.
• It also provides liaison for urgent demands from hospital wards.
Night service:
• If the patient arrives during the night, he/she may be kept under
observation and put in contact or referred to the competent MHC the
following day.
In the morning:
• The MHC’s control and manage the PTDS’s activities directly and are
responsible for activating the community responses as quickly as possible,
usually passing by to the CMHC within 24 hours.
• Even when hospitalisation occurs, which is quite rare, it always takes
place within the continuity of the community interventions being carried
out by the competent MHC (crisis joint plan).
• Even the involuntary treatments are preferably applied in the competent
CMHC and not in the emergency unit.
Responding to crisis
in the community
• Intervention is as far as possible in vivo, within service users’
homes or other places they frequent.
• Responses are quick and flexible, avoiding waiting lists and
other bureaucratic obstacles to accessing services.
 CRISIS AT THE HEART OF MH CARE
Make full “use” of the crisis:
• Crisis is multiplying resources
• Crisis is increasing informations and knowledge around the
person
• Crisis is increasing communication within the service
(“subjectivization”, “illumination” as a social visibility)
Key procedures
• Emergency reduced to a minimum (proactivity and
continuity of care de-construct emergencies)
• Walk-in, immediate intake and assesment, easy
access, low threshold to early signs, respite to deescalate, etc
• Early and quick intervention in real time: take your
role and be responsible. This reassures agents of
referral, e.g. relatives and the SN in general.
In the intervention:
• De-codifyingcrisis through knowledge and narratives:
participatory meaning-making aorund the question:
“why the crisis?”
• Individual plans and using all support systems, incl.
the Centre.
Contact
• It is the workers at the centre who are called upon in
the first instance when a request for treatment is
made.
• If the patient does not present himself at the centre,
the workers soon take on an active role in
establishing contact.
• The places of contact will be those where the patient
spends his time naturally (his home, the bar, the
workplace, etc.).
• The intermediaries will be people important to his
environment.
Engaging difficult, not self-referring patient
• Contact the person by using intermediaries. If family
too much involved, contact significant others.
• Try to raise his/her demand of care
• Ask him/her where to meet
• Do it with no pressure in time
• If not possible (risk), represent your role of mediation
• Clarify who is referral. If not possible, communicate
you are embarrassed but you need to talk directly in
order to explain
• Reassure person about your role and aim in favour of
him/her
Contact
• availability itself, actually being “on the spot”
prevents traumatic impacts: just the worker’s
presence givens immediate reassurance to
relatives, neighbours and the environment.
• Being “on the spot” can defuse a crisis which
is causing anguish to the patient and to
whoever is closest to him.
Contact
• Sometimes it is not possible to defuse a situation.
This occurs most often in cases where the patient is
alone, with very few resources and very few
relationships with the outside world.
• Such a person will obstinately refuse contact and
isolate himself still further.
• The service, then, has to increase its “banal
strategies” of approach: telephone calls, messages
under the door, involvement of others such as
friends, the priest, the local policeman or the
plumber; or even attempts to make contact in
several places.
Contact
• These attempts give determined proof of attention
and help, and in this way the service tries to engage
in a reciprocal relationship which, even if it is
conflictual, constructs a real frame of reference
around the individual towards which he can direct
his actions and behaviour.
• In order to avoid escalation, the service is
increasingly obliged to show its flexibility.
Contact
• In the end, an escalation can conclude with “physical” contact
with the patient which can be both dramatic and “strong”.
• Opening the door (rarely forcing: 6.9% requested the
collaboration, at the first contact, of emergency services,
which, in our case, signifies police and fire Dpt.) is also a
symbol for the breaking of the psychotic circle, the entry of
real faces and the end of the nightmare.
• Even when the patient persists in seeing the worker or the
service as an intruder, all subsequent moments of offering,
listening and practical help (in the home or in the centre)
manage to break down the diffidence and reluctance and
create a worker-patient relationships, and the therapeutic
program can commence.
Treatments
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Biological (mostly oral medications)
Psychological (individual and group therapies)
Family interventions & psycheducation
Social network intervetions (neighbours, employers
etc)
Cultural and vocational rehab - work placement
Social support
Peer support & networking
Leisure time
The Centre as a resort for crisis respite
• Hospitality is agreed without formalities with user and relatives,
and decided and managed by the same team (e.g. in case of a not
agreed self-discharge, the team operates a re-negotiation; the plan
of care is decided or re-discussed during the admission / hospitality)
– team sense of ownership
• users/guests can receive visits without restrictions and are
encouraged to keep their ordinary life activities and the links with
their environment (operators and volunteers do activities outside
with them everyday)
• it is done in the same place where users come for everyday care
and rehab, therefore crisis is “soluted” and un-emphasised in
everyday life
• often it is followed by a period of day hospital attendance to
strengthen and develop the therapeutic relationship and the
ongoing plan of care. Mean duration of 24 hr admissions is 10-12
days.
