1. Visita dei quadri dirigenti del Quebéc in
Emilia Romagna
Presentazione del DSM DP di
Ravenna
!8 Giugno 2012

2. Plan of presentation
• Law 180/78: main principles
• Mental Health Department: the present structure
of mental health services in Italy.
• A law isn’t sufficient to change old practices. The
existing weaknesses in the Italian mental health
field
• The MHDt of Ravenna. The radical transformation
of the services system (vision, policies, strenghts
and weaknesses). Main fields of intervention
• Results of the process of change

3. Law 180/78: main principles
Approved in 1978, the law 180, generally referred to as the “Basaglia
law”, marks the “Italian Revolution” in the field of mental health,
developing a radical process of change in services delivery: from
guardianship to the beginning of the patient’s de-institutionalization.
Let we try to summarize the main points of this change.
• First, the law stated that citizens’ mental health had to be
promoted by means of three levels of intervention, all deeply
interrelated: prevention, treatment and rehabilitation.
• Second, the law affirmed that the people with psychiatric
disabilities had the right to receive effective treatments in the
environment where they lived, trying both to reduce
hospitalizations and desocialization and to maintain the
connections with significative others.

4. Law 180/78: main principles
• Third, the law introduced the concept of social
inclusion as result of a range of interventions focused
on helping the person with psychiatric disabilities to
maintain or achieve valued roles in the community.
• At least, the law forbade further admissions in the
mental hospital and established the a wide net of
services that should have met the main needs both of
people with mental illness and their family members
(crisis, enrichment, treatment, rehabilitation,
relationships, etc.).

5. Mental Health Department
• Mental Health Department is the organization that
collects the whole array of community based
psychiatric services.
• In the Italian Health Reform, the terms “Department”
means: Integrated Organization of complementary
services ( named Operational Units) each of them
pursuing specific objectives, all concurring for a
common goal.
• It’s one of the two community based (i.e. extra-
hospital) Department (the other is Primary Care
Department) and it belongs to Health Local Authority.

6. Main components of Mental Health
Department (Ravenna MHDt too)
• Community Mental Health Centers. Model of care: Community Assertive Treatment, the services
are delivered in the environment of life of people with mental illness (outpatient services) with the
mission of helping them to obtain and to maintain valid social roles.
• Psychiatric Ward (inpatient service), where people with emotional and behavioural disorganization
are helped to re-gain acceptable level of psychosocial balance.
• Psychiatric Rehabilitation Unit, compounded by Residential Facilities and Centers of Psychiatric
Rehabilitation, whose function is to develop effective programs for people with severe mental
illness that will strengthen their skills and capacities to live independently and meaningfully in the
community as more as possible.
• Apartments settled in urban area, where to help people discharged from residential facilities to
gain tenant role, according “supported housing” care model.
• Neuropsychiatry Children Services, aimed to deliver treatments and cognitive rehabilitation to
people with psychomotor deficit, language troubles and intellective disability under 18 years of age.
• Community Services for drug and alcohol abuse or dependence.

7. Some data about MHDt of Ravenna
MHDt of Ravenna
– 3 Community Mental Health Centers.
– 1 Psychiatric Ward (inpatient service) with 21 beds.
– Psychiatric Rehabilitation Unit, compounded by 3 Residential Facilities and 3 Centers of
Psychiatric Rehabilitation
– Fifteen supported houses
– 3 Neuropsychiatry Children Services
– 3 Community Services for drug and alcohol abuse or dependence.
• Number of citizens in the catchment of Ravenna: approximately 300.000
• Number of professional working in all above mentioned Unit: approximately 380
• Number of people served: approximately 4200
• Type of professional roles: psychiatrists, nurses, social workers, psychologists,
occupational therapists.

8. A law isn’t sufficient to change old
practices
Despite the existence of the Italian law 180/78,
there is a lot of evidence that most of services’
systems are mainly oriented to “stabilize” the
symptoms as unique outcome and to “replace”
many clients in the psychiatric residential
facilities, often reproducing a marginalized way
of living instead orienteering towards recovery
processes.

