Comprehensive mental health service networks: promoting person-centred and rights-based approaches

Technical package i Technical package Comprehensive mental health service networks Promoting person-centred and rights-based approaches

Comprehensive mental health service networks Promoting person-centred and rights-based approaches Technical package Comprehensive mental health service networks: promoting person-centred and rights-based approaches (Guidance and technical packages on community mental health services: promoting person-centred and rights-based approaches) ISBN 978-92-4-002584-4 (electronic version) ISBN 978-92-4-002585-1 (print version) © World Health Organization 2021 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. 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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 WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Design and layout by Genève Design. Photo credit: Cover photo: UN Photo/Martine Perret. Page 4: East Lille/ Nathalie Paulis. Page 18: Trieste/Massimo Silvano. Campinas mental health service network. The accompanying guidance document and technical packages are available here. Technical package iii Contents Foreword . . . . . . . . . . . . . .iv Acknowledgements . . . . . . . . . . . . v Executive summary . . . . . . . . . . . xiii What is the WHO QualityRights initiative? . . . . . . xix About the WHO Guidance and technical packages on community mental health services . . . . . . . . . . xx 1. Introduction ......................................................1 2. Comprehensive mental health service networks – description and analysis ................................3 2.1 East Lille community mental health service network France . . . . . . . . . . . . . . 4 2.2 Trieste community mental health service network Italy . . . . . . . . . . . . . . 18 2.3 Brazil community mental health service network a focus on Campinas. . . . . . . . . . 32 3. Moving forward: from concept to good practice comprehensive mental health service network .. 55 References . . . . . . . . . . . . . 62 iv Comprehensive mental health service networks Foreword Around the world, mental health services are striving to provide quality care and support for people with mental health conditions or psychosocial disabilities. But in many countries, people still lack access to quality services that respond to their needs and respect their rights and dignity. Even today, people are subject to wide-ranging violations and discrimination in mental health care settings, including the use of coercive practices, poor and inhuman living conditions, neglect, and in some cases, abuse. The Convention on the Rights of Persons with Disabilities (CRPD), signed in 2006, recognizes the imperative to undertake major reforms to protect and promote human rights in mental health. This is echoed in the Sustainable Development Goals (SDGs) which call for the promotion of mental health and wellbeing, with human rights at its core, and in the United Nations Political Declaration on universal health coverage. The last two decades have witnessed a growing awareness of the need to improve mental health services, however, in all countries, whether low-, medium- or high-income, the collective response has been constrained by outdated legal and policy frameworks, and lack of resources. The COVID-19 pandemic has further highlighted the inadequate and outdated nature of mental health systems and services worldwide. It has brought to light the damaging effects of institutions, lack of cohesive social networks, the isolation and marginalization of many individuals with mental health conditions, along with the insufficient and fragmented nature of community mental health services. Everywhere, countries need mental health services that reject coercive practices, that support people to make their own decisions about their treatment and care, and that promote participation and community inclusion by addressing all important areas of a person’s life – including relationships, work, family, housing and education – rather than focusing only on symptom reduction. The WHO Comprehensive Mental Health Action Plan 2020–2030 provides inspiration and a framework to help countries prioritize and operationalize a person-centred, rights-based, recovery approach in mental health. By showcasing good practice mental health services from around the world this guidance supports countries to develop and reform community-based services and responses from a human rights perspective, promoting key rights such as equality, non-discrimination, legal capacity, informed consent and community inclusion. It offers a roadmap towards ending institutionalization and involuntary hospitalization and treatment and provides specific action steps for building mental health services that respect every person’s inherent dignity. Everyone has a role to play in bringing mental health services in line with international human rights standards – policy makers, service providers, civil society, and people with lived experience of mental health conditions and psychosocial disabilities. This guidance is intended to bring urgency and clarity to policy makers around the globe and to encourage investment in community-based mental health services in alignment with international human rights standards. It provides a vision of mental health care with the highest standards of respect for human rights and gives hope for a better life to millions of people with mental health conditions and psychosocial disabilities, and their families, worldwide. Dr Ren Minghui Assistant Director-General Universal Health Coverage/Communicable and Noncommunicable Diseases World Health Organization Technical package v Acknowledgements Conceptualization and overall management Michelle Funk, Unit Head, and Natalie Drew Bold, Technical Officer; Policy, Law and Human Rights, Department of Mental Health and Substance Use, World Health Organization (WHO), Geneva, Switzerland. Strategic direction Strategic direction for the WHO documents was provided by: Keshav Desiraju, Former Health Secretary, New Delhi, India Julian Eaton, Mental Health Director, CBM Global, London, United