by Mario Sellini
Suffice it to say that the public resources that are allocated annually to the protection of mental health amount to over 3.1 billion euros. Of these, about 50% is destined for the private sector, on the basis of the sacrosanct principle of subsidiarity, without which the welfare system would not hold up. This condition makes the demonization for the 10 million allocated for the psychological bonus appear absolutely instrumental
28 FEB – The definitive approval of the ‘Milleproroghe’ decree finances and makes the so-called “psychological bonus” payable to citizens in possession of the necessary income requirements. A proposal born and presented in Parliament during the discussion and approval of the 2022 stability law. The amendment, although shared by all parliamentary groups, did not find the necessary financial coverage.
A spontaneous popular initiative has collected in a few weeks over 300,000 signatures from citizens who have loudly asked for funding. In the history of popular petitions it is among those that have obtained the highest number of adhesions to the point of deserving the transformation into a bill of popular initiative.
This figure alone should make us think. It certainly gave thought to national and regional politics, which immediately accepted this request. It should make all those who have to do with such a delicate health issue reflect. Those who continue to have a critical position towards the so-called psychological bonus should reflect much more.
That the psychological bonus is not the definitive solution to solve the problem of suffering, pain and psychological discomfort, has been reiterated and emphasized by many, starting with the parliamentarians who presented and approved the article of the law. This was confirmed by Minister Speranza. Prime Minister Draghi himself reiterated this at a press conference.
Everyone agrees on the need to do much more. All agree on the absolutely pre-eminent role that the public service must play in this field and on the subsidiary support role of the private sector. On the other hand, it is certainly not the 10 million euros allocated to private psychologist specialists that shift health care in the field of mental health to the private sector.
Suffice it to say that the public resources that are allocated annually to the protection of mental health amount to over 3.1 billion euros. Of these, about 50% is destined for the private sector, on the basis of the sacrosanct principle of subsidiarity, without which the welfare system would not hold up. This allows us to state that already today, the activity of the DSM is, among all the activities of the Health Service, the one with the highest rate of privatization. We can say that at least 50% of the budgets of the individual DSMs are allocated annually to the private sector.
This condition makes the demonization for the 10 million allocated for the psychological bonus appear absolutely instrumental.
1,500 million euros v / s 10 million
It is still not clear to us whether between the two terms used: the noun “bonus” and the adjective “psychological”, the first (bonus) or the second (psychological) creates more problems.
And away to the distinctions: …we could have done more … do better … do differently.
Conference of DSM leaders, psychiatric associations and societies, while recognizing the desirability of an intervention, seem to contest its finalization with the result of creating a great confusion between psychological interventions, psychiatric and child neuropsychiatric interventions and interventions in the field of mental health.
These are areas and sectors of health protection that perform tasks and functions in contiguous areas, but also very different and distinct from each other and precisely for this reason not fungible. Collaboration and interdisciplinary work is a cornerstone of health care to which we must all refer.
It is absolutely acceptable that psychologists can and should be provided for in the psychiatric services activities (thus the ‘mental health services’ / ‘mental health centers’ have been reformulated and renamed). That psychologists must be present in child neuropsychiatry services is equally true, as it is true that they have a role in the DSM. On the other hand, we absolutely agree on the need to adjust the staffing of the DSMs. But we would like to understand why mental health centers today have to be called ‘territorial psychiatry services’. But this is perhaps another story.
Mental health / psychiatry is only one of the very numerous areas of intervention of psychology in the field of health.
Beyond the specific area of mental health / psychiatry, in which psychologists certainly have a function to perform, there are many others that have nothing to do with mental health / psychiatry and DSM. By way of example: district assistance, home care, hospital activities, first aid, day surgery and day hospital, transplants, palliative care, oncology, rehabilitation and post-acute long-term care, organization (INAIL CNOP protocol), family clinics , minors and adults with chronic physical diseases, pain therapy, etc.
It is clear to everyone, according to the scientific evidence, that psychological interventions in these areas have nothing to do with psychiatric / mental health interventions. Unless we want to consider any citizen who temporarily experiences a situation of discomfort, suffering or psychological pain as a patient and user of the DSM and territorial psychiatric services. If that were the case, we would have psychiatrized the entire user of the Health Service. It is not us psychologists who do not want this.