BUT IT IS NOT ONLY FOR CRISIS:
• also people for rehab plans or social needs temporarily unmet (e.g.
homeless), in order to avoid any form of social drift. It is also a
means to re-start with a stuck case, focusing service’s attention and
resources for a new plan of care
Crisis management in the Centre
Actions in crisis management
• Personalise the ‘control’ of the problematic or difficult user, including personalised
bedside assistance if necessary and / or ‘holding’ in preventing possible acting-out
• Contract the form of acceptance/admission with the user, from the DH to daynight hospitality
• Status of ‘hospitality for health’
• Continuous effort to obtain compliance with treatment/care through a relationship
based on trust
• Inclusion of the user in crisis in both structured and non-structured activities
• Escape” / looking for / re-negotiating return: “what was wrong with you in the
centre?”
Involving the team
• Information managed collectively (not by select individuals/operators)
• Case notes and the team’s activities: should always be related to individual lifestories, group discussion and the group’s sense of community
Key elements of crisis management
• 1) Negotiating reasons, even in difficult
situations
• 2) Maintaining the social system
• 3) Mobilising human and institutional
resources
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1) Negotiating reasons, even in difficult situations
The hospitality/admission response in the CMHC is
applied on the basis of "case by case" evaluations
and not merely severity and risk assessment.
It’s important to negotiate and openly express the
reasons leading to the decision to provide hospitality
for someone in a Centre (transparency)
If the user leaves the centre, every effort is made to
re-establish contact by seeking him out and listening
to his requests and claims (re-contracting).
Resistance conditions in general can be overcome if
we put attention on flexibility, availability, and
informal style of relating. It allows at maintaining an
extremely low use of compulsory treatments.
2) Maintaining the social system
• Shared responsibility (among user, service, family and
other users who will provide support) and constant
search for agreement.
• The inside and the outside of the therapeutic context
(the user can go outside, though perhaps accompanied,
may go back home for a period of time, request the
response to immediate needs, etc.).
• This form of hospitality will thus be situated within the
continuity of a project, of a before and after, of which it
will be a temporary and passing moment.
• Instead, in a community Service, the “bed” can be used
in a flexible way, depending on the need for institutional
protection of the most varied user-types.
• The CMHC's 24-hour hospitality does not sever ties with
his/her environment (family contacts, time away from
the centre alone or accompanied, taking care of specific
personal needs).
Crisis as a social system intervention
• Participatory de-codifying
• Mediating points of view
• Modification of demand
• Relieving the burden
• Sharing decision and risks
• Plannig recovery phases
• Discussion / negotiation
The only way to make social systems work is sharing
responsibility and empowering them
3) Mobilising human and institutional
resources
• A first network of relationships is provided by the
operators whose willingness and availability is in direct
relation to the closeness of their relationship with the
patient.
• Out of this informal way of containing his anxiety there
emerges, at minimum, a personalized therapeutic
relationship with a limited nucleus of operators who
make themselves more directly available in the various
stages of the intervention, and thus “enter into play”
with him.
• Decoding crisis through the confrontation and mediation
among different viewpoints and needs (PARTICIPATORY
DECODIFICATION OF THE CRISIS).
Integrated and comprehensive
response (social and medical)
• Therapeutic plans are based on individual history, needs and
wishes. It allows the service to obtain and maintain service
users’ consent to and engagement in treatment.
• Establishing a relationship is the first priority.
• Comprehensive/integrated responses between social and
health, therapeutic and welfare assistance. This involves:
• the use of resources which the Service has available;
• the activation of health and social services;
• the use/exploitation of resources which may be present in the
micro-social context.
Resources directly provided by the Centre
concerning whole life and recovery:
• living situation (restoration, maintenance and cleaning,
the search for other housing solutions)
• money, income (cash subsidies, use of the safe in centre,
daily money management on a temporary basis, action
taken in defense and protection of property)
• personal hygiene (laundry, personal cleanliness,
hairdresser, linens)
• work possibilities (assignment to a co-operative society,
chores at the centre, work grants)
• free time (workshop in theatre, painting, music, graphics,
sewing, ceramics, gymnastic and boating, day trips,
holidays, parties, cinema, shows).
Do’s and Don’t’s of Psychiatric Crisis
Intervention incl. Residential Care
Do’s
• Being with, staying with, doing together among workers and with users
• Negotiate and be accountable for everything
• Minimise barriers between operators/users
• Do normal things in a normal environment
• Involve users in running the Centre (telephones, maintenance of the
facilities, cooking, accompaniment and support to others in crisis)
Don’t’s
• Reduce the compartmentalisation and ’turf’ issues connected with
individual locations / facilities (no to roles/spaces)
• Don’t separate persons receiving hospitality from other users
(‘dissolve’ the crisis in normal, everyday living)
• No systems of restraint
The person and not the illness at the center
of the process of care for recovery and
emancipation through users’ active
participation in the services
(up close, nobody is normal)
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The Mission of MHD
•
The MHD shall operate for the elimination of any form of stigmatisation,
discrimination and exclusion concerning the mentally ill persons.
•
The MHD is engaged to actively improve full rights of citizenship for the mentally
ill persons.