9. Main weaknesses
• Increased awareness of the inadequacy of the stabilization paradigm
(interventions only in acute phase of mental illness, desired outcome: symptoms
remission).The consequence: many people with mental illness who are stabilized
but disabled and isolated .
• Low clients’ families involvement in their relatives’ treatment plan and lack of
support to patients’ families.
• Increased number of clients placed into public and private psychiatric residential
facilities with increased costs.
• Lack of monitoring of the quality, of the effectiveness and of outcomes of
treatments
• Lack of community based professional competence of practitioners

10. What we learned during these years
• The traditional treatments, medication and crisis
interventions, have shown their selves inadequate to
met the different needs of people with psychiatric
disabilities and insufficient to increase role functioning
in the real world.
• It follows that it’s necessary to pay a greater attention
to the tools and the methods with which to counteract
the disabling effects of the mental illness on the
individuals that suffer from it.

11. Building a rehabilitation and recovery-
oriented Mental Health Department
Mentioned above considerations have
prompted the Local Health Authority of
Ravenna to promote a radical services
system’s change through a change of the
paradigma (from biomedical paradigma
to biopsychosocial paradigma).

12. Holistic approach (biopsychosocial model)
• To adopt a holistic approach means that
people with psychiatric disabilities, before
being defined as sick, cases or diagnosis, are
regarded as unique persons, each of them
with three closely connected dimensions:
biological, psychological and social.
• The biopsychosocial model counteracts the
risk of fragmentation of interventions and,
therefore, of the person.

13. The vision of MHDt of Ravenna
The whole array of services, each for own
specific field of action, has the purpose to
increase the personal and social functioning
and subjective well-being of people with
psychiatric disability, in order to be able to
perform successfully a valid social role in the
enviroment of chose (job, housing, education,
meaningful activities in the community) with
the least professional support .

14. Principles and values
• Limiting disabily’s impact through psychosocial treatment and
social supports
• Encouraging client’s incolvement in own treatment
• Strenghten successes ; don’t blame person for his/her failures
• Building close relationship with person with mental illness , who is
allowed to risk, to mistake and to have the same apsirations all
human beings have
• Focusing on strenghts; don’t amplify deficits

15. Actions we are doing to promote
change
• Increasing practitioners’ knowledges, attitudes and skills about
psychosocial evidence practices and concept of recovery .
• Orienting daily practices to scientific evidence
• Spreading culture of outcomes’ assessement
• Identifying measures of recovery-related outcome.
• Reducing the use of psychiatric residential facilities through supported
housing and vocational programs .
• Increasing the number of people discharged from the psychiatric
residential facilities through supported housing and vocational programs .

16. Actions we are doing to promote
change
• Helping to change the believes of many mental health professionals
which think that serious mental illnesses have almost a poor
prognosis associated with and that the people who psychiatric
disabilities cannot lead a meaningful life rich without the
continuous support of psychiatric services;
• Encouraging the introduction of the concept of recovery in the man
therapeutic approaches to people with mental illness, with
particular reference to individual treatment plans’ outcomes that
do not just concern remission of symptoms and of relapses but also
the personal and social functioning, quality of life and the
subjective perception of a state of well-being

17. Actions we are doing to promote
change
• Favouring the overcoming of prejudices of many families about the concept of
recovery , often rejected for fear either of painful hopes or of the implied
challenges of the recovery process (increased relapses and hospitalization rates).
Helping family members to recognize the outcomes of recovery, even those one
minimal.
• Promoting the adoption of programs of supported housing, supported education
and supported employement, helping patients to carry out social roles, according
to the principle that the people with psychiatric disabilities had the right to receive
effective treatments in the environment where they lived, trying both to reduce
hospitalizations and desocialization and to maintain the connections with own
environment and with others.
• Changing the objectives of the programs implementing psychosocial programs
that counteract:
– De-socialization (reciprocal detachment between the individual and his
enviroment)
– Internal stigma (powerlessness, shame, worthlessness, inability to take over
own life)
– Giving-up hope, purposes and every effort to change
•

18. Main policies we are carrying on
– The training of the workforce: the “core” of the process of change
– Continuous training of workforce (interdisciplinary and
involving the whole system) about EBPs and concept of
recovery
– Training programs’ coordinators in order to learn
leadership skills
– Carrying on a process of de-institutionalization from
residential facilities
– Strenghtening partership with families and with
Associations of families
– Encouraging the birth of Associations of Users and their
participation in services’ quality assessment
– Implementing person -centered programs for specific
targets of population

19. The training of the workforce: the
“core” of the process of change
• In the process of change of the mental health services system of
Ravenna, great importance is been attributed to the personnel
training.
• Need to increase professional competence of the workers stems
from the lack of adequate tools to cope with psychiatric disability
and to make the workers competent to help the disabled people to
achieve personal goals and to develop processes of recovery.
• To adopt evidence based practices and to measure the outcomes,
it’s necessary to supply the personnel with effective tools, through
a continuous learning process (intensive training in the workplace
and regular supervisions).
• The importance of recruiting skilled and motivated practitioners ,
has also often been highlighted. It is well-known how the negative
attitudes of the professionals influence the consumers’ outcomes.

