Changing patterns in mental health care: report on a WHO working group, Cologne, 27 November–1 December 1978

EURO Reports and Studies 25 Changing Patterns in Mental Health Care Report on a WHO Working GrouP REGIONAL OFFICE FOR EUROPE World Health Organization COPENHAGEN @ EURO Reports and Studies 25 Changing Patterns in Mental Health Care Report on a WHO Working GrouP Cologne 27 November - 1 December 1978 REGIONAL OFFICE FOR EUROPE World Health Organization COPENHAGEN 1980 @ ISBN 92 9020 1649 @ World Health Organization 1980 Publications of the World Health Organization enjoy copyright pro- tection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. For rights of reproduction or translation, in part or in toto, of publications issued by the WHO Regional Office for Europe application should be made to the Regional Office for Europe, Scherfigsvej 8, DK-2100 Copenhagen Q, Denmark. The Regional Office welcomes such applications. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerni.ng the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not men- tioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The views expressed in this publication are those of the participants in the Working Group and do not necessarily represent the decisions or the stated policy of the World Health Organization. PRINTED IN DENMARX Reissued under ISBN: 9789289024754 (print) in 2025. Originally published under ISBN-10: 9290201649. ISSN 0250-8710 (print) CONTENTS Introduction. l.l The Working Group. . 1.2 Scope and purpose of the meeting 1.3 Backgroundinformation 2. Emerging trends in mental health care . 2.1 The changing social and medical background 2.2 Changes in the utilization of mental health services. 2.3 Changing pattems of psychiatric morbidity 2.4 The transition from institutional to community-based care 2.5 Constraints in mental health services development . 3. Planned innovations in mental health care 3.1 An ltalian model: Trieste 3.2 A model in the Federal Republic of Germany: Mannheim 3.3 A Swedish model: the Nacka Project 3.4 Mental health services in Leningrad. 3.5 The experimental services viewed in perspective 4. Changing patterns of care for subgroups and special problems 4.1 Long-term care and rehabilitation of the chronic mentally disabled 4.2 New trends in the provision of mental health care for young people Zurich . 4.3 Development of crisis intervention and psychiatric emergency services. 4 .4 Voluntary organizations, self-help groups and mental health care. . 4.5 Levels of mental health care 5. Conclusionsandrecommendations 5.1 Conclusions. .. 5.2 Recommendations References Page I I I ) J 3 4 4 4 7 8 9 t4 l8 23 24 28 28 3l 37 42 43 45 45 46 4',1 49Annex List of participants WHO WORKING GROI,]P ON CHANGING PATTERNS IN MEMAL HEALTH CARE Cologne,2T November - I December 1978 I. INTRODUCTION l.l The Working Group A Working Group on Changing Patterns in Mental Health Care met in Cologte, Federal Republic of Germany, from 27 November to I Decem- ber 1978. The meeting was convened by the WHO Regional Office for Europe as part of its long-tern programme in mental health (1970-83), with finan- cial and organizational support provided by the Govemment of the Federal Republic. The Group consisted of 22 psychiatrists, public health administra- tors and other experts from 13 countries, appointed as temporary advisers to WHO, together with 2 members of the Regional Office secretariat (see Annex). Professor H. tldfner was elected as Chairman of the meeting and Professor B. Cooper as Rapporteur, while Dr A.E. Baert acted as Secre' tary. The participants were warmly welcomed on behalf of the Federal Ministry for Youth, Family Affairs and Health by Dr H. Bialonski, Head of the Mental Health Section, who noted that the theme of the meeting was particularly opportune in the Federal Republic at a time when the Government was drawing up plans for future mental health care in the light of a widely discussed expert commission report on the situation in German psychiatry. 1.2 Scope and purpose of the meeting There are still more than I million people in mental hospitals in the Euro' pean Region. A quarter of these establishments have more than 1000 beds. The transition from institutional care to comprehensive conrmunity care for the mentally ill, including those with chronic, disabling conditions, is a major objective of the WHO European mental health programme. Within the framework of this progamme and the subprogramme on development of community mental health care, the Regional Office is en- gaged in a series of coordinated activities to examine and stimulate new developments and changes in the pattems of care for the mentally disordered. I Possibilities for increased outpatient services, for occupational rehabilita- tion and for accommodation of chronically disabled persons in homes or supervised hostels are behg explored, in relation to the stated intention of many governments to reduce the numbers of beds in large mental hos- pitals. There are indications that the provision of psychiatric units in general hospitals, of crisis intervention units and of a range of ambula- tory facilities - outpatient clinics, day hospitals, day centres, rehabilita- tion units and sheltered workshops - is enabling treatment in the com- munity of many patients who would otherwise have to be admitted to mental hospitals. Finally, the growth of related professional and voluntary agencies, in- cluding social welfare services, youth advisory services, home care services for the elderly, aftercare clubs, self-help groups and Telephone Samaritans, is serving to increase the range and scope of mental health care by bringing new groups of mentally disturbed or at-risk persons into contact and by pro- longing contacts with discharged hospital patients. The Regional Office is concemed, in accordance with its policy, to examine ways in which new developments in community mental health care are being implemented in the various European countries, at national, regional or local level, and to assess how far they are contributing to in- creased effectiveness of care lor the mentally ill and disabled. With this aim in view, the Group was asked to consider recent developments in a number of European centres where planned innovations in mental health care have been put into effect, and to assess how far they could and should be applied on a wider scale. The focus of enquiry, in short, was to be fixed not on national trends but rather on a number of selected local ex- periments which might serve as demonstration models for future develop- ment. 1.3 Background information Because the meeting formed one of a series of activities in the WHO European mental health progranune, the Group was able to draw on earlier reports for background information, and to relate current developments in mental health care to this framework. Of particular relevance were the report on a survey on menta.l health services in Europe (1) and the re- ports on meetings on comprehensive psychiatric services and the com- munity (2), psychiatry and primary medical care (3), constraints in men- tal health services development (4) and the future of mental hospitals (5). In addition, a number of participants, at the request of the Regional Of- fice, provided information papers dealing with developments in local ser- vices or with certain aspects of mental health care of which they had special knowledge. 2 2. EMERGING TRENDS IN MENTAL HEALTH CARE 2.1 The changing social and medical background Contemporary developments in mental health care in many parts of Europe are taking place against a background of demographic and social change. In some countries reduced mortality and birth rates have led to an increase in the proportion of the elderly in the population, to a point at which age-related problems of ilhess and dependency are becoming critical. Economic recession has multiplied the numbers of the unemployed, creating massive social problems, especially among such vulnerable groups as unskilled workers, immigrants and schoolJeavers. The housing situation is deteriorat- ing in many large cities, whjle at the same time various indices of social pathology, including rates of crime, juvenile delinquency and attempted suicide, are on the upswing. Concurrently with the ongoing structural changes and closely linked with them, a number of sociocultural trends may be discerned which have implica- tions for mental health. They include the decline in family and neighbour- hood support systems, the individual's gowing sense of remoteness from power and from the decision-making processes, the increasing material ex- pectations of a consumer-oriented society, loss of religious faith and decline in the Church's role, the spread of sexual emancipation through greater availability of birth control methods and a rapid increase in social and geo- graphic mobility in many societies. Less widely recogrized, but also of great significance for mental health care, are changes in the provision and organization of medical and social services. Costs of health care have escalated, with continuing monetary infla- tion, and in some countries have reached a level at which they are difficult to support. The consequences can already be seen in a cutting-back ofmedi- cal and social programmes, and in shortages of skilled manpower. Simul- taneously, demands for greater specialization and more advanced technolory have led to the construction of huge new hospital complexes which are often distant from the centres of population they serve. Not all current change is inimical to the principles and progressof com- munity mental health care. Important favourable trends can also be discemed. Psychiatric departments have been established in many general hospitals. General medical practice in some countries is based more and more on multi- disciplinary teams, in which groups of physicians collaborate with nurses, social workers and other professionals. There is a growing readiness, irmong physicians in all specialties, to acknowledge the importance of psychological and social factors of disease. The emergence from medical schools of a new generation of physicians who have received some grounding in the behavioural and social sciences may be expected to reinforce these trends. J 2.2 Changes in the utilization of mental health services Against such a background, it is hardly surprising that the nature and content of psychiatric practice are also changing, even in those regions where the service structure has remained little altered in recent years. Certain broad trends are discernible across Europe and are already being reflected in the national statistics. Contact rates as a whole continue to rise, mainly because of steep increases in the rates for outpatient and day patient care, while at the same time the average duration of hospital stay, and with it the total number of persons occupying psychiatric beds, is decreasing. The spectrum of treated psychiatric morbidity is changing. Rates for alcohol-related diseases and for attempted suicide, especially self-poisoning, are climbing sharply - a trend confirmed by epidemiological survey findings. The numbers of treated psychogeriatric disorders are rising, and these conditions represent an in- creasingly important priority in mental health care. The frequency of alcohol- related problems, drug abuse, delinquency and behaviour disorders appears to be on the increase .unong young people, while the age at which such problems present is falling. 2.3 Changing patterns of psychiatric morbidity It is seldom possible, front routine descriptive statistics, to decide if, or to what extent, observed trends in service utilization reflect corresponding trends in the incidence and distribution of morbidity, or how far they can be explained by demographic, social or attitudinal factors, or by changes in ser- vice provision. Some trends, such as the steeply rising rates of alcoholism and suicidal behaviour, are probably independent of changes in health care, whereas others, such as the increase in psychosocial "crises" reported from many centres, or the steep climb in rates of child psychiatric and child guidance referral, are more likely to be due - at least in part - to the growing availability of special facilities. Whatever the underlying caus€s, there can be little doubt that the content of psychiatric practice, as well as the demand for care, is altering in ways which the psychiatrist cannot always foresee and can seldom control. It follows that mental health services must be sufficiently flexible to adapt to changing condi- tions, simply in order to keep pace with events in society. However, this kind of response is not in itself sufficient, since in no country up to now have mental health services as a whole achieved a satisfactory standard of provision. They must, therefore, not simply adapt to change: they must also improve. 2.4 The transition from institutional to community-based care In the evolution of mental health services which has occurred in dif- ferent European countries during the past quartertentury, it is posible to 4 discern a number of common trends. Progress has begun, typically, within the mental institutions, where medical and nursing staff have striven to advance from a basically custodial to a therapeutic type of regime, to mitigate the more harmful aspects of prolonged institutional life and to reduce the segregation of chronic patients, with the help of active rehabilitation and discharge policies. It has then extended to the development of extramural and community-based ser- vices, including facilities for ambulant treatment, and at the same time to the establishment of closer links with general medical care. As a result of this exten- sion, the focus of attention has begun to shift from the patient in a hospital setting to the mentally sick person within a family group and a community, while the goal of rehabilitation is now seen increasingly not as discharge of the patient from hospital but rather as achievement of the best possible level of functioning and adaptation for the family as a whole. Despite national differences in socioeconomic development and in pol- itical infrastructure, there appears to be a growing consensus in many parts of Europe that care of the mentally ill and handicapped can be most effectively provided within the framework of an integrated, community-based service structure. Underlying this concept is the fundamental principle that the sys- tem as a whole should make care available for all forms of mental disorder occurring in the at-risk population, its component parts interacting with one another to form a network of facilities and professional teams. This conceptual and strategic approach is now being codified in a number of countries in new legislation, and underpinned by the organization of psy- chiatric and related services into area groups, or "sectors", each taking re- sponsibility for a geographically defined population. By this means, it is in- tended that continuity of care from one type of service to another, and also from one illness episode to another, should be facilitated and that appropriate treatment should become available to all groups of patients in the at-risk population, including those who are the least rewarding. The sectorization of mental health services creates - or at any rate makes conspicuous - a number of problems concerning the organization of medical and social care, which can be summarized as follows. (l) A conflict may arise between the policy of basing all services as far as possible on the community, so that they may be easily accessible to patients and their families, and the need to provide for some persons highly specialized or intensive forms of care, which can be organized only at a regional or national level. The way in which this general problem presents will obviously depend upon the size of the area covered by the sector service, and the den- sity of population within this area. Planning for a "standard" sector popula- tion will clearly present very different problems in a sparsely populated rural area and in a large industrial city. So far, most schemes for sectorization ap- pear to have been influenced most strongly by the situation in big cities, and the special problems of rural populations have been little discused. 