Luca Negrogno
To have a positive relationship with the community, it is necessary to open “popular” verification sites on the outcomes and performance of services, their equity, their ability to reduce inequalities. We need to have faith in the possibility of intelligent bottom-up cooperation which is activated if spaces for responsible management of public powers open up.
Brambilla and Maciocco’s book “From Health Homes to Community Homes – The challenge of the PNRR for territorial health care” (1) allows us to deepen the relationship between Primary Care and Mental Health in the rethinking of territorial services. The book contains a series of stimuli to reflect on the redefinition of the mission and methods of taking charge of the mental health needs of the population, also on the basis of new epidemiological reading models, capable of restoring the dynamic stratification of users by levels of clinical risk and need for care intensity. The challenge is more central than ever, given the proliferation of discourse and awareness on anxiety disorders, depression and other so-called “common” conditions, which increasingly affect a new population compared to that traditionally associated with mental health centres.
We can take this opportunity to redefine the mission of mental health services from the point of view of territorial, public, initiative and health promotion intervention. In the current configuration of mental health services, although there is a certain variability on the national level in terms of organizational structures (2), it is established that the Mental Health Centers (CSM) are the territorial structures that decline all the functions at the local level by the Mental Health Departments for the adult user segment. Where it occurs, the simultaneous presence of different articulations for different user groups does not change this principle: prevention, for example, is a right that belongs to adults and adolescents in equal measure. The question can be further complicated if we also take into consideration the territorial psychology or neurology services, as occurs with particular integrated programs in Bologna: psychological or psychotherapeutic services, or neurodivergence assessment, with consequent indications of supports for inclusion, is not something that, as responding to an autonomous organizational articulation, pertains to a defined user segment.
In the book, the authors explain well that the fragmentation and multiplication of “vertical” programs has favored the concentration on the hospital and on specialist servicesreducing overall accessibility and equity which are instead guaranteed by a horizontal and integrated approach to services, in relation to the social and the community. Reversing this trend is the challenge today. Integration means that the entire population belonging to a Mental Health Center has the right to treatment, prevention and rehabilitation interventions, meaning the entire population present in the area in which the Mental Health Center insists, given its service function “also” of first level. Therefore it is problematic that the Mental Health Centers focus only on the population treated “specially”. Being in the group of the population “taken care of” means going through the activation of “medical-specialist” interventions which from the first contact (many of those that take place today in our Emiliano-Romagna AUSL are “spontaneous”, i.e. they do not go to the doctor of General Medicine) go towards clinical-psychiatric treatment, which is the most frequent “product” according to information systems. We should be very vigilant about the risk that the only entry service is reduced to a first interview with formulation of the diagnosis and “consequent” pharmacological prescription also for the so-called “mild” disorders: we would be heading towards a form of psychiatrization that is materially and ethically unsustainable, as well as grossly inappropriate according to the existing scientific literature.
Today we are witnessing a crisis in the helping professions and the particular declination of this crisis in local mental health services is expressed as an “identity crisis” with respect to the role and professional mandate of those who work there. In dialogue with service operators in various meetings on recovery in Bologna, a malaise emerged relating to the identity not only of individual professionals but of the entire service, whose placement in the context of specialist services/basic services is in fact highly controversial .