Kingdom Sarah Kline, Co-Founder and Interim Chief Executive Officer, United for Global Mental Health, London, United Kingdom Hernan Montenegro von Mühlenbrock, PHC Coordinator, Special Programme on Primary Health Care, WHO, Geneva, Switzerland Michael Njenga, Executive Council Member, Africa Disability Forum, Chief Executive Officer, Users and Survivors of Psychiatry in Kenya, Nairobi, Kenya Simon Njuguna Kahonge, Director of Mental Health, Ministry of Health, Nairobi, Kenya Soumitra Pathare, Director, Centre for Mental Health Law and Policy, Indian Law Society, Pune, India Olga Runciman, Psychologist, Owner of Psycovery Denmark, Chair of the Danish Hearing Voices Network, Copenhagen, Denmark Benedetto Saraceno, Secretary General, Lisbon Institute Global Mental Health, CEDOC/NOVA, Medical School, Lisbon, Portugal Alberto Vásquez Encalada, President, Sociedad y Discapacidad (SODIS), Geneva, Switzerland Writing and research team Michelle Funk and Natalie Drew Bold were lead writers on the documents and oversaw a research and writing team comprising: Patrick Bracken, Independent Psychiatrist and Consultant, West Cork, Ireland; Celline Cole, Consultant, Department of Mental Health and Substance Use, WHO, Aidlingen, Germany; Julia Faure, Consultant, Policy, Law and Human Rights, Department of Mental Health and Substance Use, WHO, Le Chesnay, France; Emily McLoughlin, Consultant, Policy, Law and Human Rights, Department of Mental Health and Substance Use, WHO, Geneva, Switzerland; Maria Francesca Moro, Researcher and PhD candidate, Department of Epidemiology, Mailman School of Public Health Columbia University, New York, NY, United States of America; Cláudia Pellegrini Braga, Rio de Janeiro Public Prosecutor’s Office, Brazil. Afiya House – Massachusetts, USA: Sera Davidow, Director, Wildflower Alliance (formerly known as the Western Massachusetts Recovery Learning Community), Holyoke MA, USA Atmiyata – Gujarat, india: Jasmine Kalha, Program Manager and Research Fellow; Soumitra Pathare, Director (Centre for Mental Health Law and Policy, Indian Law Society, Pune, India). Aung Clinic – Yangon, Myanmar: Radka Antalikova, Lead Researcher, Thabyay Education Foundation, Yangon, Myanmar; Aung Min, Mental health professional and Art therapist, Second team leader, Aung Clinic Mental Health Initiative, Yangon, Myanmar; Brang Mai, Supervisor Counsellor and Evaluation Researcher (team member), Aung Clinic Mental Health Initiative, YMCA Counselling Centre, Yangon, Myanmar; Polly Dewhirst, Social Work and Human Rights Consultant/ Trainer and Researcher of Case Study Documentation, Aung Clinic Mental Health Initiative, Yangon, Myanmar; San San Oo, Consultant Psychiatrist and EMDR Therapist and Team Leader, Aung Clinic Mental Health Initiative, Yangon, Myanmar; Shwe Ya Min Oo, Psychiatrist and Evaluation Researcher (team member), Aung Clinic Mental Health Initiative, Mental Health Hospital, Yangon, Myanmar. vi Comprehensive mental health service networks BET Unit, Blakstad Hospital, vestre viken Hospital Trust – viken, Norway: Roar Fosse, Senior Researcher, Department of Research and Development, Division of Mental Health and Addiction; Jan Hammer, Special Advisor, Department of Psychiatry, Blakstad Division of Mental Health and Addiction; Didrik Heggdal, The BET Unit, Blakstad Department; Peggy Lilleby, Psychiatrist, The BET Unit, Blakstad Department; Arne Lillelien, Clinical Consultant, The BET Unit, Blakstad Department; Jørgen Strand, Chief of staff and Unit manager, The BET Unit, Blakstad Department; Inger Hilde Vik, Clinical Consultant, The BET Unit, Blakstad Department (Vestre Viken Hospital Trust, Viken, Norway). Brazil community-based mental health networks – a focus on Campinas: Sandrina Indiani, President, Directing Council of the Serviço de Saúde Dr. Candido Ferreira, Campinas, Brazil; Rosana Teresa Onocko Campos, Professor, University of Campinas, Campinas, Brazil; Fábio Roque Ieiri, Psychiatrist, Complexo Hospitalar Prefeito Edivaldo Ors, Campinas, Brazil; Sara Sgobin, Coordinator, Technical Area of Mental Health, Municipal Health Secretariat, Campinas, Brazil. Centros de Atenção Psicossocial (CAPS) iii – Brasilândia, São Paulo, Brazil: Carolina Albuquerque de Siqueira, Nurse, CAPS III – Brasilândia, São Paulo, Brazil; Jamile Caleiro Abbud, Psychologist, CAPS III – Brasilândia, São Paulo, Brazil; Anderson da Silva Dalcin, Coordinator, CAPS III – Brasilândia, São Paulo, Brazil; Marisa de Jesus Rocha, Ocupational Therapist, CAPS III – Brasilândia, São Paulo, Brazil; Debra Demiquele da Silva, Nursing Assistant, CAPS III – Brasilândia, São Paulo, Brazil; Glaucia Galvão, Supporter Management of Network and Services, Mental Health, Associação Saúde da Família, São Paulo, Brazil; Michele Goncalves Panarotte, Psychologist, CAPS III – Brasilândia, São Paulo, Brazil; Cláudia Longhi, Coordinator, Technical Area of Mental Health, Municipal Health Secretariat, São Paulo, Brazil; Thais Helena Mourão Laranjo, Supporter Management of Network and Services, Mental Health, Associação Saúde da Família, São Paulo, Brazil; Aline Pereira Leal, Social Assistant, CAPS III – Brasilândia, São Paulo, Brazil; Iara Soares Pires Fontagnelo, Ocupational Therapist, CAPS III – Brasilândia, São Paulo, Brazil; Igor Manoel Rodrigues Costa, Workshop Professional, CAPS III – Brasilândia, São Paulo, Brazil; Douglas Sherer Sakaguchi, Supervisor Técnico, Freguesia do Ó, Brasilândia, São Paulo, Brazil; Davi Tavares Villagra, Physical Education Professional, CAPS III – Brasilândia, São Paulo, Brazil; Alessandro Uemura Vicentini, Psychologist, CAPS III – Brasilândia, São Paulo, Brazil. East Lille network of mental health services – France: Antoine Baleige, Praticien hospitalier, Secteur 59G21, Centre Collaborateur de l’Organisation mondiale de la Santé (Lille, France); Alain Dannet, Coordonnateur du GCS, Centre Collaborateur de l’Organisation mondiale de la Santé (Lille, France); Laurent Defromont, Praticien hospitalier, Chef de pôle, Secteur 59G21, Centre Collaborateur de l’Organisation mondiale de la Santé (Lille, France); Géry Kruhelski, Chief Nurse Manager, Secteur 21, Centre Collaborateur de l’Organisation mondiale de la Santé (Lille, France); Marianne