5 (2) Plans for the development of community-based services have frequently been linked with proposals to abolish the existing institutions for the mentally ill - above all, the mental hospitals. There is still disagreement whether, in the long term, mental hospitals can and should be abolished, or whether a need for such institutions - if only on a reduced scale - will remain. Most authorities, however, are agreed that closure of mental hospitals in the short term would involve the discharge of large numbers of severely disabled per- sons for whom as yet no alternative forms of care exist, and that the only humane and realistic policy is to reduce the numbers of mental hospital beds gradually, as alternative services become available. In the words of a previous working group (5): "lt is easier to close a mental hospital than to resocialize and rehabilitate its inmates. Doing away with the mental hospital will not do away with psychiatric morbidity in the patients, their families, or the larger community. But a properly integrated mental health system could do more than any mental hospital to achieve this aim". This viewpoint implies that reduction in the numbers of rnental hospital beds and admissions should proceed in pace with the creation of alternative services, such as psychiatric units in general hospitals, day hospitals, out- patient clinics, aftercare hostels and rehabilitation workshops. Apart from the capital costs involved, such a prograrrrme may give rise to difficult admin- istrative problems. Thus, the whole system of organizing and financing hos- pital care may be quite separate from that relating to non-hospital residential care, social services or occupational rehabilitation. Effective coordination at local level may then be impossible until or unless formal agreement has been reached at national level between the various departments concerned and, sometimes, until new legislation has been introduced. (3) Similar problems of coordination, or of demarcation of responsibility, may arise between the various specialist and professional groups concerned with the long-term care of the mentally ill and handicapped. Often the admin- istrative boundaries lor health, education, social welfare and other relevant services do not coincide, so that it is impossible to define a sector population for which a single set of services bears responsibility. Because of the competing demands made on different services, each of which has its own priorities, there may be great difficulty in building and maintaining multidisciplinary mental health care teams in which psychiatrists, nurses, social workers and other professionals can use their skills to full advantage. (4) One important professional $oup poses special problems: namely, the medical practitioners, both specialized and general, who in many European countries are not part of the organized service structure, but function as in- dependent, self-employed persons. The extent to which this group can be successfully integrated into a mental health care system will depend upon the extent and quality of cooperation achieved between the local services and 6 each practitioner. This point is of crucial importance, not merely because a large portion of the total psychiatric manpower may be in private medi- cal practice, but also because, as has been repeatedly demonstrated by general practice and community surveys, a large part of the burden of medical care for mentally sick persons outside hospitals is borne not by psychiatrists but by general practitioners who, moreover, in most instances also undertake the general medical care of the patients' families. The contribution of the general medical practitioner has received too little attention in the planning of community mental health services, and few serious attempts have been made as yet to achieve an effective balance be- tween specialist and generalist (primary care) facilities within the mental health care system. (5) Diagnosis and treatment of mental illness by general practitioners and other nonspecialists in the community represents an important step towards secondary prevention, i.e., recogtition of illness and institution of treatment measures at the earliest possible stage in order to reduce the risk of chronicity and long-term handicap. Developments of this kind can be most successfully promoted where the local psychiatrists are willing and able to take an active part, for example by providing a consultative service, by carrying out domi- ciliary visits together with the practitioners, etc. Since, however, manpower resources are strictly limited, the psychiatrist working in a community mental health service must have a scheme of priorities in deciding how much, if any, of his time he can devote to such consultative tasks without neglecting the needs of the most severely ill and disabled groups of patients. There is a lack of guidelines which would help him to arrive at the best compromise solution. Similarly, redeployment of hospital nursing staff to meet the requirements of a comprehensive, community-based service appears to be proceeding on a basis of trial and error in some places, but with no clearly formulated prin- ciples or guidelines. (6) The transition from hospital-based to community-based systems of care cannot be achieved simply by means of legislation or by administrative decree. Like all such reforms, it also calls for a sense of vision and purpose; more specifically, it requires a commitment, arnong the professionals involved, to the basic principles of mental health care and to the interests of the men- tally sick and their families. In the last analysis, a shift in public attitudes is also necessary. 2.5 Constraints in mental health services development Of special relevance in this context is the report of the Working Group on Constraints in Mental Health Services Development (4). After reviewing the current situation in l6 countries of the European Region,it was concluded 1 that progress towards comprehensive, community-based mental health care was in all these countries disappointingly slow and that the reasons were to be found in a complex group of problems - financial, organizational, politicd and attitudinal - for which no simple solutions could be found. The nature of these problems was succincfly formulated as follows: "The Working Group reaffirmed the value of the concept of comprehensive community mental health care, but concluded that it was not being satisfactorily applied because of prejudice, public and professional iglrorance, lack of staff and material resources, poor coordination and administration, political vacillation and out- dated legislation". In the face of this challenging conclusion, it seemed appropriate and in- deed urgent, in the present discussions, to examine to what extent and how successfully certain local area schemes in a number of countries have been able to progress towards the goal of comprehensive community mental health care, even though the national situation has not always been wholly favour- able to such a trend. For the same reason, it was considered expedient not to concentrate on services in those countries with the most highly developed mental health services, but also and in particular to consider schemes in countries with diflicult organizational or economic problems, or with little tradition of community-based care. 3. PLANNED INNOVATIONS IN MENTAL HEALTH CARE The task of the Group was to examine some possible strategies for approaching the goal of comprehensive community mental health care, as exemplified by a number of current experimental services being con- ducted at local level in different parts of Europe, and to assess, on the ba- sis of this eyidence, the feasibility under differing national conditions of effecting the transition from institutional to community-based forms of care. Some of the services have been set up deliberately with the goal of comprehensive community mental health care in view; others have more limited objectives, such as the provision of facilities for the elderly, for young persons, or for crisis intervention. Scientific evaluation, or even the possibility of systematic assessment based on adequate descriptive statis- tics, is still lacking for many of the services. Taken together, they provide nonetheless a convincing practical demonstration that progress towards the goal of comprehensive community care can be achieved, given the will and determination, by planned change in the structure and organization of existing services. Moreover, some of the experiments suggest that such prog- ress can be made without any large capital expenditure or increase in running costs. 8 3.1 An Italian model: Trieste 3. I . 1 Mental health care in Italy Under the provisions of legislation adopted in 1968, Italian mental hos- pitals should not have more than 650 patients. Many of the larger hospitals with more than 1000 beds have been dividedupinto2 ormore units. Owing to the lack of alternative facilities, many of the hospitals also have a very high percentage of elderly residents; moreover, they must provide custodial care for brain-damaged and severely mentally handicapped patients. In recent years, a growing consensus among the general public and politicians has come to support the view that mental hospitals should be reduced and eventually abolished, because they may cause chronicity and always produce isolation from society. Under the 1968 legislation every province should provide a network of small departments for outpatients. In addition, particularly in northern Italy and in the cities, psychiatric departments have been set up in general hospitals. With the gradual development of a national health scheme in the years 1975-19, steps have been taken to establish mental health ser' vices which function in close liaison with general medical services through small units serving defined population sectors. 3.1 .2 The changtng pattern of mental health csre in Triestea The Province of Trieste forms a narrow coastal strip, almost surrounded by Yugoslavia, in the extreme north+ast corner of ltaly. Before the First World War it was part of the Austro-Hungarian Empire and from that time the psychiatric service was based on admission to a mental hospital, built in 1908. The mentally retarded as well as the mentally ill were admitted, but elderly persons with senile dementia and other organic brain syndromes went to a separate hospital for chronic physical disorders. The 1968 legislation modified the regulations concerning the size and staffing of mental hospitals and introduced voluntary treatment for patients, but in 1969 only 52 of the 1262 patients in the Trieste mental hospital were there on a voluntary basis. The high ratio of 4 beds per 1000 population at that time reflected the medical stafl's cautious attitude towards hospital discharge. Some follow-up and preventive work was undertaken in a centre in the city and in 3 small clinics elsewhere in the Provincp. Their connexion with the hospital service was, however, tenuous and often ineffective. The Provincial Government, anxious to change this situation, appointed Dr F. Basaglia as director of the hospital in 197 l. Following his appointment, more physicians, social workers and nunes were recruited to fill vacant posts, 9 a Based on information provided by Dr D.H. Bennett. and a policy of abolishing the mental hospital and replacing it by other forms of service was put into effect. By the end of 197 l,202beds had been vacated and 230 of the remaining 1060 patients had been transferred to voluntary status. In the years that followed the tempo of change was maintained. Patients who remained in hospital were moved to mixed wards, and increasing num- bers were given voluntary status. As part of the restoration of civil status for discharged patients, arrangements were made for them to receive a social security allowance of up to 60000 lire per month. Plans were drawn up, in consultation with the Provincial President, to transfer patient care from the hospital to the community. The hospital catchment area was divided into 5 sectors, or districts, each with a population of approximately 60 000 per- sons. Each district and corresponding division of the hospital had its own team of physicians and nurses, and usually a social worker as well. Hospital patients were transferred to wards allocated to the team responsible lor their residential district. Those patients who were asessed as being capable of community lile were discharged if they had, or could find, somewhere to live. They were then followed up in their homes by the district team which at first operated from a hospital base. Following the discharge of patients, 2 hospital wards were closed n 1972. Previously there had been only I male and 1 female ad- mission unit in the hospital; now admission units were established in each of the 5 hospital divisions and accepted patients according to their residential sector. In 1973 a workers'cooperative was established which enrployed pa- tients on paid contract work. Many elderly disabled,long-stay patients who could not be discharged were given the status of "guests". This entitled them to the payment of social benefits and relieved thern of certain legal disad- vantages. Wards and former staff accommodation were converted to pro- vide them with group apartments on the hospital site. Such rapid changes were not accepted without protest. During 1972 utd 1973 there was a series of strikes by nuning statf who objected to the closing of wards and the presence of student and graduate volunteers. In the end the nurses' resistance was overcome and their small administrative hierarchy dis- banded. There was some bitterness between physicians and nurses, and the latter group split between those who elected to remain in the hopsital and those who chose the community care system. ln 1974 the first 3 district mental health centres were opened. With the support of 3 teams, each now based