•
The MHD shall ensure that the community mental health services of the LHC
have a coherent and unique organisation as a whole, through a strict coordination of actions and links with the other services of LHC, particularly with
general health districts and emphasizing the relationships with the Community
and its institutions.
Where are the ”beds” today?
Year 1971: 1200 beds in Psychiatric
Hospital, closed down in 1980
after a 9-year process of phasing
out.
Year 2010: 91 beds of different
kind:
• 26 community crisis beds
available 24 hrs. Mental Health
Centres (11 / 100.000
inhabitants)
• 59 places in group-homes (24 /
100.000)
• 6 acute beds in General Hospital
(3,5 / 100.000)
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Some relevant outcomes
•
In 2010, only 16 persons under involuntary
treatments (7 / 100.000 inhabitants), the
lowest in Italy(national ratio: 25 / 100.000); 2
/ 3 are done within the 24 hrs. CMHC
•
Open doors, no restraint, no ECT in every
place including hospital Unit
•
No psychiatric users are homeless
•
Every year 220 trainees in Social Coops and
open employment, of which 10% became
employees
•
Social cooperatives employ 600
disadvantaged persons, of which 30%
suffered from a psychosis
•
The suicide prevention programme lowered
suicide ratio 40% in the last 15 years
(average measures)
•
No one in Forensic Hospitals
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How much does it cost?
1971:
• Psychiatric Hospital 5 billions of
Lire (today: 28 million €)
2009:
• Mental Health Department
Network 18,0 millions €
• 79 € pro capita
• 94% of expenditures in community
services, 6% in hospital acute beds
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Day-night admissions at CMHCs
Admitted people
25,000
750
20,000
600
15,000
450
10,000
300
5,000
150
Years 1981 - 2010
Admitted people number
Day-night admission days
Day-night admission days at the MHC
Admissions at the General Hospital Psychiatric Unit (GHPU)
Admission days at the GHPU
Inpatients at the GHPU
1,200
200
1,050
160
750
600
120
450
300
80
150
-
40
1996
1997
1998
1999
2000
2001
2002 2003 2004 2005 2006 2007 2008 2009
Years 1996 - 2010
2010
Inpatients at the GHPU
Admission days
at the GHPU
900
Compulsory Medical Treatments (CMT) at Mental Health Centres (MHCs)
People admitted under CMT at the MHC
450
45
300
30
150
15
-
1996
1997
1998
1999
2000
2001
2002
2003
2004
Years 1996 - 2010
2005
2006
2007
2008
2009
2010
Inpatients under CMT at MHCs
CMT days at MHCs
CMT days at the MHC
Compulsory Medical Treatment (CMT) admissions at the General Hospital Psychiatric Unit (GHPU)
People admitted under CMT at the GHPU
125
20
100
16
75
12
50
8
25
4
-
1996
1997
1998
1999
2000
2001
2002
2003
2004
Years 1996 - 2010
2005
2006
2007
2008
2009
2010
People admitted under CMT at the GHPU
Admission days
under CMT at
the GHPU
CMT days at the GHPU
Outcomes in Trieste (crisis)
• No involuntary treatments in Barcola
• Reduction of nights in acute service in the general hospital
• Even reduction of bed use in the Centre (to ¼) in 20 years
including long term bed use.
• Reduction of people arriving at the emergency call (118) and
casualty dept. (50% in 20 years) – because of work carried out
by CMHC
• Acute presentations not so frequent anymore – less
disorganised
• Long-term care only in the community (at home, in the
centres and group-homes), not in hospital – but it decresed.
• Available alternatives e.g. woman recovery home
Crisis research in Italy (Mezzina et al., 2005): the
conclusions
Determinants of a quick crisis resolution are:
• use of a wide range of community interventions (networking,
home treatment, family support, social work, rehab, job
placement, etc), and an established trustee relationship
while hospitalization does not have relations with any better
crisis outcome. Hospitalization:
• does not depend on “severity” (measured with a wide
number of variables)
• is more likely after the intervention of general emergency
agencies (ambulances / police)
• shows to a daily medium dosage of medications (BDZ /
Antipsichotics) that is double
Implementation of 24hr CMHCs
In Italy MH Dept generally focussed on facility-based care.
Very poor inpatient care in the DCS (15 beds in GH), crowded and with the
use of restraint (70%).
Therefore 24hr centres are claimed by Carers organisation and mentioned in
Regional Plans (Puglie, Toscana, Sardegna) over the last 5 years.
24hr CMHCs implemented:
• In italy: in the whole Region Friuli-Venezia Giulia (1.200.000) and scattered
abroad other italian sites (Sardegna, Campania, Toscana, Emilia-Romagna,
Lazio, etc)
• In South Stockholm (from 90’s on) with no hospital beds at all
• In Brasil (Santos) in the 90’s
• In Boulder (Colorado) - R. Warner
Plans in the UK: Kingstanding - B’Ham (’98), Epping - North Essex (2005),
Plymouth (?)
So what works? (the means)
• Trustee relationships
• Continuity of care / of experience (no
disruption)
• Hope
• Self-determination
• The person’s history or narrative