20. Effects of lack of workforce
competency
The lack of appropriate knowledges, abilities
and attitudes to assist users in their processes
of rehabilitation and recovery reduces
personnel effectiveness and gives rise to :
– Repeated failures and intense emotional reactions,
that may put into some negative attitudes and
behaviors

21. Negative workforce reactions to programs’ (and
users’) failure
• Avoiding relationship with user.
• Using diagnostic labels to explain failures
• Considering disfunctional behaviors an expression of
seriousness of mental illness and of progressive
deterioration.
• Repeating every day the same intervention, even if
clearly ineffective.
• Taking up role of entertainer, baby-sitter, guardian or
substitute of familiars.
• Devaluing own professional role .

22. The training of the workforce: the “core” of the
process of change
• On account of this, we plan annual training programs (18
seminars every year) for the all teams working in Mental
Health Department (approximately 300 practitioners) , aimed
to teach personnel:
– the knowledges and the abilities needed to help people with
mental illness to have a meaningful life in their community, i. e. to
re-learn and to practice the daily living activities.
• We promote a continuous training in the workplace
• We support practitioners monthly with supervision and work-
team in order to convert theory in practice
• The whole personnel is involved in the training programs,
(including psychiatrists).

23. Two levels of training
The training has been organized in two
levels:
–Training for people working day to day
with patients
–Training to develop new competences
for the leadership.

24. First level (Psychiatrists, Psychologists Nurses,
Social Workers, Occupationa Therapists )
Goal: Development of Staff Professional Competence
Abilities
• Building a relationship of support and partnership with clients and their families .
• Using motivational techniques.
• Adopting care planning oriented to the patients’ objectives.
• Delivering group treatments of social skill training
• Supporting patients in the community through practicing social roles
• Relating with social referees supporting user’s social role (employers, teachers,
neighbours, etc.)
• Listening, understanding, supporting, involving and orienteering clients’ families,
helping them to cope with dysfunctional behaviours of relative.

25. Second level (Leadership
Competence )
Goal: to increase the leadership’s competence
• Orienting staff to change.
• Motivating staff, helping it to overcome
resistance to change
• Supporting and supervising staff.
• Checking patients’ care planning and assessing
outcomes.
• Promotin peer support.

26. Three level of competence
• Exposure
• Experience
• Expertise

27. Carrying on a process of de-institutionalization
from residential facilities
Increasing number of persons discharged from the public and private psychiatric
residential facilities, through:
• developing effective programs in the public and private residential facilities through them people with
severe mental illness may enhance their skills and choice
• drawing up a rehabilitation treatment individual plan for each patient living in public and private
residential facilities, highlighting personal objective and the desired outcome
• using the supported housing and vocational programs to promote discharge.
• planning a re-entry in their places of origin of patients placed in extra-provincial residential facilities
• improving the quality of the long-term treatment for patients with serious disability and progressive
deterioration (so-called “patient without hope) .
• opening the MHDt to the community

28. Opening the mental health services to
the community
The Mental Health Services System is not self-sufficient,
but must develop and implement integration strategies
with all the stakeholders, with the aim.
– to reduce the dependence of the service users on
the mental health system
– to acquire the appropriate resources (jobs,
houses, leisure facilities, educational
opportunities) that are essential for the social
inclusion in the ordinary community environments

29. Actions taken in the community
• Raising awareness with City Officials to gain
housing (a model of supported housing).
• Creating awareness in Employment Agencies
to increase opportunities.
• Involving no-profit organizations to support
patients practicing social roles.

30. Tasks of case-manager
• Taking responsibility for the treatment plan
and assessing the psychosocial outcomes
• Liaison with all practitioners and stakeholders
involved in the treatment plan
• Support to users’ everyday lives. Contextual
issues are explicitly present on the
practitioners agenda
• Taking responsibility for users during
hospitalizations too.

31. Strenghtening partnership with families and
with Associations of families
The need of building a partnership between
families and professionals stems from:
1. an high percentage of people with psychiatric
disabilities lives in family (more than 60%) and
the most of patients dwelling independently or
in the residential facilities has frequent contacts
with the parents
2. the family both strongly influences the
outcomes of treatments and plays a crucial role
in the recovery of his relative.