on a centre, the process ofdischarge and desegregation of the patients continued. The total number of residents in the hospital was by now reduced to 810; 350 voluntary patients, 100 compul- sory patients and 360 "guests". When a long-standing proposal to rebuild the hospital came up for consideration in 1975, it was shelved. The first goup apartments and 2 further centres were opened in 1976. The last centre opened n 1977. With the completion of the community system of centres and teams, hospital admissions, which had been reduced, l0 could be discontinued. However, while the centre staff supervised l8 group apartments with 80 beds, the centres themselves lacked beds and night siafl and so could not admit acutely ill patients who needed an overnight stay. For such patients it was decided to provide a single admission unit situated on the hospital site, but linked to the centres and having no con- nexion with the hospital. The most recent innovation is an emergency service, which provides consultation in the general hospital casualty department and arranges emer- genry admissions. In Trieste, the bulk of patients are brought to, and ad' mitted through, the casualty department. Formerly, decisions about admis- sion were made by a physician without psychiatric training. Now the emer- gency team screens referrals and seeks effective alternatives to hospital admission where possible. Recent figures show that about 427o of those referred to the emergency service are sent to the admision unit, 3Wo are sent home, 14% are admitted to various general hospital units and 8% are sent directly to the mental health centres. As a result, referrals to the admission unit have been reduced, as have compulsory admissions. Thus in 1977 therc were no admissions to the mental hospital but 492 patients were referred to the admission unit. 3.1.3 Appraisal and conclusions In general, the changes described are in line with contemporary trends in European psychiatric practice, as well as with the recommendations of a num' ber of wHo meetings. It is not possible, without further detailed information, to make a full evaluation of the adequacy, effectiveness and efficiency of the new services. However, from the available data one can draw certain con- clusions, amounting to a preliminary appraisal, as follows. (l) Transfonnation of the mental hospital Reforms related to conditions in the hospital were speedily introduced. Ward doors were opened, the numbers of compulsory patients reduced and financial benefits hcreased. Those patients unable to find community place- ment were encouraged to live more independently as "guests" in facilities on the hospital site. In spite of these improvements, it was decided that the hospital strould be eliminated when its functions had been taken over by a community-based service. The change in the hospital population is sum- marized in Table l. (2) Continuing responsibility for patients Although the staff h Trieste distrust the concept of mental illness, they accept a continuing responsibility for the psychiatric needs of former hospital ll Table 1. Change in mental hospital population, Trieste, 1967 -1977a Year Total Legally committed patients Voluntary patienB "Guests" 't967 1968 r969 1 970 1971 1972 1973 1974 1975 1976 1977 1250 1270 1250 1 140 1050 980 890 810 700 600 450 1250 1240 1210 1 230 830 500 200 100 90 50 40 30 40 t't0 230 430 420 350 150 80 50 50 270 360 460 470 360 a Based on a census of inpatients, reported on 1 January each year patients and of the provincial population. Sectorization of the catchment area ensures that services are geographically accessible to the whole popula- tion. The provision of mental health centres, group apartments and other parts ol a supportive community system was synchronous with the reduction in hospital beds. Staff and patients moved to the community , ryi passu with the closure of the hospital wards. There was no interruption of responsibility, and staff and patients were "deinstitutionalized" together. (3) Comprehensiveness and vaiety of senices The services provide inpatient, outpatient and day patient care. There are links with the general hospital and the neurological department, each of which admits an uncertain number of psychiatric patients, and with the uni- versity psychiatric clinic. These links may be strengthened following the implementation of a new mental health law of 1978. There are consultative, emergency and rehabilitation services. Apartments, sheltered workshops and residential care are provided on the hospital site. Uttle emphasis is placed on formal psychiatric treatment; medication is prescribed but is regarded largely t2 as a means of establishing a relationstrip with the patient. Other forms of physical treatment are not employed, nor is individual or group psycho- therapy. There is an insistence that patients must be listened to, that their needs must come {irst, and that relationstrips between patients and staff should be devoid of either condescension or deference. The overall impres- sion is of a psychosocial supportive system rather than of medical treatment provision in the narrow sense. (4) Integration within the services Although the central administration is small, the services are well inte- grated. Physicians and nurses from the centres visit the admission unit daily, staff the emergency service on a rota basis, supervise the apartments and make numerous home visits. The Province has provided each centre with two official cars. The teams have frequent meetings with each other and with the director. Observation suggests that the existing links ensure adequate com- munication and appropriate transfer of patients between various parts of the services, although admission to the mental hospital is now proscribed. (5) Effect on psychiatric morbidity It is not possible from the available evidence to say whether or not the services decrease or contain psychiatric morbidity. In practice, humanitarian conc€rn with the patients' environment and welfare are more evident than any planned prograrnme of treatment or rehabilitation. Nevertheless, there is a widely held belief that the mental condition of many patients has been improved. Certainly the social and ctnical state of those attending centres or Iiving in apartments appears to be better than that of those who remain in the few hospital wards. (6) Staffing and costs Staffing levels are not unduly high and have not increased significant- ly since l97l (Table 2). When the overall costs of the services, which in- clude running costs, personnel, food and pharmaceutical costs, as well as social security benefits, are corrected for inflation, they show a real increase of only 13.5% between 1972 urd 1977. Costs of food and medication have decreased, operating costs vary little, while costs ofsocial benefits have markedly increased. Capital expenditure has been on a limited scale. The centres have been housed in modest or even dilapidated buildings already owned by the Province, which, where necessary, have been partially reno- vated. The proportion of the Provincial Government's budget allocated to the services is said to have been reduced from about 6Vo n l97l to 45Vo fit more recent years. l3 Table 2. Overall current costs of mental health services, Trieste (million lira) Maintenance, Year Staff catering, Pharmaceuticals heating Financial Capital costs benefits under paid by the provincial Province public works Total 1970 197 1 1972 1 973 1974 1975 1976 1977 612 676 897 't219 1478 1488 1779 2091 2150 2029 210,9 2779 2865 2987 3731 4389 100 140 160 165 104 135 154 80 38 47 58 87 100 1v 178 121 121 300 2940 2893 3345 4551 4607 51 81 6821 6761 40 437 980 80 (7) Unresotved questions There are a number of questions still to be answered. The first relates to the nature of services needed in future for the psychiatrically disabled and mentally retarded long-stay patients who still live on the site of the mental hospital. The second question concerns the stafls belief that in the absence of admission to the hospitd there will be no new long-stay patients. It is most unlikely that psychiatric disability will disappear with the dissolution of the hospital. Finally, how in ltaly's national health scheme will the staff of a socially oriented psychiatric system integrate with medically oriented psy- chiatrists and other hospital physicians? 3.2 A model in the Federal Republic of Germany: Mannheim 3.2.1 Mental health care in the Federsl Republic The lust survey of mental hospitals in the Federal Republic, carried out in 1973 on behalf of an officially appointed Commission of Enquiry (6), showed a ratio of 1.8 beds per 1000 population and an additional 0.8 per 1000 in homes for the chronic mentally ill and mentally handicapped. The report was in many respects highly critical of the situation of psychiatry in the country. One-third of the hospitals have more than 1000 beds each, t4 and many are far from patients'homes and communities urd suffer from a shortage of qualified stiff. Psychiatric units in general hospitals are few and viry unevenly distributed: half, for example, are situated in North Rhine-Westphalia, which contains only one-fifth of the population. The division between inpatient and outpatient care has been gradually narrowing, particularly since a recently adopted law gives all mental hos- pitals and psychiatric units in general hospitals the right to establish outpa- Lent servicis. Most ambulant treatment, however, is still provided by psy- chiatrists and psychotherapists in private office practice. Psychiatric care in rural areas is iniufficient , 6Vo of all psychiatrists working in towns with more than 100000 population. The number of day hospitals is very small, partly because the isolated position of many of the institutions makes it difficult for them to provide any form of day+are. The Commission of Enquiry considered that the mental hospitals should in future be integrated into a comprehensive system providing inpatient and ambulatory services for a defined area population of about 250000.4 More cooperation strould be developed between mental and neighbouring hos- pitals, as well as with area general practitioners, social services and other in- rtitutiont, and with psychiatrists in office practice. Mental hospitals should have not more than 500-600 beds, and the recommended size for a psy- chiatric unit in a general hospital was set at about 200 places. In the Federal Republic, as in many other European countries, there is still a shortage of detailed, accurate mental health statistics which would provide indices of the utilization of specialist services at federal level or in iach state and serve as a basis for monitoring the effects of change in health care provision. 3.2.2 The changing pattem of mental health cse in Mannheimb Mannheim is an industrial city with a population of just over 300000, situated at the junction of the River Neckar with the Rhine. It had no psy- chiatric service, apart from the mental hospital at Wiesioch, 25 km away, until 1968, when a consultative service was set up in the city general hospital. ln 1972 an inpatient unit with 55 beds and a 24-houl emergency unit were a In France, the recommended size of a catchment area is 75 000 population. D Brr"d on information provided by Professor H. Hiifner and Dr R. Schwarz. 15 established in the hospital. In 1976 these services became part of the respon- sibility of the newly created Central Institute for Mental Health, situated in the centre of Mannheim, some 2 km from the hospital. The basic concept in planning the Institute was to bring the university clinics and departments concerned with mental health (adult psychiatrv, child/adolescent psychiatry and psychosomatic medicine) together under one roof, and to link the provision of comprehensive psychiatric care for a de- fined urban population with university teaching and research activities. Practical experience in the development of community-based seryices would thus be combined with the results of applied research and evaluation. The Institute has close links with the Heidelberg University Faculty of Clinical Medicine in Mannheim, the directors of the 3 clinics in the lnstitute each holding a corresponding professorial chair in the University. The adult psychiatry clinic has 106 beds, and the child pqychiatry and psychosomatic clinics 48 beds each. All 3 clinics have an outpatient department. There is a 24-hour emergency service, run jointly by the 3 clinics. Close cooperation exists with the general hospital and its casualty department, through the psy- chiatric consultative and emergency services provided by the Institute. Sup- plementary and linked services comprise a day hospital, 2 sheltered work- shops, a half-way house with 35 places, 2 supervised hostels with 59 places in all, and 3 patients' after+are clubs. The Institute's community psychiatry department has the task of integrating these latter services and providing counselling for the local community. With the opening of the Institute in 1975, the demand for inpatient care in the mental hospital at Wiesloch began gradually to decrease. The num- ber of beds in the hospital occupied by Mannheim patients dropped from 295 at the end of 19'74 to 261 a year later and to 236 h 1976. Over the same period, the total number of admissions of Mannheim patients to the hospital has shown only a slight diminution;it appears, therefore, that the main effect has been a reduction in the average duration of stay. At the same time, the number of admissions to the Institute, as well as the number of outpatient consultations held there, has continued to increase rapidly. Fig. I shows the relationship between these opposing trends. The distribution of patients admitted to the Institute differs in some important respects from that of patients admitted to the mental hospital. The Institute's patients include a relatively high proportion under 30 years old, whereas among Wiesloch patients the over-60 age group predominates. The relatively high proportion of old people in the Mannheim population (16% over 65) underlines the need for an improved psychiatric service for this group, and a psychogeriatric department has been planned as part ofthe next phase of development of the Institute. Average duration of stay of patients in the Institute is 30 days, compared to about 200 days in the mental hospital. However, this comparison is mis- leading because the Institute has been functioning only since 1975, whereas l6 6ts ! - tfs + -!oGq- o !:6 go o 9o N oF 6i r;ts IIIt E o)Ec tr(E =E o cq) F(E o.(, .g -c(, o -o ! .9 o. ,oo o !, o,o - .d, lJ- ;€p o r; I , ,I I I o 9oP' ulo8- t I I , t a o ! s ! I G a= >E E: =3 li - q< I , , o N@N eo s pardnsospaqlo oN t7 the hospital has a proportion of long-stay patients who have been in care continuously for up to 50 years. If the calculation is restricted to patients admitted within the past 5 years, the corresponding figures are 30 days for the Institute and 60 days for the hospital. 