Ramonet, Psychiatrist, Sector 21, Centre Collaborateur de l’Organisation mondiale de la Santé (Lille, France); Jean-Luc Roelandt, Psychiatrist, Centre collaborateur de l’OMS pour la Recherche et la Formation en Santé mentale, Etablissement Public de Santé Mentale (EPSM) Lille-Métropole, France; Simon Vasseur Bacle, Psychologue clinicien /Chargé de mission et des affaires internationales, Centre Collaborateur de l’Organisation mondiale de la Santé (Lille, France), Etablissement Public de Santé Mentale (EPSM) Lille-Métropole et Secteur 21, France. Friendship Bench – Zimbabwe: Dixon Chibanda, Chief Executive Officer; Ruth Verhey, Program Director (Friendship Bench, Harare, Zimbabwe). Hand in Hand supported living – Georgia: Eka Chkonia, President of the Society of Georgian Psychiatrists, Associate Professor at Tbilisi State Medical University, Clinical Director at the Tbilisi Mental Health Center, Tbilisi, Georgia; Amiran Dateshidze, Founder, NGO-Hand in Hand, Tbilisi, Georgia; Giorgi Geleishvili, Director of Evidence Based Practice Center, Psychiatrist at Tbilisi Assertive Community Treatment Team, Individual Member of International Association for Analytical Psychology, Tbilisi, Georgia; Izabela Laliashvili, Manager, NGO-Hand in Hand, Tbilisi, Georgia; Tamar Shishniashvili, Director, NGO-Hand in Hand, Tbilisi, Georgia; Maia Shishniashvili, Founder, NGO-Hand in Hand, Tbilisi, Georgia. Technical package vii Hearing voices support groups: Gail Hornstein, Professor of Psychology, Mount Holyoke College, South Hadley, MA, USA; Olga Runciman, Psychologist, Owner of Psycovery Denmark, Chair of the Danish Hearing Voices Network, Copenhagen, Denmark. Home Again – Chennai, india: Vandana Gopikumar, Co-Founder, Managing Trustee; Lakshmi Narasimhan, Consultant Research; Keerthana Ram, Research Associate; Pallavi Rohatgi, Executive Director (The Banyan, Chennai, India). Nisha Vinayak, Co-lead for Social Action and Research, The Banyan Academy, Chennai, India. Home Focus – West Cork, ireland: Barbara Downs, Rehabilitative Training Instructor, Home Focus Team; Kathleen Harrington, Area Manager; Caroline Hayes, Recovery Development Advocate, Home Focus Team; Catriona Hayes, Clinical Nurse Specialist/Community Mental Health Nurse, Home Focus Team; Maura O’Donovan, Recovery Support Worker, Home Focus Team; Aidan O’Mahony, Rehabilitative Training Instructor, Home Focus Team; Jason Wycherley, Area Manager (National Learning Network, Bantry, Ireland). KeyRing Living Support Networks: Charlie Crabtree, Marketing and Communications Manager; Sarah Hatch, Communications Coordinator; Karyn Kirkpatrick, Chief Executive Officer; Frank Steeples, Quality Assurance Lead; Mike Wright, Deputy Chief Executive Officer (KeyRing Living Support Networks, London, United Kingdom). Kliniken Landkreis Heidenheim gGmbH – Heidenheim, Germany: Martin Zinkler, Clinical Director, Kliniken Landkreis Heidenheim gGmbH, Heidenheim, Germany. Link House – Bristol, United Kingdom: Carol Metters, Former Chief Executive Officer; Sarah O‘Leary, Chief Executive Officer (Missing Link Mental Health Services Bristol, United Kingdom). Nairobi Mind Empowerment Peer Support Group, USP Kenya: Elizabeth Kamundia, Assistant Director, Research, Advocacy and Outreach Directorate, Kenya National Commission on Human Rights, Nairobi, Kenya; Michael Njenga, Executive Council Member, Africa Disability Forum, Chief Executive Officer, Users and Survivors of Psychiatry in Kenya, Nairobi, Kenya. Naya Daur – West Bengal, india: Mrinmoyee Bose, Program Coordinator; Sarbani Das Roy, Director and Co-Founder; Gunjan Khemka, Assistant Director; Priyal Kothari, Program Manager; Srikumar Mukherjee, Psychiatrist and Co-Founder; Abir Mukherjee, Psychiatrist; Laboni Roy, Assistant Director (Iswar Sankalpa, Kolkata, West Bengal, India). Open Dialogue Crisis Service – Lapland, Finland: Brigitta Alakare, Former Chief Psychiatrist; Tomi Bergström, Psychologist PhD, Keropudas Hospital; Marika Biro, Nurse and Family Therapist, Head Nurse, Keropudas Hospital; Anni Haase, Psychologist, Trainer on Psychotherapy; Mia Kurtti, Nurse, MSc, Trainer on Family and Psychotherapy; Elina Löhönen, Psychologist, Trainer on Family and Psychotherapy; Hannele Mäkiollitervo, MSc Social Sciences, Peer Worker, Unit of Psychiatry; Tiina Puotiniemi, Director, Unit of Psychiatry and Addiction Services; Jyri Taskila, Psychiatrist, Trainer on Family and Psychotherapy; Juha Timonen, Nurse and Family Therapist, Keropudas Hospital; Kari Valtanen, Psychiatrist MD, Trainer on Family and Psychotherapy; Jouni Petäjäniemi, Head Nurse, Keropudas Hospital Crisis Clinic and Tornio City Outpatient Services (Western-Lapland Health Care District, Lapland, Finland) Peer Support South East Ontario – Ontario, Canada: Todd Buchanan, Professor, Loyalist College, Business & Operations Manager, Peer Support South East Ontario (PSSEO), Ontario, Canada; Deborrah Cuttriss Sherman, Peer Support for Transitional Discharge, Providence Care, Ontario, Canada; Cheryl Forchuk, Beryl and Richard Ivey Research Chair in Aging, Mental Health, Rehabilitation and Recovery, Parkwood Institute Research/Lawson Health Research Institute, Western University, London, Ontario, Canada; Donna Stratton, Transitional Discharge Model Coordinator, Peer Support South East Ontario, Ontario, Canada. Personal Ombudsman – Sweden: Ann Bengtsson, Programme Officer, Socialstyrelsen, Stockholm, Sweden; Camilla Bogarve, Chief Executive Officer, PO Skåne, Sweden; Ulrika Fritz, Chairperson, The Professional Association for Personal Ombudsman in Sweden (YPOS), Sweden. viii Comprehensive mental health service networks Phoenix Clubhouse – Hong Kong Special Administrative Region (SAR), People’s Republic of China: Phyllis Chan, Clinical Stream Coordinator (Mental Health) - Hong Kong West Cluster, Chief of Service - Department of Psychiatry, Queen Mary Hospital, Honorary Clinical Associate Professor - Department of Psychiatry, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, People’s Republic of China; Anita Chan, Senior Occupational Therapist, Occupational Therapy Department, Queen Mary Hospital, Hong Kong SAR, People’s Republic of China; June Chao, Department Manager, Occupational