Crisis intervention in the local community:experience from Trieste, Italy

Roberto Mezzina, MH Dept of Trieste – Director, WHO CC

Lyngby, Denmark14 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.

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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).

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 non-professional 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 usersTime of crisis disconnected from

ordinary lifeStay insideA stronger patients' roleMinimum 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• ViolenceIllness /symptoms /body-

brain

• 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 de-escalate, 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

• 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 CentreActions 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 day-night

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 life-

stories, 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

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 / negotiationThe 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

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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)

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 co-ordination 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.

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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

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 CMHCsIn 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. WarnerPlans 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