3.2.3 Appraisal ond conclusions The creation of the Institute has greatly increased the scope for com- munity mental health care in Mannheim, and in so doing has served to meet an urgent need. There are some indications that an increasing proportion of treatment episodes are being dealt with successfully on an outpatient basis, but this trend is not reflected in any decrease in inpatient admissions which, indeed, continue to rise steadily. It appears, on present evidence, highly unlikely that the 106 beds provided for adult psychiatric care in the Institute will be sufficient to meet the needs of the Mannheim popula- tion, or to obviate the existing need for beds in the area mental hospital. This is partly due to the fact that, while total bed occupancy has fallen in recent years, the number of inpatient admisions is still rising. Acute illness episodes and psychiatric emergencies account for an increasing proportion of the total admissions. More and more persons are seekinB help lrom the Institute for family and social crisis situations, no doubt partly because it provides a 24-hour service. Im- proved social service facilities would probably help to relieve this pressure on the psychiatric services and to avoid applying a psychiatric label unnecessarily to many social problems. For certain patient groups (notably alcoholics, drug addicts and psychogeriatric patients), there is a growing need for treatment and care services, which up to now could not be adequately met. 3.3 A Swedish model: the Nacka Project 3.3.1 Mentol health care in Sweden ln 1973 there were 4.6 psychiatric beds per 1000 population in Sweden - one of the highest ratios in the Region. In addition there were 1.2 beds per 1000 population for the mentally retarded. Of the psychiatric illness beds, half were still in mental hospitals, the remainder mainly in general hospital psychi- atric departments. The psychiatric admission rate rose from 5.5 per 1 000 popu- lation in 1960 to 14.3 per 1000 in 1973, an increase of almost 2OWo. The trend towards an improved standard of care in mental hospitals, dating from the mid-1950s, received a new impetus in 1963 when respon- sibility for such hospitals was transferred from the state to the county coun- cils. This was a decisive step in efforts to integrate psychiatric and general medical care. At the same time it became more widely realized that the old men- tal hospitals, which had not been planned, built or equipped with the aim l8 of rehabilitation in mind, were to a large extent unsuitable for this purpose. Since then, a number of committees have discussed the future use of the men- tal hospitals, and tlere is general agreement that they must be replaced by alternative forms of care. Some, however, have been built only within the past 30 years and cannot easily be abandoned. It is not only the financial realities which stand in the way. The number of beds for psychiatric care must be increased, and willingress to follow up and rehabilitate patients with the aid of community and primary care services must be cultivated. Few general hospitals have agreed to undertake the care of committed psychiatric patients, and there is an obvious reluctance among medical staff to do so. Moreover, the number of patients committed under the country's detention act remains high, the proportion being currently about 25%. Practically all such patients are admitted to mental hospitals. The next step will be conversion of mental hospitals into homes for the chronic mentally sick, which would serve as annexes to the psychiatric de' partments in general hospitals. This development, however, is not regarded as a final goal, shce it cannot provide a satisfactory substitute for closure of the mental institutions and their replacement by small treatment units based on the local communities. Although comprehensive sectorized services were officially recommended in 1974, as yet only one such service exists. lack of money is not a serious impediment, but political pressures have tended to set priorities in the allocation of resources, which favour a continuing dependence on, and predominance of, large institutions. The National Board of Health and Welfare is currently trying to limit the renovation of existing mental hospitals unless at the same time plans are submitted for building small treat- ment units. Differences in psychiatric ideology, causing confusion and mis- understanding, have delayed development. There are too few psychiatrists and psychotherapy is a relatively neglected area in training. The existing legis- lation presents impediments to multidiscipinary teamwork. 3.3.2 Changing pattems of mental health care in Nackaa The Nacka Project is the name given to an experimental reorganization of psychiatric outpatient and crisis intervention services that was undertaken in an outer suburb of Stockholm in 1974, covering an area with a population of about 75 000. For several years the local psychiatric services had been regarded with increasing dissatisfaction, being limited to treatment in either infrequent and thinly staffed outpatient clinics, or admission to the distant state mental hospital (50 km). The tendency towards increasing emphasis upon outpatient and community-based services had been apparent in other a Based on information provided by Dr J. Cullberg and C.C. Stefansson t9 countries and in other areas of Sweden lor some years, so the Nacka Project was organized to provide immediate, comprehensive psychiatric services with minimal reliance upon inpatient facilities. The primary objective was "to seek and offer decent, effective alter- natives to inpatient psychiatric care". Morc specific subsidiary objectives were: (a) to olfer a comprehensive psychiatric service for a district; (b) to deterrnine to what extcnt inpatient care requirements could be reduced through the developnlent ol outpatient programmes; (c) to set up an organizational framework and to cstablish effective col- laboration with all institutions und authorities dealing with mentally disordered persons or high-risk groups within the population; (/) to contribute to the planning of luture developments in mental health care in the county council's area of jurisdiction- During 1973 the stafl and otlter resources needed for the new pro-jecl were brought together, sonte being diverted from the hospital inpa- tient facilities that would otherwise have been provided. originally the project teanrs would have preferred to have direct control over some in- poticnt beds, but this provcd irnpossible. Instead, they have evolved a very closc relationship with the nearby Lrngbrtl htlspital, where patients are admitted as necessary. The project sta{-f have, in fact, the right to admit patients, though in practice this right is never exercised in a one-sided or peremptory f ashion. The area covered is a suburb on the eastern edge ol Stockholm, about l0-15 knr fronr the city centre, with a population of about 75 000. Three outpaticnt centres have been opened in this area and each deals with a spec- ified one-third of the population. Each centre has a team of 13, comprising 2 psychiatrists, 2 social workers, 2 psychologists, 2 senior psychiatric nurses, 2 assistant psychiatric nurses and 3 secretary/receptionists. The senior psychiatrist in each team is designated as team leader. Between them the 3 centres provide their areas with psychiatric services that deal with both urgent and non-urgent requests for help, 24 hours a day, and are directly accessible to all agencies and to the general public. In practice, most of the requests come direct from individuals and families themselves, and the first contact is usually made by telephone. The secretary/receptionists play an important part in monitoring these telephone requests, in deciding which team member is the most appropriate to ask to deal with the more serious calls for help, and in redirecting other enquiries. The 3 centres deal with about 90 new cases a month, or about 1000 a year. The total number of visits made is about 10000 per year. Although much of the work of the teams is aimed at rapid problem-solving, and so can 20 be regarded as a form of crisis intervention, the project also aims to provide long-term outpatient care, and a number of long-term therapeutic gloups are organized, including Sroups for couples with marital problems. consultative services are provided to social welfare agencies, general practitioners, district nurses, schools, the police, etc. Preventive work, which it ttre ueginning was a quite undeveloped Iield, now includes such activities as group work with first-child parents, psychosocial advisory services and peda- gogic counselling. The initial aim was to devote one-third of the working time io consultative and one-third to preventive activities, but in view of the clinical load this has not proved feasible. Since the beginning of the project a case register has been kept so as to provide a means of quantifying the work of the teams and of permitting some degree of evaluation. Data from the case register, covering all patient contacts over a 2-year period, were compared with corresponding figures for the service population in the 2-year period before initiation of the project. Fig. 2 shows only slight difflerences in the numbers of patients diagnosed as having psychotic or neurotic disorders, but a very large increase in the number under "crisis reactions". The same statistical comparison shows that total outpatient consultations hcreased by over 100%, whereas in- patient admissions of individuals fell by 32%. Conesponding figures for the remainder of the County of Stockholm showed only minimal differ- ences in outpatient and inpatient statistics between the 2 time periods under comparison. It would appear that the main effect of the new services as regards patient utilization has been a rapid growth of demand by a group which had not made much contact with the existing services, namely, persons con- fronted with acute, traumatic life-events. This goup comprises mostly first- contact patients, with a high frequency of attempted suicide and early stages of alcohol abuse. Furthermore, an analysis of the patient groups by social class revealed that the great overall increase in "crisis reactions" had occurred principally among middle-class and lower-middle-class goups, and had not iffected the lowest social class groups. This suggests that the frequency of direct self-referral, and especially of telephone referral, to the new services was strongly influenced by social class. 3.3.3 Appraisol and conclusions When a well-equipped outpatient organization is introduced in an area and accepts direct referral and self-referral as part of a front-line service, it will draw more patients suffering from acute and traumatic life+vents, particularly from middle-class and lower-middleclass sections of the popu- lation. However, more generally there will be a reduction in psychiatric inpatient admissions. The question of crisis intervention is discussed further under 4.4. 2l c ,9 o o o z 2 800 2 400 2 000 1 600 1 200 800 400 Fig. 2. Nacka Project: patients per 1fi) fi)O population in different diagnostic groups 71 2 628 101 530 176 Psychosis Control population Projea population Neurosis and border line "Crisis reactions E ')') 3.4 Mental health services in Lrningnda The principles of development and provision of mental health services in the USSR may be summarized as follows: (a) primary, secondary and tertiary prevention, screening and diagnosis oi mental disorders; observation and follow-up of high-risk groups; (D) accessibility of mental health services for all sections of the popu- lation; (c) specialization of mental health services to meet the needs of all subgroups of mentally disturbed persons, including borderline cases and persons at high risk of mental disorder; (d) continuity of care for patients who have to be referred from one part of the mental health services to another (e.g., from outpatient clinic to day centre to hospital); (e) rehabilitation of psychiatric patients, aimed at reduction of secondary handicaps and disability, resettlement h work and a normal social en- vironment, and prevention of relapse and readmission; (/) provision of mental health care in the community, as a major priority. In accordance with these principles, the existing mental health agenciesin kningad were linked together to form an integrated system, and a new policy for mental health care was implemented, emphasizing the principles of reha- bilitation and resocialization of the mentally ill in their local communities. In recent years the services have been elaborated and a number of special facilities have been introduced, including a psychiatric emergency unit, intensive care wards, a central outpatient clinic, a night centre for alcoholics, and a night sanatorium for neurosis cases from all parts of the city, in addi- tion to the existing clinics in each district. At the same time, a centre for epileptic patients, comprising an outpatient clinic, admission wards and a neurosurgical unit, has been established, as well as a network of psychiatric day centres in each district clinic. This has led to a decrease in the numbers of beds in the mental hospitals. The mental hospitals have been sectorized, each division taking patients from a defined catchment area based on the administrative districts of Lrnin- grad (population: 200000-5m000). There has also been some increased specialization of inpatient care, so that there are now wards designated for 4 Based on information provided by Dr D.N. Isaev. 