From this controversial positioning of mental health centers on the specialist/basic axis, some phenomena emerge that we begin to read in the various working groups:
- a difficulty in defining the professional identity of the medical profession, with the consequent problems of recognition, clarity in the interpretation of the mandate, the possibility of using a variety of tools in one’s own action in a fair and sustainable way. Similar problems are experienced in cascades by other professional groups, which often end up being employed (and interpreted) as mere defensive outposts in the face of an avalanche of indiscernible and unorganizable requests, limiting themselves to placing their own body and good will between this avalanche and doctors’ offices
- a difficult identification of path definitions: “welfare”? “rehabilitative”? “maintenance”? “with a project”? it is almost never clear what these definitions refer to and above all, if these definitions do not hide some “obscure” form of penetration of Tudor Hart’s Inverse Care Law (3) , namely the principle according to which “the availability of good medical care tends to vary inversely with the need for it in the population served”, which we know is often “hidden” behind the definitions of user groups
- this controversial declination on the specialist/basic axis means that the CSMs do not have explicitly differentiated – but professionally integrated – paths internally to respond to different care needs. Rather, this diversification of paths seems to take place “de facto”, determining particular clinical trajectories (if we look at the number of dropouts for example, but on this we should better interrogate the data of the Regional Mental Health Information System): on the one hand, users who experience forms of “abandonment” after a first visit with a “mild” diagnosis that results in a drug prescription and which is never followed by a second call (in this regard we should investigate the folders automatically closed by the Information System after 180 days without services, in 2020 they were more than a thousand, and at the end of 2023 how many will there be?). On the other hand, high-intensity pathways are developed for people with a high “clinical risk”, which often take the form of recourse to beds in residential accommodation or in private clinics with special agreements. This gap seems to be characterized by great risks of inappropriateness and we can hypothesize that it impacts already problematic existential pathways in such a way as to reproduce and increase social inequalities, cause phenomena of non-acceptance of help and increase in self-stigma, the overall drop in trust in public service. Declining trust in the public service results, where it is socio-economically possible, in an increase in the demand for private psychotherapy (psychotherapy constitutes an extremely small percentage of the services provided).
In this lack of identity with respect to the possibilities of intervention, the appropriateness and ultimately the ethics of the public service, a “poor” operational and organizational quality is generated which takes the form of:
- working method determined by “urgency”, which implies subordination to external requeststo the other agencies that have the power to determine emergencies or press for their recognition, generating integration difficulties and conflicts (for example with the social, judicial, criminal, police agencies, public housing bodies: the requests that come from these areas – declined as requests for control, prevention/management of deviance, delegation of any criminal liability for crimes…)
- a lack of reflection on the mandate which leads to the inability to exercise a deconstructive reading of the question, therefore also to act in a mode of initiative and promotion. Reasoning from the point of view of integration between mental health and primary care means instead maintaining the operational, epistemological and organizational unity between the moment of rehabilitation, treatment and prevention in the hands of each single territorial structure; thinking of one’s catchment area as the entire resident population, i.e. finding ways of acting and interpreting needs that overcome the distinction between patients taken care of and the rest of the population, combining medical-centric interventions with non-medical interventions , from the perspective of self-help, recovery and community empowerment. Working in this non-medical-centric integrated way also means restoring dignity to all the other looks and figures present in services today (social workers, psychologists, educators, rehabilitation technicians, occupational therapists) but also users, families, informal networks and, why not , new professional figures, nine agencies and new perspectives (experts by experience, community health mediators, anthropologists/ghe).
What is the organizational structure that can perform this function? As Maciocco and Brambilla explain, health houses first and community houses today are incubators of experiments and good practices, from whose analysis we can give some indications for responding to current open questions:
- with a view to requalifying public spending, a larger integrated social and health fund is neededbut without a predetermined basket of interventions towards which to spend resources: the planning of interventions must be linked to innovative and participatory forms of reading needs, in a dialectical way with the communities
- to have a positive relationship with the community, it is necessary to open “popular” checks on the outcomes and performance of services, their equity, their ability to reduce inequality. We need to have faith in the possibility of intelligent bottom-up cooperation which is activated if spaces for responsible management of public powers open up.
Luca Negrogno, Sociologist, Gian Franco Minguzzi Institution, Bologna.
Bibliography
- Brambilla A, Maciocco G. From Health Homes to Community Homes. Carocci Publisher. Rome, 2022.
- Various authors. Changing needs and service models: the role of mental health departments”. OASI 2022 Report. Cergas – Bocconi. Milan, 2022.
- Tamburlini G. The Law of reverse assistance. International Health.