Therapy Department, Queen Mary Hospital, Hong Kong SAR, People’s Republic of China; Bianca Cheung, Staff of Phoenix Clubhouse, Phoenix Clubhouse/ Occupational Therapy Department, Queen Mary Hospital, Hong Kong SAR, People’s Republic of China; Eileena Chui, Consultant, Department of Psychiatry, Queen Mary Hospital, Hong Kong SAR, People’s Republic of China; Joel D. Corcoran, Executive Director, Clubhouse International, New York, NY, USA; Enzo Lee, Staff of Phoenix Clubhouse, Phoenix Clubhouse/ Occupational Therapy Department, Queen Mary Hospital, Hong Kong SAR, People’s Republic of China; Francez Leung, Director of Phoenix Clubhouse, Occupational Therapist, Phoenix Clubhouse/ Occupational Therapy Department, Queen Mary Hospital, Hong Kong SAR, People’s Republic of China; Eric Wong, Staff of Phoenix Clubhouse, Phoenix Clubhouse/ Occupational Therapy Department, Queen Mary Hospital, Hong Kong SAR, People’s Republic of China; Mimi Wong, Member of Phoenix Clubhouse, Hong Kong SAR, People’s Republic of China; Eva Yau, Honorary member of Friends of Phoenix Clubhouse, Faculty Member of Clubhouse International, Founding Director of Phoenix Clubhouse, Hong Kong SAR, People’s Republic of China. Shared Lives – South East Wales, United Kingdom: Emma Jenkins, Shared Lives for Mental Health Crisis Manager, South East Wales Shared Lives Scheme, Caerphilly CBC, United Kingdom; Martin Thomas, Business Manager, South East Wales Shared Lives Scheme, Caerphilly CBC, United Kingdom; Benna Waites, Joint Head of Psychology, Counselling and Arts Therapies, Mental Health and Learning Disabilities, Aneurin Bevan University Health Board, United Kingdom; Rachel White, Team Manager, Home Treatment Team, Adult Mental Health Directorate, Aneurin Bevan University Health Board, United Kingdom. Soteria – Berne, Switzerland: Clare Christine, Managing Director, Soteria Berne, Berne, Switzerland; Walter Gekle, Medical Director, Soteria Berne, Head Physician and Deputy Director, Center for Psychiatric Rehabilitation, University Psychiatric Services, Berne, Switzerland. Trieste Community Mental Health Network of Services – italy: Tommaso Bonavigo, Psychiatrist, Community Mental Health Centre 3 – Domio, Mental Health Department of Trieste and Gorizia, WHO Collaborating Centre for Research and Training – Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), Trieste, Italy; Mario Colucci, Psychiatrist, Head of Community Mental Health Centre 3 – Domio, Mental Health Department of Trieste and Gorizia, WHO Collaborating Centre for Research and Training – Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), Trieste, Italy; Elisabetta Pascolo Fabrici, Director, Mental Health Department of Trieste and Gorizia, WHO Collaborating Centre for Research and Training – Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), Trieste, Italy; Serena Goljevscek, Psychiatrist, Community Mental Health Centre 3 – Domio, Mental Health Department of Trieste and Gorizia, WHO CC for Research and Training – Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), Trieste, Italy; Roberto Mezzina, International Mental Health Collaborating Network (IMHCN), Italy, Former Director, Mental Health Department of Trieste and Gorizia, WHO Collaborating Centre for Research and Training – Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), Trieste, Italy; Alessandro Saullo, Psychiatrist, Community Mental Health Centre of Gorizia, Mental Health Department of Trieste and Gorizia, WHO Collaborating Centre for Research and Training – Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), Trieste, Italy; Daniela Speh, Specialized Nurse, Coordinator for Training, Mental Health Department of Trieste and Gorizia, WHO Collaborating Centre for Research and Training - ASUGI Corporate Training and Development Office – Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), Trieste, Italy; Marco Visintin, Psychologist, Community Mental Health Centre of Gorizia, Mental Health Department of Trieste and Gorizia, WHO Collaborating Centre for Research and Training – Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), Trieste, Italy. Tupu Ake – South Auckland, New Zealand: Janice McGill, Peer Development Lead; Ross Phillips, Business Operations Manager (Pathways, Auckland, New Zealand). Technical package ix Mental health networks from Bosnia and Herzegovina, Lebanon and Peru Bosnia and Herzegovina: Dzenita Hrelja, Project Director, Mental Health / Association XY, Sarajevo, Bosnia and Herzegovina. Lebanon: Rabih El Chammay, Head; Nayla Geagea, Legislation and Human Rights Advisor; Racha Abi Hana, Service Development Coordinator (National Mental Health Programme, Ministry of Public Health, Lebanon). Thurayya Zreik, QualityRights Project Coordinator, Lebanon. Peru: Yuri Cutipe, Director of Mental Health, Ministry of Health, Lima, Peru. Technical review and written contributions Maria Paula Acuña Gonzalez, Former WHO Intern (Ireland); Christine Ajulu, Health Rights Advocacy Forum (Kenya); John Allan, Mental Health Alcohol and Other Drugs Branch, Clinical Excellence Queensland, Queensland Health (Australia); Jacqueline Aloo, Ministry of Health (Kenya); Caroline Amissah, Mental Health Authority (Ghana); Sunday Anaba, BasicNeeds (Ghana); Naomi Anyango, Mathari National Teaching & Referral Hospital (Kenya); Aung Min, Aung Clinic Mental Health Initiative (Myanmar); Antoine Baleige, Centre Collaborateur de l‘Organisation Mondiale de la Santé, Lille (France); Shantha Barriga, Disability Rights Division, Human Rights Watch (Belgium); Peter Bartlett, School of Law and Institute of Mental Health, University of Nottingham (United Kingdom); Marie Baudel, Laboratoire DCS - Droit et changement social, Université de Nantes (France); Frank Bellivier, Ministry of Health (France); Alison Brabban, Tees, Esk & Wear Valleys NHS Foundation Trust (United Kingdom); Jonas Bull, Mental Health Europe (Belgium); Peter Bullimore, National Paranoia Network (United Kingdom); Raluca Bunea, Open Society Foundations (Germany); Miroslav Cangár, Social Work Advisory Board (Slovakia); Mauro Giovanni Carta, Department of Medical Science and Public Health, University of Cagliari (Italy); Marika Cencelli, Mental Health, NHS England (United