23 intensive care, for treatment of mixed psychiatric and somatic disease, for the care of elderly patients and for special rehabilitation and training. ln ad- dition, psychiatric wards have been opened in the city general hospitals within the past few years. Preventive work is undertaken through polyclinics for somatic diseases and the general hospitals, by primary care personnel, and through a health education centre. Teams of psychiatrists, psychologists and allied workers carry out this preventive work in a number of ways: (a) health education in the factories, industrial plants, schools and local communities; (b) screening of high-risk groups in various subpopulations (e.g., ado- lescents in school, factory workers); (c) routine compulsory examination of all children before the first year ofschool and again in the tenth year; (d) compulsory examination of all applicants for certain types of work (e.g., railway, bus and train drivers). Registers of the mentally ill, maintained in the outpatient units, permit systematic follow-up and clasification of patients according to the course and severity of their disorders. The system of follow-up is geared to this classification, the most acute cases being seen each week, the less acute each month, and the more chronic each quarter or, finally, once a year. 3.5 The experimental services viewed in perspective This brief summary of four different service models illustrates not only the diversity of current approaches to the organization and development of community mental health care, but also the difficulties which must be faced in any attempt at comparative evaluation. To begin with, it is axiomatic that the information obtained about any service will vary with the source from which it is derived. Only in one instance - thatof theTriesteservices -wasit possible to draw on information gathered by a sympathetic but critical observer, who was not prepared to accept any of the service team's own as- sumptions about their work without first asking searching questions, and who then made his own independent appraisal. Even in this instance, only tenta- tive conclusions could be reached because of a lack of firm, precise infor- mation about the effects the new services were having on the mental health and welfare of patients and their families. Evaluation, in short, demands impartial enquiry and the use of objective measures. Secondly, it is not clear to what extent each of the four service models represents an experiment or new departure from an existing system. In Trieste, there has clearly been a radical departure from the type of service usual in ltaly, although not of the revolutionary nature claimed by some 24 members of the "antipsychiatry" movement. Many changes introduced in Trieste are strongly reminiscent of reforms described by some services in the United Kingdom and elsewhere in the 1950s and 1960s. It seems clear that the changes reported from Mannheim and Nacka also represent - though in very different ways - deliberate, planned attempts to set up demonstration models of mental health care, differing more or less radically from more conven- tional types of service in the Federal Republic and in Sweden, respectively. The Mannheim services have been heavily influenced by the recommendations and guidelines issued by the Commission of Enquiry, whereas the Nacka Project is basically experimental. The development of services in lrningrad, by way of contrast, does not seem to have been stimulated or guided by any corresponding dissatisfaction with the existing provision of mental health care in the Soviet Union. The services are not regarded as experimental, or as constituting a radical departure from the conventional system, but rather as a logical development and ex' tension of the type of service provided in all large cities. The pace of develop- ment, and the extent to which various specialized agencies have been suc' cessfully integrated into the overall mental health care system, will obviously vary from one city to another according to financial resources and to the energy with which the goals are pursued, but the underlying philosophy is not thought to be different. Finally, it is apparent that individual services must adapt themselves to meet the requirements of existing local and national situations. Whereas, for example, the ratios of psychiatric beds to population in Trieste and in Stockholm at the beginning of the present decade were both over 4 per 1000, Mannheim, with a ratio under the Federal Republic average of 1.8 per 1000, was suffering from a serious shortage of beds for the mentally ill. The build-up of community services in Mannheim has therefore had to be accompanied, not by a reduction, but by an increase in the total number of psychiatric beds - although, as has been noted, the number of beds in the area mental hospital has fallen steadily. Similar discrepancies between the general levels of provision of care in different service areas could be documented in relation to the ratio of com- pulsory to voluntary hospital admissions, the numbers and ratios of trained professional staff, the extent of medical insurance coverage for the mentally ill, the part played in treatment and care of the mentally ill by private agen- cies, etc. Public willingness to tolerate the presence of mentally disturbed persons in the community may also vary greatly from place to place. The success of a new, innovative service must be judged, therefore, not by any absolute standards, but rather by the measure of improvement achieved over the existing facilities in that area. All the services under review appear to be moving towards the common goal of comprehensive community mental health care. For the reasons out' lined above, it is not yet posible to say which of them offer the best prospect 25 or which, in terms of cost-benefit analysis, would prove to be the best buy. All are in some respects atypical, and none provide a blueprint for change which could be adapted for widespread use. At this stage, it may be more useful to reconsider some of the initial conclusions which members of the different service teams have reached as a result of their experience of what must be in large part a process of advance through trial and error. The report from Trieste underlines what is already known from ex' perience in some other areas, namely, that the run-down of a large mental hospital, though largely advantageous, may result in an increasingly stagtant, custodial environment for the residue of chronic patients who cannot be dis- charged because they are too severely disabled and there is nowhere else for them to go. This risk will obviously be greatest when admissions cease al- together so that the hospital becomes virtually a closed system. The running- down proces strould, therefore, be planned carefully so as to proceed in phase with a build-up of alternative services in the community. Moreover, the needs of the group of new long-stay patients, who will continue to ac- cumulate whatever forms of psychiatric care are provided, must be clearly foreseen and allowed for in planning future services. A closely related problem is that of staff morale and the redeployment of trained professionals to meet changing service needs. The run-down of a men- tal hospital may lead to demoralization of nuning and other trained staff, whose lives and careers are closely bound upwith its future. Moreover,there is an ever-present danger that transfer of mentally ill persons from institu' tions to the community may in some instances mean transfer from trained profesional care to untrained care or to no care at all (7). It is therefore essential that, in any process of transition from hospital to community-based care, the active support and cooperation ofnursing and other professional staff should be gained and the potential contribution of such personnel to the new, developing services should be maximized through careful redeployment. If the introduction of new service facilities does not represent an organic part of the development of area services, but is sponsored by a university department, research foundation or other quasi-independent body, there is a risk that two standards of mental health care will be created, and that in the long term this trend will be deleterious for those patients who are wholly dependent upon the public service. The service teams in Mannheim and Nacka have both shown clear awareness of this problem and have pointed to dis- parities in age, diagrrostic and social class distribution between the patient- clienteles of the new services and those cared for by the existing, traditional services. The participation of university clinics and departments of psychiatry in community mental health care is of the greatest importance for progress in this field. It can be most succesfully achieved where responsibility is accepted for the mental health care of a sector population, including services for the chronically ill and handicapped. Clearly, this kind of integration will hardly 26 be possible if a gross disparity exists between the per capita costs of pa- tient care in the university-based as compared with the public services. Such a development also logically implies los of the privilege to select for care those patients considered suitable and to transfer those con- sidered unsuitable to other services. University departments, however, must continue to meet their teaching and research commitments in addi- tion to any area service responsibilities. In practice, therefore, an effec- tive system of priorities must be worked out and some degree of compro- mise will be necessary. The Nacka Project poses most exptcitly a question which, however, also arises in connexion with the other services: namely, as mental health care faci.lities are made more readily accessible to the general public - in particular by means of self-referral and telephone referral - how is the level of demand to be contained within manageable limits? Further, how can one ensure that demands for help or advice from the more articulate, better informed and better educated groups do not gain undue priority over the needs of those who, though perhaps more severely ill and handi- capped, make fewer demands or appeals for help? Easy, relatively infor- mal access is an important condition for the functioning of community mental health services and is essential in any programme of secondary pre- ventive care, but its potential dangers and disadvantages nrust be clearly recognized. A fundamental issue is the extent to which psychiatric flacil- ities should function as first<ontact, or front-line, agencies and how lar referral should be channelled through general practitioners and other pri- mary care agents. A common characteristic of many modern, population-based rnental health services, especially those in large cities, is the tendency towards in- creasing complexity and specialization. This trend is particularly well marked in the case of lrningrad, but seems bound to gain greater prominence also in the other services under review. The positive aspect of this trend is that the special needs of more and more subgroups with mental disor<ters -- maladjusted children and adolescents, alcoholics, narcotic addicts, the men- tally retarded, elderly patients, etc. - can be met within the boundaries of a service area, thus reducing the numbers of persons who must be seg- regated in distant institutions. The negative aspect resides in a danger that such highly specialized services may become too big and unwieldy to func- tion as an integrated whole, and that mental health care may become in- creasingly fragmented. Under such conditions a family-oriented approach to mental health care becomes especially difficult to achieve or to main- tain. Organizational complexity also tends to encourage the growth of an administrative hierarchy, whose leaders may be remote from the daily prob- lems of treatment and care. The issue of specialization versus integration can perhaps be seen most clearly in relation to the organization of care for certain subgoups, discussed in the following section. 27 4. CHANGING PAMERNS OF CARE FOR SUBGROI.JPS AND SPECIAL PROBLEMS It has been postulated as a fundamental principle of health care provision that planning should be based on the needs of the people for whom the services are planned, rather than on the organization of institutions. The provision of suitable care for all mentally ill and mentally handicapped persons in an area population inevitably requires sound differentiation of services - €.8., for old people, for children and adolescents, for alcoholics and drug ad- dicts, etc. - ffid, moreover, these specialized services may need to have working links with other parts of the health care system at least as strong as those they have with the rest of the mental health services. To take an obvious example, child psychiatric services may be more closely linked with paediatric and child health services than with local agencies for adult psychiatric care. Thus, a sustained effort is needed to ensure that the mental health services as a whole do not become fragmented as they develop more speciatzed and differentiated treatment facilities. In this section, the provision of specialized services within a system of comprehensive community mental health care will be discused and illustrated in relation to a number of special problems of care which fall within, or on the margins of, the field of responsibility and competence of the mental health services. 4.1 Long-term care and rehabilitation of the chronic mentally disabled It is increasingly common to differentiate between old long-stay patients, who are the traditional residents of the mental hospitals, and new long- stay patients, who have been admitted within the past few years but who, despite all available modern methods of treatment and rehabilitation, be- come institutionalized and cannot be discharged. The distinction is use- ful in differentiating between a very large patient group which accumu- lated under custodial care and a relatively small group which still tends to accumulate in even the best+quipped and most progressive mental hos- pitals. Its usefulness is, however, limited by the fact that mental hospitals in some countries (including some which are still largely custodial in func- tion) have in recent years implemented a policy of discharging large num- bers of cfuonically disabled and elderly infirm patients to nursing homes, old people's homes and other nonpsychiatric institutions, as part of the growing tendency to separate the mental hospital's two traditional main functions: medical treatment and custodial care. This policy was original- ly intended to form part of the move towards corununity mental health care, but there is growing doubt whether in practice the results have always fulfilled this intention. 28 4.1 .l changing potterns of supportive core for the chronic mentally ill Baden-Wirttemberga Weinsberg psychiatric hospital, in Baden-Wiirttemberg, provides services to a largely rural population of almost I rnillion. Since 1969 it has pursued an active treatment, rehabilitation and discharge policy. From 1969 to 1975 admissions doubled, the rate of discharge to residential care trebled (from 100 to 250 per annunr) and the number ol hospital beds lell fronr a peak o1935 in 1970 to 660 in 1975 (i.e., from 1.0 to 0.7 per 1000 population). To evaluate the policy of discharge to residential care a follow-up study of rlischarged patients was carried out. The preliminary findings may be surn- nrarized as follows. By the end of 1915,1 l4l patients had been discharged to supportive residential care. Of these,220 were found to have died and 657 to be still in 7l residential institutions. Of the latter group. 38a/a were 65 years old or over. ln 31% ol cases the discharge diagnosis was schizophrenia , in 19% psychogeriatric or organic mental disorder, and in l0% nrental retardation. Ol the residential group, only one-quarter were in hospital-al'tiliated institutions (halfway houses, etc.), the retnainder were itt nursing honres lor thc agcd, dcspite the lact that 5Uit were under 65 years old. In nrost ol' these honles the ex-psychiatric patients forrned a rninority. Investigation of a stratilled subsanrple showed that the nursing hclme group actually had more severe pqychiatric synrptonx than those in the hospital after-care hostels' A group ol 177 was found to be mute or allttost mute. -The nursing hontcs were judged, using the criteria olWing & Brown (8), to provide a less satisfactory milieu and poorer facilities for after- care and rehabilitation than the hospital aftercare hostels. ln general, they were found to reproduce the well-known negative characteristics ol old-style custodial mental hospitals, though on a smaller scale. 