They are the citizens who do not want to be labeled and ‘stigmatized’
The pandemic has made even more evident what we psychologists have been emphasizing for some time. But above all it has become no longer postponable for citizens who, also due to the pandemic, have experienced first-hand what suffering and psychological pain can mean. Labeling as psychiatric patients and DSM users citizens experiencing a temporary psychological malaise constitutes a dramatic error on the epidemiological level, but also on the communicative level, because it accentuates the already widespread phenomenon of health poverty and distancing from treatment. To the citizen who lives in a situation of psychological pain, he cannot be told: “you have to go to psychiatry”, “you have to go to a psychiatry service, before a psychologist takes you on you must be labeled as a psychiatric patient”.
Forcing these citizens actually means pushing them towards private care and this is what happens today: those who want psychological treatment can only turn to private individuals and only if they have the necessary economic resources. And it can only go to the private, not only because there are few psychologists in the public, but above all because to get to a psychologist he must be labeled as a drug addict / psychiatric / neuropsychiatric patient etc. If the citizen is not first ‘tagged’ he will not find the possibility of listening.
Over the last few years it has been realized that silo organization does not guarantee citizens. That it is absolutely essential to implement a transversal model of organization of psychology in public health, based on interdisciplinarity and multi-professionalism, a transversality that also guarantees the necessary flexibility in the use and placement of the human and professional psychological resources available in the Company, on the basis of real structural needs and emerging in the territories. The art. 20 bis of Law 176/20 acknowledges the need to move from a rigid organization (structures / silos) to a functional, transversal and flexible one.
There was no shortage of positions that also go beyond the judgment on the psychological bonus. There are even those who have asked to review the parliamentary initiative to establish the primary care psychologist, forgetting, perhaps, that the Constitutional Court, on the basis of a substantial body of legislation, has confirmed the validity and legitimacy of this legislative initiative.
The Italian Society of Psychiatry has even contested the function and usefulness of the primary care psychologist, considering a primary care intervention to be useless … so much is the DSM / Psychiatry. Yet we are talking about distinct levels of intervention that are the foundation of any health policy that distinguishes first and second level interventions. Perhaps a trivial example can help: a citizen who for a certain period of time cannot sleep at night does not have direct access to a second-level health facility. He doesn’t go directly to a neurology / neurosurgery department, much less a psychiatry service. Like a pregnant woman, she finds listening, counseling and psychological intervention in the Family Counseling Center, certainly not in the psychiatry service or in the DSM.
In this regard, the Administrative Magistracy has very well defined the role of psychology and the figure of the psychologist in the field of health protection: “It is a professional figure called to respond to the increasingly pressing requests for care coming from the social context, marked by the constant and continuous increase of the phenomena of discomfort (from disorders in eating behavior, to gambling addiction, to the phenomena of juvenile discomfort, up to more recent episodes of discomfort, individual, family and social, related to the pandemic emergency), instances that have contributed to highlighting a new dimension of the right to health, that of mental health, which cannot be reduced reductively in the sense of mere absence of psychiatric pathology, but which requires us to consider the immaterial substratum of the human being and his ability to relate to his fellow men. These are aspects of the individual that, due to their delicacy and complexity, can only be entrusted to the care of a specialized professional figure. “
Although it is quite clear that psychological interventions must always be contemplated in an interdisciplinary and multiprofessional integration process which may, in some cases, certainly include psychiatrists, but which must include integration with many other medical disciplines (pediatricians, gynecologists, oncologists, cardiologists, surgeons, neurologists, child neuropsychiatrists, primary care doctors, etc.) and with all the other professional figures present starting from nurses.
If someone should then have any doubts about the real, concrete and exclusive autonomy of the professional activities we are talking about, perhaps it is appropriate to recall what was established by the Constitutional Court with sentence no. 412/1995.
In point 4 of the Recital in law: “By regulating for the first time the organization of the profession of psychologist, the legislator has decided to to reserve the exercise of this profession – characterized by the use of cognitive and intervention tools for prevention, diagnosis and qualification activities – rehabilitation and support in the psychological field – for graduates in this discipline, after a practical training, have passed the state exam and are enrolled in the appropriate professional register. The same law governs, in addition to the activities of the psychologist, also the exercise of psychotherapeutic activity, which is not limited to the study of conduct, but provides for treatment and non-pharmacological cure of disorders and requires specific and further training.”
Mario Sellini
Presidente Form-AUPI(Unitary Association of Italian Psychologists)
February 28, 2022
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