32. Strenghtening partnership with
families and with Associations of families
Some of the most important task of the mental
health community practitioners toward families are:
• to listen, understand, support, involve and orient
clients’ families, helping them to:
– to cope with dysfunctional behaviours of relative,
– to understand their meanings
– To grasp the relative’s progresses and
• to maintain hope also when there are steps
backward and relapses

33. How we support parenting role
• Psychoeducation (single and group sessions)
• Mutual support groups of family members of
people who are experiencing onset of mental
illness
• Mutual support groups of family members of
people with mental illness in chronic phase
• Mutual support groups of families with relatives
living in the residential facilities.

34. Promoting the assessment of quality of mental
health services by Association of Families
• Periodical meetings (every three months) with
the main Association of Families of people
with psychaitric disability .
• Periodical meetings (every three months) with
the main Association of Families of people
with cognitive disability
• Periodical meetings (every three months) with
the main Association of Families of people
with alcohol or drug dependence or abuse.

35. Encouraging the birth of Associations of Users and
their participation in services’ quality assessment
• MHDt of Ravenna fosters the growth of Users’
Association. At present there are two Association
of Users that are seriously committed to educate
the community about recovery and mental illness
and to counteract the social stigma.
• Users’ Association or single users in recovery are
involved as teachers in training programs of our
Department
• Users’ Association or single users in recovery are
involved in the planning of services and in the
assessement of their quality.

36. User -centered programs: overcoming fragmentation between the differente
component of MHDt and between mental health services and other health
services and social agencies
• In the last decades number of people with mental illnes that need
integrated multifimensional interprofessional treatments is
increased drammatically.
• There is need of going beyond services that works each on their
own (failure of parallel model as well as sequential model)
• In this context, the «core» is person and his /her treatment plan
and not services or professionists. Different competences are
involved on the basis of the different needs of people. and not
because practitioners belong to specific Unit or Service.
• This model implies to build an interprofessional team (practioners
come from different Unit and service) and to plan perodical
meetings between all practioners involved with the aim to rewiev
the treatment plan

37. What targets of population are suitable for
person-centered programs?
– People with Dual Diagnosis (practitioners «lended» from: Community Mental Health Centers ,
Psychiatric Rehabilitation Unit, Community Services for drug and alcohol abuse or
dependence, Social Services)
– People with severe personality disorders (practitioners «lended» from: Community Mental
Health Centers , Psychiatric Rehabilitation Unit, Community Services for drug and alcohol
abuse or dependence, Social Services)
– Ealry intervention for young people with psychiatric disorders and disadapative behaviours
(practitioners «lended» from: Community Mental Health Centers , Psychiatric Rehabilitation
Unit, Neuropsychiatry Children Services, Community Services for drug and alcohol abuse or
dependence, Social Services, Family Clinic)
– People with autistic spectrum disorder. There is a specitfiv program funded by Region Emilia
Romagna
– People with mental illness in phase of remissione that have basic social needs (hpusing,
employment, subsidies, economic resources to access meaningful social activities)
(practitioners «lended» from: Community Mental Health Centers , Psychiatric Rehabilitation
Unit, Social Services)
– People with intellectual disability (practitioners «lended» from: Community Mental Health
Centers , Neuropsychiatry Children Services, Primary Care)
– Elderly people with phisical and mental illnees (practitioners «lended» from: Community
Mental Health Centers , Primary Care , Social Services)

38. Person-centered programs: how to
increase their effectiveness?
In order to increase effectiveness of
person cenetered programs is necessary
to define a network manager for each
program, with the following task
• To join together the team at least weekly in order to rewiev
the treatments’ plans
• To warrant that practitioner share information and all know
the objective of interventions delivered by colleagues;
• The whole team is trained according to the most recent
acquisitions in the field and it is responsible of expected
outcomes.

39. Early intervention program
• Ealry intervention program takes in charge young people (fourteen
years old to twenty years old) with:
– signs of byopsychosocial vulnerabilty
– prodromal simptoms
– Clear pychopathology and/or disadaptative behaviuors, indicative of clear
psychosys.
• The program is carried on by a devoted interprofessional team, (
psychiatrists, psychologists, family therapists, case managers,
expert in alchool and drugs dependance and abuse, social workers),
coming from the varies services of Department or from other
health services (family clinic) and from social services.