4.1 .2 Problems of discharge policy There are now probably as many mentally disabled persons in non- hospital institutions as in psychiatric hospitals. There is no objection in principle to a division of this kind, provided the caring, supportive and re- habilitative functions of the mental hospital are adequately taken over by a Based on information provided by Dr H. Kurue 29 the other institutions and both are integrated into a comprehensive mental health care system. However, in the Federal Republic, as in some other coun' tries, it is to be feared that many of the chronic mentally disabled are being transferred to facilities on the "offside" of the reform facilities. Whereas treatment-oriented services profit from the high prestige of specialist medicine, the supportive care agencies, because of their low prestige, tend to lag further and further behind. A number ofcontributory factors can be discerned. (a) In strarp contrast to the size of the chronic sector, there are few data available from the responsible administrations. No commercial enterprise could survive with such poor book-keeping. (D) There is no effective planning for supportive services oriented to meet the differentiated needs of an area population. (c) For hospitals there is an effective public financing and auditing of investments, but for supportive institutions there is no equivalent public financing and no comparably effective control. (d) In most nonhospital institutions, the per diem costing does not allow for sociotherapeutic staff. (e) Treatment in hospital is covered by health insurance, supportive care by social welfare. Social insurance funds do not cover costs of rehabilitation to prevent invalidity in mental illness (with the exception of alcoholism). The result is that traditional custodial care is now being provided in an unknown number of nonhospital institutions instead of in a smaller number of mental hospitals under psychiatric responsibility. 4.1 .3 A boardingout scheme for discharyed chrunb mental patients: Belgiuma An example of a different approach to the problem of supportive care is provided by the boardingout scheme at St Josef Hospital, Kortenberg, Bel' gium, which takes advantage of the centuries-old tradition of foster-family care for the mentally ill in Geel. Until 1968 it was exceptional for the facilities offered in Geel to be used for discharging chronic patients from the mental hospital. In that year, how- ever, transfer to the community in Geel was introduced as a regular procedure. Resistance to the new scheme had to be met from 3 sides: nursing personnel, patients and relatives. This resistance gradually weakened and in the period 1968-74 a total of 64 patients was placed in foster-family care in Geel. The 30 d Based on information provided by Professor R.A. Pierloot main diagnostic categories represented were chronic schizophrenia and mental retardation. Nearly half the patients concerned had been in the mental hos- pital continuously for over l0 years, one-third had no contacts with rela- tives, while the remainder had contact with distant relatives only or could not retum to their families. In a follow-up study carried out in 1975, 52 of the discharged patients were found to be still in foster-family care in Geel and 4 had been taken back by their own families. Only 6 patients had been readmitted to psychiatric wards, and I had committed suicide. Of the 52 patients remaining in Geel, 49 were considered to be well integrated in their foster homes. While the clinical condition of most of this latter group remained almost unchanged, their social functioning appeared to have improved. Most were able to take part in family activities and to carry out useful work. A minority remained inactive and isolated. The differentiation between schizophrenia and mentally retarded subgroups did not seem to have any strong bearing on the social outcome. 4.2 New trends in the provision of mental health care for young people Zuicha Over the past two decades, new forms of counselling and treatment for young people have been set up in most highly industrialized countries in order to meet a growing demand for help from a section of the popula- tion which remains largely outside the ambit of more conventional mental health services. The main factor contributing to this development has been the growth of adolescent subcultures with their own value systems, needs, and loyalties, in large measure rejecting the help of established psychiatric or social welfare agencies. This rejection stems in part from the fact that most of the existing agencies have concentrated on the needs of adults, or altematively of children, and that the special problems of the adolescent have been too little recogrized or understood. It must, however, also be partly ascribed to the particular structure and organization of most estab- lished services. Developments in youth advisory services in I I European countries were reported by Robert et al. in a study undertaken for the WHO Regional Of- fice for Europe (9), and their objectives were then discussed by a working group (10). The newly created facilities - advisory centres, hostels, clinics, etc. - are characterized by new forms of organization and work style, de- liberately geared to the needs and attitudes of young persons. In particular, they are typified by informal modes of access, based largely on self-referral, and as a result are confronted by a wide range of unselected problems, a Based on information supplied by hofessor A. Uchtenhagen. 3l extending from the "normal" difficulties of adjustment of healthy young people to the most severe forms of mental disorder, drug dependence, chronic malidjustment and delinquency. Other prominent features are an absence of systematic diagrostic and clinical assessment procedures, a willingness to experiment with new therapeutic techniques, a tendency towards blurring of professional roles among the staff, and a preference for unbureaucratic, non' hierarchical forms of organization, as well as for therapeutic goals based on psychosocial rather than biological concepts. With increasing experience, the disadvantages of this kind of nonhier' archical, partly nonprofessional, teamwork have also become apparent. There may be a tendency towards over-identification with the clients and their wishes; an insufficiently critical or selfcritical habit of seeking scape- goats and of blaming the authorities for all personal problems; a form of elitist attitude based on shared ideology and membership of an "insider" group. In some instances, these tendencies have resulted in more or less chronic conflicts with the local authorities who are responsible for medical, educational and social welfare and employment services - a situation which inevitably reduces the usefulness and efficiency ofthe youth advisory centres to a serious extent. The outstanding organizational problem with which youth counsel' ling services are everywhere confronted is that of coordination with various other kinds of service dealing with young persons, including educational, social, medical and employment agencies. This has led at times to a state of virtual segregation, or self-isolation, of the counselling centres, with consequent limitation of their effectiveness - and even to closure. The problem of coordination is most conspicuous in relation to community mental health services, since close cooperation and liaison with such ser- vices is essential if the counselling centres are to offer effective care, or even a useful screening system, for psychotic, alcoholic, drug-dependent and maladjusted young persons - to say nothing of those who are at high risk of such conditions. Where youth counselling and treatment services have been successfully integrated with the local mental health services, they have proved a most important and valuable adjunct. In Zurich, a "drop-in" advisory centre for young people forms part of the city's social psychiatric service network, co- orainitia by the Department of social Psychiatry of Zurich University (see Fig. 3). The growing importance of the centre within this broader context is illustrated by Figs 4 and 5, which show the numbers of clients and patients dealt with by various branches of the services in successive years, from l97l to 1977.It can be seen that the centre, since its establishment in 1973, has reported the largest number of contacts of any. ln 1977 , the total number of clients seen was 827 and the total number of consultations 8462. Fig. 6 illustrates the coordination and functional relationships of the different youth counselling and treatment services. 32 Fig. 3. Psychiatric services, Zurich UniveEity psychiatric clinic 450 Department of Social Psychiatry C li n ical Deparlment Depanment of Research Outpatient clinic N Outpatient clinic S 188 Night hospital I Night hospital ll 11 Day hospital 30 25 Day centre 12 I Gerontopsy ch iatric consullation service Gerontopsychiatric hospital 162 24 t5 placemenl service Patients'households 1 1 R tation centre "Drop in" advi$ry centre drug addicls Docu mentation, regarch, teach ing Privale assciation lor the advancement o, social psychiatry city + 400000 population region + 540O0O population ZURICH 33 900 800 700 600 500 400 300 200 100 80 70 60 50 40 30 20 10 0 Fig. 4. Total numbers of psycfriatric patients, Zurich, 1971-77 $- 2+3l0 ----.----_------ 9 '---' 6 4+5 1971 1972 1973 1974 1975 Outpatient clinics Night hospitals Day hospital Day centre "Drop-in" advisory centre Gerontopsychiatric consu ltation service Psychiatric family placement service t 7. 1976 1977 2+3 - 4+5 - $- J oooot 8-- 9 ---- 10.-- 34 Fig. 5. Total number of consultations/treatment days, Zurich, 1971-77 900m 80 000 70 000 60 000 11000 10 000 I 000 I 000 7 000 6 000 5 000 40m 3 000 2 000 1 000 0 --------- -t--Jo--J- i1 .t' //n:' 8/ 4+5 b 2+3 7 1971 1972 1973 1974 1975 1976 1977 Outpatient clinics Night hospitals Day hospital Day centre "Drop-in" advisory centre Psychiatric family placement service 2+3 4+5 6 7 8 11 - 35 Fig. 6. Youth counselling and treatment services, Zurich -----l c .9 Eoq l0 -----1 I ___J tr o ,F .s! o:E C = Parole officers, fprobation officers,! social seruice I for offenders I Departmerit of Justic{ I Prison after-care system Citv ad minislration youth offlce Youth advisory centre Association for youth help in Horgen asaspvar': - youth groups Therapeutic g9IIumJ University psychiatric clinic Outpatient clinicsWorking group foryouth problems c€nt rel I SPD Private rehabi I itation centre for drug addicts Private rehabilitation centre for addict{ advisory centre WorkstloOs Association for I sheltered work i Blue Crcas counselling frvicefor alcohdics"Work-fut"groups Advisory c€ntres _ t_.___Psychratnsts and psychologists in private practice University psychiatric clinic for children and adolescenB Street workersl I 36 I Experience in Zurich indicates that such services should try to fulfil the following criteria: - coordination and cooperation with a wide range of professional agencies; - flexibility in meeting new demands and situations, including, when necessary, some modification in professional roles of the team members; - maintenance of an appropriate balance between preventive work (counselling, fostering of self-help and independence) and therapeutic work (short- and long-term treatment, individual specialized psycho- therapy, and pharmacotherapy) ; - acceptance of defined limits of competence and of the necessity for external supervision; - periodic reassessment (through follow-up, dropout rates, etc.); - emphasis on increasing the social competence of the client as a pri- mary goal of therapy. 4.3 Development of crisis intervention and psychiatric emergency servicesa Current European interest in crisis intervention services can be traced back at least to the pre-war work of Querido in Amsterdam (12),but its more recent catalyst appears to have been the development of "crisis theory" in the United States, largely as a result of psychiatric experience in new com- munity mental health centres in that country. The development of services in Europe with a specific commitment to crisis intervention and emergency psychiatry took place some years later than in the United States. An important factor in the European trend has been the rising public demand for urgent help at times of emotional distress and personal crisis, best illustrated by the rapid increase in self-poisoning and attempted suicide rates. This dramatic rise has resulted in a search for forms of action other than those offered by conventional psychiatric and social services, even in countries already well endo'ved with community agencies of one kind and another. Contemporary crisis intervention and psychiatric emergency services appear to represent one of the main professional responses to this demand. In most countries there have also been developments such as "walk-in" clinics and "drop-in" centres for young people (cf.4.2), district social service offices, and voluntary assistance agencies such as the Telephone a Incorporating information compiled by Professor J.E. Cooper (11). 