Kingdom); Vincent Cheng, Hearing Voices, (Hong Kong); Dixon Chibanda, Friendship Bench (Zimbabwe); Amanda B. Clinton, American Psychological Asscociation (USA); Jarrod Clyne, International Disability Alliance (Switzerland); Joel D. Corcoran, Clubhouse International (USA); Alain Dannet, Centre Collaborateur de l‘Organisation Mondiale de la Santé, Lille (France); Bhargavi Davar, Transforming Communities for Inclusion – Asia Pacific (TCI–AP) (India); Adv. Liron David, Enosh - The Israeli Mental Health Association (Israel); Sera Davidow, Wildflower Alliance (formerly known as the Western Massachusetts Recovery Learning Community) (USA); Larry Davidson, Program for Recovery and Community Health, School of Medicine, Yale University (USA); Gabriela B. de Luca, Open Society Foundations (USA); Laurent Defromont, Centre Collaborateur de l‘Organisation Mondiale de la Santé, Lille (France); Keshav Desiraju, Former Health Secretary (India); Julian Eaton, CBM Global (United Kingdom); Marie Fallon- Kund, Mental Health Europe (Belgium); Julia Faure, WHO Consultant (France); Silvana Galderisi, University of Campania „Luigi Vanvitelli“ (Italy); Rosemary Gathara, Basic Needs Basic Rights Kenya (Kenya); Walter Gekle, Soteria Berne (Switzerland); Piers Gooding, Melbourne Social Equity Institute, University of Melbourne (Australia); Ugne Grigaite, NGO Mental Health Perspectives (Lithuania); Ahmed Hankir, Institute of Psychiatry, Psychology and Neuroscience, King‘s College London (United Kingdom); Sarah Harrison, International Medical Corps (Turkey); Akiko Hart, National Survivor User Network (United Kingdom); Hee-Kyung Yun, WHO Collaborating Centre for Psychosocial Rehabilitation and Community Mental Health, Yong-In Mental Hospital (Republic of Korea); Helen Herrman, Orygen and Centre for Youth Mental Health, The University of Melbourne (Australia); Mathew Jackman, Global Mental Health Peer Network (Australia); Florence Jaguga, Moi Teaching & Referral Hospital (Kenya); Jasmine Kalha, Centre for Mental Health Law and Policy, Indian Law Society (India); Olga Kalina, European Network of (Ex)Users and Survivors of Psychiatry (Denmark); Elizabeth Kamundia, Kenya National Commission on Human Rights (Kenya); Clement Kemboi Cheptoo, Kenya National Commission on Human Rights (Kenya); Tim Kendall, Mental Health, NHS England (United Kingdom); Judith Klein, INclude-The Mental Health Initiative (USA); Sarah Kline, United for Global Mental Health (United Kingdom); Humphrey Kofie, Mental Health Society of Ghana (Ghana); Martijn Kole, Lister Utrecht Enik Recovery Center (Netherlands); Géry Kruhelski, Centre Collaborateur de l‘Organisation Mondiale de la Santé, Lille (France); Kimberly Lacroix, Bapu Trust for Research on Mind and Discourse (India); Rae Lamb, Te Pou o te Whakaaro Nui (New Zealand); Marc Laporta, Douglas Hospital Research Centre, The Montreal PAHO/WHO Collaborating Centre for Reference and Research in Mental Health, Montréal xComprehensive mental health service networks (Canada); Tuncho Levav, Department of Community Mental Health, University of Haifa (Israel); Konstantina Leventi, The European Association of Service Providers for Persons with Disabilities (Belgium); Long Jiang, Shanghai Mental Health Centre, Shanghai Jiao Tong University, WHO Collaborating Centre for Research and Training in Mental Health (China); Florence Wangechi Maina, Kenya Medical Training College, Mathari Campus (Kenya); Felicia Mburu, Validity Foundation (Kenya); Peter McGovern, Modum Bad (Norway); David McGrath, David McGrath Consulting (Australia); Roberto Mezzina, International Mental Health Collaborating Network (IMHCN), Italy, Former Director, Mental Health Department of Trieste and Gorizia, WHO Collaborating Centre for Research and Training – Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), Trieste, Italy; Matilda Mghoi, Division of Mental Health, Ministry of Health (Kenya); Jean-Dominique Michel, Pro Mente Sana (Switzerland); Tina Minkowitz, Center for the Human Rights of Users and Survivors of Psychiatry (USA); Faraaz Mohamed, Open Society Foundations (USA); Andrew Molodynski, Oxford Health NHS Foundation Trust (United Kingdom); Maria Francesca Moro, Department of Epidemiology, Mailman School of Public Health, Columbia University (USA); Marina Morrow, Realizing Human Rights and Equity in Community Based Mental Health Services, York University (Canada); Joy Muhia, QualityRights Kenya, Division of Mental Health, Ministry of Health (Kenya); Elizabeth Mutunga, Alzheimers and Dementia Organization (Kenya); Na-Rae Jeong, WHO Collaborating Centre for Psychosocial Rehabilitation and Community Mental Health, Yong-In Mental Hospital (Republic of Korea); Lawrence Nderi, Mathari National Teaching & Referral Hospital (Kenya); Mary Nettle, Mental Health User Consultant (United Kingdom); Simon Njuguna Kahonge, Ministry of Health (Kenya); Akwasi Owusu Osei, Mental Health Authority (Ghana); Cláudia Pellegrini Braga, Rio de Janeiro Public Prosecutor‘s Office, Brazil; Sifiso Owen Phakathi, Directorate of Mental Health and Substance Abuse Policy, Department of Health (South Africa); Ross Phillips, Pathways (New Zealand); Dainius Puras, Human Rights Monitoring Institute/ Department of Psychiatry, Faculty of Medicine, Vilnius University (Lithuania); Gerard Quinn, UN Special Rapporteur on the rights of persons with disabilities (Ireland); Marianne Ramonet, Centre Collaborateur de l‘Organisation Mondiale de la Santé, Lille (France); Julie Repper, Nottinghamshire Healthcare Trust, University of Nottingham (United Kingdom); Pina Ridente, Psychiatrist, Italy; Jean- Luc Roelandt, Centre collaborateur de l‘OMS pour la Recherche et la Formation en Santé mentale, Etablissement Public de Santé Mentale (EPSM) Lille-Métropole (France); Grace Ryan, Centre for Global Mental Health, London School of Hygiene and Tropical Medicine (United Kingdom); San San Oo, Aung Clinic Mental Health Initiative (Myanmar); Benedetto Saraceno, Lisbon Institute Global Mental Health, CEDOC/NOVA, Medical School (Portugal); Natalie Schuck, Department of Transboundary Legal Studies, Global Health Law Groningen Research Centre, University of Groningen (Netherlands); Seongsu Kim, Mental Health Crisis