40. Eatly – intervention program
• Each of these practiontioners spends part of due work hours in order to
deliver treatments and to participate in team meetings.
Work in progress:
• Just in these days we are negotiating one/two devoted practioners , that
are expected to take officially part in the team, with social services as well
as we are going to plan a training course, aimed to give the appropriate
tools whole team. The course will start in september and will involve all
services taking part in the program.
• A Primary Care Departement is expeted to partecipate in the program in
the next future and in the way that have to be defined yet.

41. Program for people with Intellectual disability
• Ri-examination of the whole population of users with intellectual disability (adults
and under eighteen years old) living in the public and private residential facilities,
with the aim to verify the quality and the effectiveness of care planning and the
outcomes.
• Identification of standards of clinical practice, orienting the long-term treatment
for patients with intellectual disability and progressive deterioration.
• Implementation of EB Psychosocial Practices in all settings of care (in home as
well as in the in residential facilities) , through learning of shared method, aimed
to increase personal and social functioning and to decrease dysfunctional
behaviours.
• In other words, paying a greater attention to tools and methods that counteract
the disabling effects of cognitive disability on the person and his enviroment
implementing such knowledge in clinical practice, so that services and treatment
must reorient the approaches towards emphasizing resources and strengths and
minimizing peoples deficits. .
• In order to realize the last point, we agreed a shared training with Social Services
that will build the basis for a integrate model of take in charge.

42. Some barriers that prevent from implementing
persone –centered program and tema work
1. The same clinician has the responsability of specific functions
(delivering EB treatment) as well as of generic functions (liaison with
general practitioners and general hospital, forensic psychiatry,
bureaucratic and adminitrative tasks, night or holiday shifts in
psychiatric ward).
2. Often there is a conflict between generalist model and EB prctices
model
3. Italian managers and practitioners aren’t used to work in team, to share
knowledges, to peer supervision and to life long learning and workplace
continuous trainig. Most of us have been leanrnig to work in isolated
and fragmented way for years, with the complicity of academic culture.
4. So sometimes new way to approach the complexity breeds strong
resistance to change, expecially among those who have been used to
intervene on symptoms only and not on the whole person.

43. Results of process of change (2007 –
2011)
General results:
• Increased level of professional competence (knowledges, abilities and attitudes) and motivation of
the workforce.
• Increased quality of the delivered services through the development of a competent workforce.
• Decreased recourse to psychiatric residential facilities.
• Increased number of patient living in the residential facilities who has been able to obtain and
maintain a job or to attend education classes.
• Increased number of persons discharged from the psychiatric residential facilities, using the
supported housing and vocational programs.
• Increased satisfaction of families, more involved in the treatment plan of their relatives.
• Containment of the costs due both to the staying in psychiatric residential facilities indefinitely and
to the increase of hospitalizations owing to lack of rehabilitation:
• Increased cooperation between professionals and families.
• Increased adequacy of treatments, since the patients are been replaced in residential setting
according their levels of functioning and the desired outcomes.
• Some patients gained capacity to support clients with severe dysfunctional issues.
• Improved families-relatives relationships.

44. Results of process of change (2007 –
2011)
Results relating to gained social resources
The continuous action of social awakening that the
Psychiatric Rehabilitation Unit carried out has been
able to gain some essential resource to make the
process of de institutionalization concrete and
visible. The most important has been 11
apartments obtained from social services of the
main local governments. Another significant result
has been the increase of jobs for people with
mental illness in the social cooperative.

45. Results of proecces of de-
istitutionalization (2007 – 2011)
Results related to process of de-institutionalization.
• 60 Patients discharged from the psychiatric residential facilities . As regard
the achieved outcomes of the supported housing program up to now, they
are the following:
– All patients discharged were able to live independently in their apartments,
showing a higher level of functioning than that one showed in the residential
facility, and to maintain the apartments for more than six months.
– There weren’t turbulent relationships with neighbours.
– From beginning of the process of discharging, two patients relapsed but they
came back in their apartments after a brief hospitalization.
• 120 Patients assisted in their housing (reduced use to psychiatric
residential facilities).
• 120 Clients have lived in their housing or with family for more than six
months, without hospitalization.

46. Further areas of improvement of
MHDt of Ravenna
– Improving the level of integrated cooperation with Social
Services and general practioners, especially for people with
byopsychosocial needs
– Building focus groups with general practitoners in order to:
• Highlighting the main difficulties that general practitioner have to deal
with when they assist a persone with mental illness
• Highlighting the main difficulties that general practitioner have to deal
with when they interact with mental health community based services
• Defining how to support each other and to share information more
efficiently
– Improving the level of integrated cooperation with our provider
accreditate private hospital in order to orient it to EBPs and
recovery priciples.