37 Samaritans (cf . a.a\. Presumably all these facilities can be taken as indications of an increasing expectation in urban communities that help will be available, on demand, for personal distress as well as for illness. These expectations and demands seem to be on the increase in spite of improved standards of hving and of physical health for the majority, and greatly advanced medical technolory. The paradox constitutes one of the most important sociomedical problems of contemporary industrial society, and as such is worthy of investigation. In a study of crisis intervention and psychiatric emergency services in 15 European centres undertaken for the Regional Office for Europe (/1), Professor Cooper found a characteristic pattern of activity which appeared to distinguish the specialized "crisis unit", whether operating independently or as part of comprehensive mental health services. The following com- ponents were defined. (a) Frequent meetings of the multidisciplinary staff team: usually two a day, plus additional contacts between team members or subteams. (D) Frequent interviews and contacts of individual team members with patients, their families, and outside agencies between the team meetings. Here again, contacts are often daily or even more frequent. (c) Rapid decision-making on the basis of easily accessible information about the current situation. Case records tend to be correspondingly brief, in contrast to the detailed anamnesis, extensive case notes and systematic diagnostic assessment practised in psychiatric clinics. (d) Clinical responsibility is usually shared and conventional profes' sional roles become blurred and overlap. (e) A rapid tumover of patients with a correspondingly short period of involvement and follow-up. The initial intensive care lasts as a rule only a few days and is followed by less frequent contacts spread over the next few weeks. Though all these features are found singly in other psychiatric and social work settings, they tend to be clustered together in the type of services described here, and can fairly be regarded as constituting contemporary "crisis practice". A question of some importance in this context concems the relationship of crisis intervention services to local medical, psychiatric and social agencies and, in particular, their position within sectorized or community mental health services. From the available evidence, no simple answer can be given to this question. Some crisis intervention services have been developed as part of 38 an overall plan lor community mental health care and form an integral component of the area services; others have been set up by voluntary or- ganizations, or represent joint ventures by municipal authorities, churches, and other interested bodies. It is also noteworthy that a high proportion of existing centres have been developed as part of university psychiatric departments, some, but by no means all, of which-have well-defined clinical and service responsibilities for area populations. The extent to wtuch the tunitrrins ano type ot clientele of crisis inter- vention services place thenr firmly within the lield of specialist mental health care varies greatly from one centre to another. Their style of operation -in particular, acceptance of self-referred clients ("walk-in" or "drop-in" consultations, telephone consultations, etc.) means not only that some centres function to a large extent as tiont-line services in the primary care field, but also that a high proportion of their clients cannot and should not be classified as psychiatric cases, or indeed as having psychiatric problems in the accepted sense. It is perhaps significant that the demand for this type of service appears to be greatest in areas where the primary health care ser- vices are relatively poorly developed and general medical practice is rela- tively undervalued. That crisis intervention services can, nevertheless, lorm an integral part of community rnental health care is demonstrated by those centres which have been created as part of a diflerentiated care system in the way that the "drop-in" advisory centre lor young people in Zurich lorms part of the overall social psychiatric services ol that city (c1.4.2). In Helsinki. for example, the "walk-in" outpatient clinic ol the Hesperia psychiatric hos- pital is linked very closcly to the rest of the psychiatric services, including an intensive care ward, which can deal with all but the rnost seriously ill self-poisoning cases. Much eflort has gone into the organiz.ation of psy- chiatric emergency services in Helsinki, stinrulated by the fact that the city's suicide rate is among the highest in the world. The "walk-in" clinic is open to all comers, day and night. Patients may refer thentselves direct and unan- nounced, or may come by arrangement from health centres (primary care centres), the general hospital or the "SOS" suicide prevention centre. No exact statistics ol the reasons for referral, or of the diagnoses made, are available; it is, however, estimated that only about half the cases are re- garded as psychiatric in the usual sense and that only about one-fifth are subsequently admitted to psychiatric inpatient care. The remainder are given outpatient appointments, at the Hesperia hospital if urgent or at the psychiatric outpatient department of the municipal general hospital if less urgent. In addition, the "walk-in" clinic receives as many as 100 telephone calls daily from potential patients, or from former patients and their rela- tives. The overall picture is one of a very active all-purpose outpatient de- partment, with special emphasis on crisis intervention and emergency work, within the framework of urban psychiatric services. 39 In Groningen a psychiatric emergency unit with I I beds has been operated by the University Department of Psychiatry on the premises of the university general hospital since 197 l.It was set up with the aim of providing a more rapid system of clinical assessment for emergency refenals than was avail- able in the other sections of the Department or in the provincial mental hospital. Although there is no fixed rule, it has always been intended that inpatient care should last only a few days - preferably not more than 3 or 4. In addition, the unit aims at lowering the threshold for referrals from all kinds of firstJine workers, including lay people, social workers, the police, etc., and in doing so to offer them some relief in the management of crises involving persons whom they are helping or supporting, somedmes over pro- longed periods of time. Because of its central position, the unit tries to facil- itate collaboration and referral betweeen the various parts of the overall community services. The unit handles about 500 admissions annually, the single most corrrmon type of case comprising patients who have attempted suicide and are referred from outpatient clinics or from local general practi- tioners. Mean duration of stay has fallen steadily over the yean, and is now from 3 to 4 days, only 20% of patients remaining as long as I week. About 6Vo of patients are discharged home and about 25% arc transferred to other psychiatric facilities. Requests for admission come from many sources, in' cluding patients themselves and their relatives. In Mannheim the psychiatric emergency services are based on the Central Institute for Mental Health and form an integral part of the total care it provides. Fig. 7 shows how closely the services are interwoven with the cor- responding inpatient and outpatient facilities for the less acute forms of psy- chiatric disorder. A 24-hour emergency service is provided by the general practitioners of the city. In cases of acute illness or crisis a house visit is made. The patient will then, if necessary, be referred to the emergency unit of the city general hospital or, if a psychiatric emergency is diagnosed, direct to the emergency service of the Institute. As many forms of emergency brought to the general hospital - g.8., suicide attempts, acute alcoholic states, etc. - also require psychiatric assessment and management, a 24-hour psychiatric consultative service is provided by the Institute to the general hospital. This service dealt with 758 episodes n 1976 and with 712 n 1977. Two psychiatrists are on duty in the Institute at night and at weekends to deal with acute emergencies and crises. In addition,large numbers of acute cases are dealt with in the outpatient clinics of the Institute during normal consulting hours. These clinics are organized on a teamwork basis and have a staff of psychiatrists, psychologists, social worken and nurses. If short'stay inpatient care is required, emergency cases can be admitted to the intensive care unit of the Institute. [n contrast to some crisis intervention centres which exercise a higNy selective policy, the intensive care unit is equipped to take patients who are also physically ill, and the bed occupancy ratio is 40 Fig. 7. Organization of psychiatric emergencY services in Mannheim l 24 hour prad it roners e mergen cy Servrce Illllir----lir----.llntr---l Psychialrists in praclice [4annheim general hosprtal E nrergency unit with psych iatric service Outpatient det)artment with ice Approxr 180O beds ' t/ srvice With focus on crisis intervention lnpalient and day hospital wards I 06 beds 20 places Central lnstitute for Mental Health prevention/drug and alcohol dependene; other advisrv srviGs; mutual marriage elf Social srvtes, ,amily depanrcnt, elc. Community psych ratr y depanment Mixed 24 beds Mixed wards 24 beds E mergency ward 1 0 beds Psychog€riatilc day hospital 12 plaes General practitroners (includinq home vrsrtsi 4l tl- I I very high (h 1977, for instance, it averaged 92.8%). Short-stay inpatient care for less acute forms of crisis can also be provided in 2 other wards of the Institute, each of which has 24 beds. Experience to date has shown that a complex system of this kind can function successfully, given a high measure of cooperation and goodwill among the participating physicians and staff. The Mannheim workers are con' vinced that their system has more to offer, under prevailing conditions in the Federal Republic, than the type of separate, autonomous crisis intervention centres advocated in some other countries - first, because the total resources of the psychiatric services as a whole can be made readily available and, secondly, because a high proportion of crises involve persons with chronic or recurring mental illness, who are already known to the psychiatric treatment teams. Mannheim thus offers an example of a type of crisis intervention service with a strongly psychiatric and medical orientation. 4.4 Voluntary organizations, self-help Sroups and rnental health carea Though to varying extents they may break down traditional professional hierarchies and role definitions, psychiatric emergency services, "walk'in" clinics and crisis intervention services nevertheless remain professional agen' cies, part of a formalized structure in which the distinction between thera- pists or care-givers, on the one hand, and patients or clients, on the other, remains clear-cut and fundamental. Yet their growth in recent years must be seen as part of a more general trend towardsprovision of help at community level, which also includes the spread and proliferation of various forms of voluntary and self-help organization. Self-help goups have recenfly received increasing attention. Several WHO publicationr have set out the philosophy, organization and achievements of altemative approaches to healfh care in developing countries, including self- help systems. Certain characteristics of self-help Sroups have been identified, including sharing of common experience;provision of mutual help and sup- port; holding of regular meetings to provide mutual aid; reinforcement of normalizing self+oncepts, collective willpower, and shared beliefs; promotion of factual information and understanding of the problem; and collective action towards destigmatization and other shared goals. In developed countries the problem confronting members of many self- help groups is that they are deviant according to the values and standards ofa society geared to narow concepts of normality, or dependent in a society which lays great importance on independence. Not surprisingly, they are fre' quently preoccupied by feelings of guilt, shame and inadequacy, and by problems of role identity, anger, aggression, and isolation from their fellows. 42 d Based on information provided by Dr P. Mason Self-help goups are difficult to classify since they have varied aims, activities and forms of organization. Different $oups of people establish dilferent degrees of self-help activity. Where groups are able to provide an alternative service or fill a gap in public provision of care, resources for self- help may come entirely from the menrbers or may depend in part on outside sources. The significance of self-help groups for mental health services arises in the first place from the nature of the groups concerned. They have been classified broadly into those concerned with the problems ol the mentally ill or lormer psychiatric patients (e.g., National Schizophrenia Fellowship, "Lift"); those concerned with psychosocial problems and crises of various kinds (e.g., Alcoholics Anonymous, Telephone Samaritans); those concerned with the relatives and dependants ol'mentally disturbed persons (e.g., "Ala- teen" for the children of alcoholics, Relatives of the Depressed): those dealing with problems of the sexually deviant (Campaign lor Homosexual Equality, Transexual Action Organization);and those for persons witl health or social problems which must be considered risk factors for nrental disorder (one-parent families, single homeless persons, the widowed, people with chronic neurological disease, etc.). It is thus evident that the functions of at least some self-help groups overlap quite extensively with those of professional mental health agencies, and that others are engaged in activities which call for liaison on a more or less systematic and continuing basis with such agencies. Time did not permit detailed discussion ol the various special types ol self-help group, or the problems of coordination and communication between such groups and the prolessional agcncies responsible lor primary health care, hospital services, social serviccs and specialist mental health services. The Group considered that sell-help is misperceived if it is seen as a sub- stitute to cover gaps in the health and social services, and emphasized that it is a basic component of primary health care. It suggested that self-help and the groups concerned with it should form the subject of another working group within the WHO European mental health programme. 4.5 Levels of mental health care The services reviewed in section 4 make up a heterogeneous mixture. It is not easy to see how each fits into the overall picture of community mental health care, or to decide what order of priority each should be accorded in a situation where money and manpower must continue to be strictly rationed. All the services are of significance for mental health care in the broad sense, but this does not necessarily mean that psychiatric resources should be directed to them. The problem is often conceptualized as one of defining the boundaries of psychiatric or mental health specialist care. This standpoint is realistic, insofar as the tasks and responsibilities of psychiatrists and other 43 specialists must be defined and delimited. Further examination, however, reveals that the problem is actually more complicated, since a number of levels of specialization can be differentiated, as follows: - professional specialists (psychiatrists, clinical psychologists, psychiatric social workers, psychiatric nurses, etc.); - professional generalists (general practitioners, nonpsychiatric phy- sicians, social workers, counsellors, etc.); - nonprofessional and voluntary workers; - self-help groups. To some extent, these levels correspond to the severity of psychiatric dis- turbance which can be dealt with by each group; thus, at one extreme, acutely psychotic or behaviourally disordered persons require the care ofpsychiatric teams, while at the other end of the scale many persons who are at increased risk of mental illness, without being ill, can be helped by voluntary and self- help agencies. According to this simple, hierarchical model, the therapeutic and caring activities of the psychiatric team are restricted to the first (special- ist) level, but this does not preclude consultative work conducted at the other levels. Facilities such as youth advisory services, crisis intervention centres, Telephone Samaritans, etc., which offer front-line care to persons who are in various forms of distress or crisis, do not constitute an integral part of the mental health services, but overlap with them to some extent in function, and there is a great need for liaison and collaboration among them. An example is provided by the supervisory and coordinating functions of the Department of Social Psychiatry of Zurich University (cf. Figs 3- 5), which provides psychiatric cover for a wide range of social and voluntary agencies, including: - working group for youth problems (therapeutic communities, "sleep- in" centres); - association for sheltered work (workshops, patient "workout" groups) ; - association for youth help ("Samovar" youth groups); - city administration youth office (youth advisory centres); - Blue Cross counselling service for alcoholics; - Department of Justice (parole officers, probation officers, social ser- vice for offenders, prison after-care system); - private rehabilitation centre for addicts: - psychiatrists and psychologists in private practice. 