Response Center, New Gyeonggi Provincial Psychiatric Hospital (Republic of Korea); Dudu Shiba, Directorate of Mental Health and Substance Abuse Policy, Department of Health (South Africa); Mike Slade, Faculty of Medicine & Health Sciences, University of Nottingham (United Kingdom); Alexander Smith, WAPR/Counseling Service of Addison County (USA); Gregory Smith, Mountaintop, Pennsylvania (USA); Daniela Speh, Mental Health Department of Trieste and Gorizia, WHO CC for Research and Training - ASUGI Corporate Training and Development Office – Azienda Sanitaria Universitaria Giuliano Isontina (Italy); Ellie Stake, Charity Chy -Sawel (United Kingdom); Peter Stastny, International Network Towards Alternatives and Recovery (INTAR)/Community Access NYC (USA); Sladjana Strkalj Ivezic, Community Rehabilitation Center, University psychiatric Hospital Vrapče (Croatia); Charlene Sunkel, Global Mental Health Peer Network (South Africa); Sauli Suominen, Finnish Personal Ombudsman Association (Finland); Orest Suvalo, Mental Health Institute, Ukrainian Catholic University (Ukraine); Kate Swaffer, Dementia Alliance International, Alzheimer‘s Disease International (Australia); Tae-Young Hwang, WHO Collaborating Centre for Psychosocial Rehabilitation and Community Mental Health, Yong-In Mental Hospital (Republic of Korea); Bliss Christian Takyi, St. Joseph Catholic Hospital, Nkwanta (Ghana); Katelyn Tenbensel, Alfred Health (Australia); Luc Thibaud, Users‘ Advocat (France); Tin Oo, Ministry of Health and Sports, Mental Health Department, University of Medicine (Myanmar); Samson Tse, Faculty of Social Sciences, Department of Social Work & Social Administration, The University of Hong Kong (Hong Kong); Gabriel Twose, Office of International Affairs, American Psychological Association (USA); Roberto Tykanori Kinoshita, Federal University of São Paulo (Brazil); Katrin Uerpmann, Directorate General of Human Rights and Rule of Law, Bioethics Unit, Council of Europe (France); Carmen Valle Trabadelo, Inter-Agency Standing Committee (IASC) on Mental Health and Psychosocial Support Technical package xi (MHPSS) Reference Group (Denmark); Alberto Vásquez Encalada, Sociedad y Discapacidad (SODIS), Switzerland; Simon Vasseur Bacle, Centre Collaborateur de l‘Organisation Mondiale de la Santé (Lille, France), Etablissement Public de Santé Mentale (EPSM) Lille-Métropole (France); Ruth Verhey, Friendship bench (Zimbabwe); Lakshmi Vijayakumar, Society for Nutrition, Education & Health Action, Voluntary Health Services (India); Benna Waites, Psychology, Counselling and Arts Therapies, Aneurin Bevan University Health Board (United Kingdom); Ian Walker, Mental Health, NCDs and UKOT Programme, Global Public Health Division, Public Health England (United Kingdom); Petr Winkler, Department of Public Mental Health, National Institute of Mental Health (Czech Republic); Stephanie Wooley, European Network of (Ex-) Users and Survivors of Psychiatry (France); Alexandre Willschleger, Mental Health, Hôpitaux Universitaires Genève (Switzerland); Peter Badimark Yaro, BasicNeeds Ghana (Ghana); Yifeng Xu, Shanghai Mental Health Centre, Shanghai Jiao Tong University, WHO Collaborating Centre for Research and Training in Mental Health (China); Luk Zelderloo, The European Association of Service Providers for Persons with Disabilities, Zero Project (Belgium); Maximilien Zimmerman, Féderation Handicap International – Humanity & Inclusion (Belgium); Martin Zinkler, Kliniken Landkreis Heidenheim gGmbH, Heidenheim (Germany). WHO Headquarters, Regional and Country Office contributions Nazneen Anwar (WHO/SEARO); Șebnem Avșar Kurnaz (WHO/Turkey); Florence Baingana (WHO/ AFRO); Fatima Batool (WHO/HQ); Andrea Bruni (WHO/AMRO); Kenneth Carswell (WHO/HQ); Vanessa Cavallera (WHO/HQ); Claudina Cayetano (WHO/AMRO); Daniel Hugh Chisholm (WHO/EURO); Neerja Chowdhary (WHO/HQ); Alarcos Cieza (WHO/HQ); Catarina Magalhães Dahl (WHO/AMRO); Tarun Dua (WHO/HQ); Alexandra Fleischmann (WHO/HQ); Stéfanie Freel (WHO/HQ); Brandon Gray (WHO/HQ); Fahmy Hanna (WHO/HQ); Mathew Jowett (WHO/HQ); Tara Mona Kessaram (WHO/Indonesia); Dévora Kestel (WHO/HQ); Kavitha Kolappa (WHO/HQ); Jason Ligot (WHO/WPRO); Aiysha Malik (WHO/HQ); Maria del Carmen Martinez Viciana (WHO/AMRO); Hernan Montenegro von Mühlenbrock (WHO/ HQ); Melita Murko (WHO/EURO); Brian Ogallo (WHO/Sudan); Sally-ann Ohene (WHO/Ghana); Renato Oliveira E Souza (WHO/AMRO); Khalid Saeed (WHO/EMRO); Giovanni Sala (WHO/HQ); Alison Schafer (WHO/HQ); Nicoline Schiess (WHO/HQ); Katrin Seeher (WHO/HQ); Chiara Servili (WHO/HQ); Julie Storr (WHO/HQ); Shams B. Syed (WHO/HQ); Mark Van Ommeren (WHO/HQ); Martin Vandendyck (WHO/WPRO); Jasmine Vergara (WHO/Philippines); Edwina Zoghbi (WHO/Lebanon). WHO administrative, editorial and other support Administrative support: Patricia Robertson, Assistant to Unit Head, Policy, Law and Human Rights, Department of Mental Health and Substance Use, WHO, Geneva, Switzerland; Editing of the Guidance on community mental health services: Promoting person-centred and rights- based approaches: Alexandra Lang Lucini (Switzerland); Editing of the Technical packages on community mental health services: Promoting person-centred and rights-based approaches: Tatum Anderson (United Kingdom) and Alexandra Lang Lucini (Switzerland); Drafting of initial summaries of the 25 good practice services: Elaine Fletcher, Global Policy Reporting Association (Switzerland); Tatum Anderson (United Kingdom); Graphic Design: Jillian Reichenbach-Ott, Genève Design (Switzerland); Other support: Casey Chu, Yale School of Public Health (USA); April Jakubec Duggal, University of Massachusetts (USA); Adrienne W.Y. Li, Toronto Rehabilitation Institute, University Health Network (Canada); Izabella Zant, EmblemHealth (USA). Financial support WHO would like to thank Ministry of Health and Welfare of the Republic of Korea for their continuous and generous financial support towards the development of the Guidance and Technical packages on community mental health services: Promoting person-centred and rights-based approaches. We are also grateful for the financial support received from Open Society Foundations, CBM Global, and the Government of Portugal. xii