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


Crisis intervention in the local community: experience from Trieste, Italy Roberto Mezzina, MH Dept of Trieste Director, WHO CC Lyngby, Denmark – PowerPoint PPT presentation

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

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
  • 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
  • Their are time-limited and dont 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
  • 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

  • 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
  • The crisis can loose its characteristics of
    rupture and dissolution of the existential
    continuity, and acquire a dynamic value.

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
  • 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
  • The three core activities of prevention, acute
    care and rehabilitation are seamlessly
  • 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
  • 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
  • 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
  • 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.

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
  • 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 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.

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.

  • 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

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

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

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
  • Maintaining social roles and networks.
  • Fostering recovery and social inclusion
  • Addressing practical needs that matter to service
  • 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
  • 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
  • Responses are quick and flexible, avoiding
    waiting lists and other bureaucratic obstacles to
    accessing services.
  • 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
  • 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.

  • 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
  • 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
  • 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

  • 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.

  • 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.

  • 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.

  • 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

  • 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
  • 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

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

Key elements of crisis management
  • 1) Negotiating reasons, even in difficult
  • 2) Maintaining the social system
  • 3) Mobilising human and institutional resources

1) Negotiating reasons, even in difficult
  • The hospitality/admission response in the CMHC is
    applied on the basis of "case by case"
    evaluations and not merely severity and risk
  • Its important to negotiate and openly express
    the reasons leading to the decision to provide
    hospitality for someone in a Centre
  • 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
  • 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

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,
  • 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
  • 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
  • Decoding crisis through the confrontation and
    mediation among different viewpoints and needs

Integrated and comprehensive response (social and
  • 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
  • Comprehensive/integrated responses between social
    and health, therapeutic and welfare
    assistance. This involves
  • the use of resources which the Service has
  • 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
  • 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,

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

  • The person and not the illness at the center of
    the process of care for recovery and emancipation
    through users active participation in the
  • (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
  • 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.

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)

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

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

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
  • 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
  • Hope
  • Self-determination
  • The persons history or narrative
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