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

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Crisis intervention in the local
communityexperience from Trieste, Italy

• Roberto Mezzina, MH Dept of Trieste
• Director, WHO CC
• Lyngby, Denmark
• 14 November 2011

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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

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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 dont provide an
  ongoing project of care.

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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

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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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Todays 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

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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.

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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.

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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 patients 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.

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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.

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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.

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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).

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The CMHC

• The Community Mental Health Services, or
  Community Mental Health Centres (CMHC), are
  responsible for a specific catchment area.
• The CMHCs 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.

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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 users concerns and needs.

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• 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.

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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 networks inputs

• Agreed / flexible rules
• Mediated time according to users needs
• Relations tend to break rituals
• Continuity of care before/during/after the crisis
• Inside only for shelter /respite
• Maximum co-presence of SN

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From hospitalisation to hospitality

• Difficult to avoid
• Locked doors
• Isolation rooms
• Restraint
• Violence
• Illness /symptoms /body-brain

• Open Door System
• Crisis / life events / experience / problems

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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

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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

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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 MHCs control and manage the PTDSs
  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.

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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)

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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.

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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.

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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

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Contact

• availability itself, actually being on the spot
  prevents traumatic impacts just the workers
  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.

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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.

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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.

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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.

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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

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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
  services attention and resources for a new plan
  of care

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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 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 teams activities should
  always be related to individual life-stories,
  group discussion and the groups sense of
  community

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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.
• Its 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.

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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).

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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

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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).

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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. 

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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).

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Dos and Donts of Psychiatric Crisis
Intervention incl. Residential Care

• Dos
• 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)
• Donts
• Reduce the compartmentalisation and turf issues
  connected with individual locations / facilities
  (no to roles/spaces)
• Dont 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)

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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
  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

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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

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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

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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 90s on) with no
  hospital beds at all
• In Brasil (Santos) in the 90s
• In Boulder (Colorado) - R. Warner
• Plans in the UK Kingstanding - BHam (98),
  Epping - North Essex (2005), Plymouth (?)

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So what works? (the means)

• Trustee relationships
• Continuity of care / of experience (no
  disruption)
• Hope
• Self-determination
• The persons history or narrative