Comprehensive mental health service networks Special thanks Aung Clinic – Yangon, Myanmar would like to thank the study participants of the evaluation research for the Aung Clinic Mental Health Initiative, service users and their families, and networks and partnerships of local and international organizations/people; and the peer support workers and peer group of Aung Clinic Mental Health Initiative for advocacy and coordinating initiatives for people with psychosocial and intellectual disability. East Lille network of mental health services – France would like to acknowledge the support to their service of the following individuals: Bernard Derosier, Eugéne Regnier, Gérard Duchéne (deceased), Claude Ethuin (deceased), Jacques Bossard, Françoise Dal, Alain Rabary, O. Verriest, M. Février, Raghnia Chabane and Vincent Demassiet. BET Unit, Blakstad Hospital, vestre viken Hospital Trust – viken, Norway would like to acknowledge Øystein Saksvi (deceased) for his mentorship, inspiration and important contribution to BET Unit. Shared Lives – South East Wales, United Kingdom would like to acknowledge the following people for their key role in the development of their service: Jamie Harrison, Annie Llewellyn Davies, Diane Maddocks, Alison Minett, Perry Attwell, Charles Parish, Katie Benson, Chris O’Connor, Rosemary Brown, Ian Thomas, Gill Barratt, Angela Fry, Martin Price, Kevin Arundel, Susie Gurner, Rhiannon Davies, Sarah Bees, and the Newport Crisis Team and Newport In-patient Unit, Aneurin Bevan University Health Board (ABUHB); and in addition, Kieran Day, Rhian Hughes and Charlotte Thomas- Johnson, for their role in evaluation. Peer Support South East Ontario – Ontario, Canada would like to acknowledge the support of Server Cloud Canada, Kingston, Ontario, Canada, to their website for the statistical data required for their service (https://www.servercloudcanada.com). Technical package xiii Executive summary Mental health has received increased attention over the last decade from governments, nongovernmental organizations (NGOs) and multilateral organizations including the United Nations (UN) and the World Bank. With increased awareness of the importance of providing person-centred, human rights-based and recovery-oriented care and services, mental health services worldwide are striving to provide quality care and support. Yet often services face substantial resource restrictions, operate within outdated legal and regulatory frameworks and an entrenched overreliance on the biomedical model in which the predominant focus of care is on diagnosis, medication and symptom reduction while the full range of social determinants that impact people’s mental health are overlooked, all of which hinder progress toward full realization of a human rights-based approach. As a result, many people with mental health conditions and psychosocial disabilities worldwide are subject to violations of their human rights – including in care services where adequate care and support are lacking. To support countries in their efforts to align mental health systems and services delivery with international human rights standards, including the Convention on the Rights of Persons with Disabilities (CRPD), the WHO Guidance on community mental health services: Promoting person-centred and rights-based approaches calls for a focus on scaling up community-based mental health services that promote person-centred, recovery- oriented and rights-based health services. It provides real-world examples of good practices in mental health services in diverse contexts worldwide and describes the linkages needed with housing, education, employment and social protection sectors, to ensure that people with mental health conditions are included in the community and are able to lead full and meaningful lives. The guidance also presents examples of comprehensive, integrated, regional and national networks of community-based mental health services and supports. Finally, specific recommendations and action steps are presented for countries and regions to develop community mental health services that are respectful of peoples’ human rights and focused on recovery. This comprehensive guidance document is accompanied by a set of seven supporting technical packages which contain detailed descriptions of the showcased mental health services 1. Mental health crisis services 2. Hospital-based mental health services 3. Community mental health centres 4. Peer support mental health services 5. Community outreach mental health services 6. Supported living for mental health 7. Comprehensive mental health service networks xiv Comprehensive mental health service networks Introduction Reports from around the world highlight the need to address discrimination and promote human rights in mental health care settings. This includes eliminating the use of coercive practices such as forced admission and forced treatment, as well as manual, physical or chemical restraint and seclusiona and tackling the power imbalances that exist between health staff and people using the services. Sector-wide solutions are required not only in low-income countries, but also in middle- and high-income countries. The CRPD recognizes these challenges and requires major reforms and promotion of human rights, a need strongly reinforced by the Sustainable Development Goals (SDGs). It establishes the need for a fundamental paradigm shift within the mental health field, which includes rethinking policies, laws, systems, services and practices across the different sectors which negatively impact people with mental health conditions and psychosocial disabilities. Since the adoption of the CRPD in 2006, an increasing number of countries are seeking to reform their laws and policies in order to promote the rights to community inclusion, dignity, autonomy, empowerment and recovery. However, to date, few countries have established the policy and legislative frameworks necessary to meet the far-reaching changes required by the international human rights framework. In many cases, existing policies and laws perpetuate institutional-based care, isolation as well as coercive – and harmful – treatment practices. a