44 It seems clear that psychiatrists and psychologists working in community mental health services will be called upon to undertake some consultative duties in addition to their clinical work with patients, and it may be as well that this fact should be recognized in their contracts and terms of work. What proportion of their working time should be devoted to consultative work must depend upon the local situation, especially since there are as yet no general guidelines on this subject. Any sharp division between preventive and clinical work, however, would be to the detriment of both. It is therefore un- desirable that such work in the community should be relegated to a sub- group of psychiatrists and other professional workers who would not be per- mitted to undertake clinical care of patients. 5. CONCLUSIONS AND RECOMMENDATIONS 5.1 Conclusions The Group noted with much interest the experimental services which were reported, based on new patterns for the organization of mental health care in the community. In the services, which are broadly in line with the recommendations of earlier working groups, favourable results are being obtained by taking special account of the social aspects of mental illness. Such experiments should be developed and pursued in all countries, but there is an urgent need for more systematic monitoring of their results and for scientific evaluation of a number of different experimental strategies. The Regional Office can play a vital role in promoting such research and in pub- licizing the results as well as national changes in service structure and legisla- tion concerning the mentally ill. No single experimental service can serve as a blueprint for change,since local systems must be planned and designed to meet local needs and to adapt to the prevailing conditions. It is therefore important to recall the following general principles underlying the concept o[ comprehensive community mental health care, since these also constitute the essential criteria by which the success ofindividual services can bejudged. - The services should be community-based, i.e., they strould provide facilities for a defined area population small enough to permit most patients to be treated within easy travelling distance of their homes. - The services should be comprehensive, in the sense that they provide a range of facilities, differentiated to meet the needs of persons suffer- ing from any form of mental illness or handicap to be found in the 45 area population. Specialized forms of care which must be provided on a regional basis should be linked to the community-based services. - The various agencies and services engaged in mental health care for each area population should be so effectively coordinated that each part of the system can contribute to the care of individual patients, according to need, and that patients or their families do not suffer any disadvantage as a result of being transferred from one part of the sys- tem to another. This point applies equally to care given by medical and social agencies and nonmedical residential care. - Services of equal quality and standard should be available to all per- sons in the service population who stand in need of mental health care, irrespective of financial or other considerations. In quality and availability, care for the mentally ill and mentally handicapped should be of a standard not lower than that provided for the physically ill. By applying these broad principles, it should be possible to monitor and evaluate the changes made in individual services, and to compare the merits and disadvantages of innovations made in different areas. The working papers presented during the meeting, together with the dis- cussion arising from them, made it clear that mental health care in many parts of the Region is in a state of transition and pointed to certain fairly specific, practical measures which could be applied more widely in order to initiate or accelerate progress from traditional custodial care towards comprehensive community mental health care. In this situation, the Group considered it a matter for geat regret that in some countries large new mental hospitals are still under construction, was of the opinion that no more such institutions should be built, and urged that in future new inpatient units strould be situ' ated in, or closely linked with, general hospitals. 5.2 Recommendations 1. The running down of existing mental hospitals should be phased so as to overlap with the building up of alternative, community'based ser- vices. In no case should chronically ill or handicapped patients be discharged from hospital until or unless adequate supporting services are provided in the community. 2. Facilities for after-care and rehabilitation strould be developed for each service population, within the service area. Joint funding or subsidy schemes should permit costs of continuing mental health care to be met outside the hospital system, whether in residential homes, hostels, sheltered workshops, or other nonmedical facilities. 46 3. Firm guidelines should be established in each country and region for the allocation of specialist manpower and working time to activities not directly connected with clinical care of patients, particularly consultative counselling and preventive work. Duties of this kind should, where ap- propriate, be specified in the contracts of mental health services. 4. Domiciliary visiting by psychiatrists and other members of the men- tal health team should be made possible, as an accepted part of the duties and responsibilities, in relation especially to pre-admission screening and to after-care following hospital discharge. 5. In the planning of menta.l health services, a clear distinction should be drawn between primary and secondary levels of care. The contribution of medical practitioners, social worken and other professionals to primary care of the mentally ill should, wherever possible, be supported and rein- forced by the formation of effective working links with area psychiatric services, as well as by the provision of opportunities for continuing educa- tion in mental health care for all the professional groups. 6. A simple type of basic documentation should be developed in each area, with careful regard for the confidentiality of personal data, so as to per- mit monitoring of the activities and utilization of different parts of the service and reliable computing of basic statistics on patient care in all parts of the system, e.g., for inpatients, day patients, outpatients, prevention, rehabilitation and after-care. REFERENCES l. May, A.R. Mental health services in Europe. Geneva, World Health Organization, 1976 (Offset Publication, No. 23). 2. Comprehensive psychiatic services and the community: report on a Conference. Copenhagen, WHO Regional Office for Europe, 1913 (EURO s414r). 3. Psychiatry and primary medical care: report on a llorking Group. Copenhagen, WHO Regional Office for Europe, 1973 (EURO 5427 l). 4. Constraints in mental health services development: report on a llorking Group. Copenhagen, WHO Regional Office for Europe, 1978 (ICP/ MNH o30 rr). 5. The future of mental hospitals: report on a Working Group. Copenhagen, WHO Regional Office for Europe, 1978 (ICP/MNH 019 II). 47 6. Bericht iiber die Lage der Psychiatie in der Bundesrepublik Deutschland. Zur psy chiatischen und psy cho therapeutischf psychosomattschen Versor- gung der Bev1lkerung. Untenichtung durch die Bundesregierung. Bonn, Deutscher Bundestag, 1975 (Dr. 7l42OO). 7. Titmuss, RJII. Community care - fact or fiction. 1n.' Freeman, H. & Famdale, J., ed. Tiends in the mental health services. Oxford, Pergamon Press,1963. 8. Wing, J.K. & Brown, G.W .Institutionalism and schizophrenio. Cantbridge University Press, 1970. 9. Robert, C.-N. et al. Patterns of youth advtsory services: report on a Study. Copenhagen, WHO Regional Office for Europe, 1977 (ICPII'INH 0r6III). lO. Objectives of youth advisory services: rcport on a Working Group' Copen' hagen, WHO Regional Office for Europe, 1978 (ICP/MNH 035 III). I l. Cooper, J.E. Chsls admission units and emergency psychiatic services. Copenhagen, WHO Regional Office for Europe, 1979 (Public Heahh in Eurupe,No. l1). 12. Querido, A-lll. The shaping of community mental health care. Bnfishjournal of psychiatry, ll4:293 (1968). 48 Annex LIST OF PARTICIPANTS Temporary Advisers Dr M.A. Bakiri, Director, University Psychiatric Sector of Oran-Sidi Chami, Sidi Chami Hospital, Oran, Algeria Dr F. Basagfia, Director, Andrea di Sergio Galatti Provincial Psychiatric Hospital, Trieste, Italy Dr D.H. Bennett, Consultant Psychiatrist,The Maudsley Hospital, l-ondon, United Kingdom Dr H. Bialonski, Head, Mental Health Section, Federal Ministry for Youth, Family Affairs and Health, Bonn, Federal Republic of Germany Professor B. Cooper, Central Institute for Mental Health, Mannheim, Federal Republic of Germany (Rapporteur) Dr J. Cullberg, Head of Clinic, Nacka Project, Sweden Miss A. Czuba, Ludwig-Boltzmann Institute for Social Psychiatry, Vienna, Austria Dr C. Gerich, Head, Mental Health Department (7), Division II, Federal Ministry of Health and Environmental Protection, Vienna, Austria Professor H. Hdfner, Director, Central Institute for Mental Health, Mann- heim, Federal Republic of Germany (Chairnwn) Dr A. Janik, Department of Psychiatry, Institute for Advanced Medical and Pharmaceutical Studies, Prague, Czechoslovakia Professor J. Jarosrynski, Chief, First Psychiatric Clinic, Institute of Psychiatry and Neurology, Warsaw, Poland Professor P. Jean, School of Public Health, Rennes, France Dr H. Kunze, Hesse State Welfare Board, Kassel, Federal Republic of Germany Dr M. Madianos, Department of Psychiatry, Faculty of Medicine, Uni- versity of Athens, Greece Dr P. Mason, Senior Medical Officer, Mental Health Division, Department of Health and Social Security, L,ondon, United Kingdom 49 Dr R. Misiti, Institute of Psycholory, National Research Council' Rome, Itdy Dr R. Navarro, Head, Department of Medical and HealthAction,A.I.S.N., Madrid, Spain Dr P.E. Odenbach, Federal Medical Council, Cologte, Federal Republic of Germany Mr W. Picard, Member, Bundestag, Bonn, Federal Republic of Germany Professor R.A. Pierloot, St. Jozefkliniek, I*uven, Belgium Dr R. Schwartz, Central Institute for Mental Health, Mannheim, Federal Republic of Germany Professor A. Uchtenhagen, Burgholzli University Clinic, Zurich, Swit' zerland llHO Regiorwl Office for Europe Dr A.E. Baert, Regional Officer for Mental Health (Secretary) Dr D.N. Isaev, Consultant 50 No. I No. 2 No.3 No.4 No. 5 No.6 No.7 No. 8 No.9 No. l0 No. ll No. 12 No. 13 No. 14 No. 15 PREVIOUS ISSI,'ES IN TI{E SERIES EURO REPORTS AND STUDIES Seniceoiented research in odolescent fertility: report on a WHO Meeting. 1979,37 pages, Sw.fr. 5. Sdium, chbides, and conductivity in dinking-water: report on a WHO Working Group. 1979,63 pages, Sw.fr. 7. The child and the adolescent in society: report on a WHO Con- ference. 1979,60 pages, Sw.fr. 7. Evoluation of inpatient nuning pmctice: report on a WHO Working Group. 1979,18 pages, Sw.fr. 4. The role and functions of rwtional irutitutions of ophthalmologl: report on a WHO Meeting. 1979, 17 pages, Sw.fr. 4. Continuing education of heolth penonnel as a factor in career development: report on a WHO Working Group.l979, 34 pages, Sw.fr. 5. Environmental health impact assessmenti repott on a WHO Seminar. 1979. 3l pages, Sw.fr. 5. htblic health aspects of alcohol and drug dependence: report on a WHO Conference. 1979,31pages, Sw.fr. 5. Manpower development in toxicologt: report on a WHO Con- zultation. 1979,20 pages, Sw.fr. 4. Health education: smoking, alcoholism, drugs: reiew of selected programmes for schoolchildren and parents. 1979,58 pages, Sw.fr.6. hinciples and methods of health education: report on a WHO Working Group. 1979,17 pages, Sw.fr. 4. The management of sexudly tmnsmitted diseases: a guide for the general practitioner. 1979,79 pages, Sw.fr.9. Ainical plwrmacological evaluation in drug control: report on the Seventh European Symposium. 1979,31pages, Sw.fr. 5. hinwry health care in Europe. 1979,40 pages, Sw. fr. 5. Receptivity to nwlorb and other parasttic diseases: report on a WHO Working Group. 1979, lO3 pages, Sw.fr. 10. No. 16 No. 17 No. l8 No. 19 No. 20 No. 2l No. 22 No.23 No.24 Health effects of the removal of substances occurring natumlly tn dinking-water, with special reference to demineralized and deslinated wster:report on a WHO Working Group. 1979,24 pages, Sw.fr.4. Radiologiul examirution of dinking-wateri rcport on a WHO Working Group. 1979,20 pages, Sw.fr. 4. Lo salubriti de l'environnement d(ms les zones touistiques euro- piennes : rapport sur la rdunion d'un groupe de travail. 1979, 37 pages, Sw.fr. 5 (English in preparation). Road trafJic accident stafistics: report on a WHO Ad hoc Technical Group. 1979,36 pages, Sw.fr.5. Research on simulation models for health rwnagementi report on a WHO Working Group. 1979,24 pages, Sw.fr. 4. Health aspects related to indoor air quality: report on a WHO Working Group. 1979,32 pages, Sw.fr.4. Nuning services: report on a WHO Symposium. 1979, 39 pages, Sw.fr.5. Training of senior public health administrators: report on a WHO Working Group, 1979,42 pages, Sw.fr. 5. Early detection of chronic lung disear,es report on a WHO Working Group, 1980,32 pages, Sw.fr.4. ^rdA.. - :jAr.rdi* ^u44$, ,: liliilri-,,'.,lrrEtrll G6old EELGruM Grrd., ItGkrch lll27 E^our I Tt Kurdr EoottboD. @. , -Tb A.od.tloa ,o vau&alfi lb v-d. lI Eltll*!., qhr toal L&.rtrd. S^x llil5. ErdDlN - W. B. g..rb.t. SDLtalrE 9, Fodrct lltlo, No.6l. P,O. ld ,lqlrrlr, t^r rr 'lr.tilierr+rr Ctlr KONO AdEtl&r. ElotDAD Th. 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McadrElrodnlr l(dsr. Maow G.200 adrdbf ttrlcnElc.r & V@arb C.4., AErll& 50rt5. C^l c t f05 - LltGClr &l E L, AD.rtrdo 60117. C^r^c r 16 JuratoEutr Kn ltl, Tcldlo 27lll, ll@ Eu,or'^Dr UbnH. urfEdrrhc, rvcoE d. !r P.tr No 167, E.P. 16t2. Xol,l^t I PORTUOAL SIARRA LBONB SINOAIOnA. N,BPUBLIC OF ITOUTII AFRICA SPAIN sRI I.ANKA SWEDBN SWTrZBRLAND SYRIAN ARr'E RAPUDLIC THAILAND TUNIIIIA TURXEY UNITED KINODOM UNITED STATBII OF AMERICA UlISR VBNEZUBLA YUOOSIAVIA ZAIIE SD.ct.l tcrm. lor d.yeloolno countrl.. ara obtalnrbl. on .ppllcltlon to th. WHO Proeramma Cootdlnttora;iiii{iti;io;at6frtiii iiitia ioovi or io thc Wodd Health ors.nlrrtlon, Dlrtrlbutlon rnd Salor E tvlc.,iili-GJnliiii.Sittriaana. Oiairrtromcountrteiwheroralci!g.nt.hrv.ngtyclbccnrPpolnt?dmly .l.o bo r.nt to'th. Gcn.ya addr.a., but muil b. p.ld lor ln pounda 3t.rllng' U5 dolltrr' or swl.r lranct. Prlc.: Sw. l?.4,- Prlcer are .ublact to chrnge wlthout notlcc. POLAND