Strategies to end seclusion and restraint. WHO QualityRights Specialized training. Course guide. Geneva: World Health Organization; 2019 (https://apps.who.int/iris/bitstream/handle/10665/329605/97892 41516754-eng.pdf). Key messages of this guidance • Many people with mental health conditions and psychosocial disabilities face poor- quality care and violations of their human rights, which demands profound changes in mental health systems and service delivery. • in many parts of the world examples exist of good practice, community-based mental health services that are person-centred, recovery-oriented and adhere to human rights standards. • in many cases these good practice, community-based mental health services show lower costs of service provision than comparable mainstream services. • Significant changes in the social sector are required to support access to education, employment, housing and social benefits for people with mental health conditions and psychosocial disabilities. • it is essential to scale up networks of integrated, community-based mental health services to accomplish the changes required by the CRPD. • The recommendations and concrete action steps in this guidance provide a clear roadmap for countries to achieve these aims. Technical package xv Providing community-based mental health services that adhere to the human rights principles outlined in the CRPD – including the fundamental rights to equality, non-discrimination, full and effective participation and inclusion in society, and respect for people’s inherent dignity and individual autonomy – will require considerable changes in practice for all countries. Implementing such changes can be challenging in contexts where insufficient human and financial resources are being invested in mental health. This guidance presents diverse options for countries to consider and adopt as appropriate to improve their mental health systems and services. It presents a menu of good practice options anchored in community-based health systems and reveals a pathway for improving mental health care services that are innovative and rights-based. There are many challenges to realizing this approach within the constraints that many services face. However, despite these limitations, the mental health service examples showcased in this guidance show concretely – it can be done. Examples of good practice community mental health services In many countries, community mental health services are providing a range of services including crisis services, community outreach, peer support, hospital-based services, supported living services and community mental health centres. The examples presented in this guidance span diverse contexts from, for example, the community mental health outreach service, Atmiyata, in India, to the Aung Clinic community mental health service in Myanmar and the Friendship Bench in Zimbabwe, all of which make use of community health care workers and primary health care systems. Other examples include hospital-based services such as the BET unit in Norway, which is strongly focused on recovery, and crisis services such as Tupu Ake in New Zealand. This guidance also showcases established supported living services such as the KeyRing Living Support Networks in the United Kingdom and peer-support services such as the Users and Survivors of Psychiatry groups in Kenya and the Hearing Voices Groups worldwide. While each of these services is unique, what is most important is that they are all promoting a person- centred, rights-based, recovery approach to mental health systems and services. None is perfect, but these examples provide inspiration and hope as those who have established them have taken concrete steps in a positive direction towards alignment with the CRPD. Each mental health service description presents the core principles underlying the service including their commitment to respect for legal capacity, non-coercive practices, community inclusion, participation and the recovery approach. Importantly, each service presented has a method of service evaluation, which is critical for the ongoing assessment of quality, performance and cost-effectiveness. In each case, service costs are presented as well as cost comparisons with regional or national comparable services. These examples of good practice mental health services will be useful to those who wish to establish a new mental health service or reconfigure existing services. The detailed service descriptions in the technical packages contain practical insights into challenges faced by these services as they evolved, and the solutions developed in response. These strategies or approaches can be replicated, transferred or scaled up when developing services in other contexts. The guidance presents practical steps and recommendations for setting up or transforming good practice mental health services that can work successfully within a wide range of legal frameworks while still protecting human rights, avoiding coercion and promoting legal capacity. xvi Comprehensive mental health service networks Significant social sector changes are also required In the broader context, critical social determinants that impact people’s mental health such as violence, discrimination, poverty, exclusion, isolation, job insecurity or unemployment, and lack of access to housing, social safety nets, and health services, are factors often overlooked or excluded from mental health discourse and practice. In reality, people living with mental health conditions and psychosocial disabilities often face disproportionate barriers to accessing education, employment, housing and social benefits – fundamental human rights – on the basis of their disability. As a result, significant numbers are living in poverty. For this reason, it is important to develop mental health services that engage with these important life issues and ensure that the services available to the general population are also accessible to people with mental health conditions and psychosocial disabilities. No matter how well mental health services are provided though, alone they are insufficient to support the needs of all people, particularly those who are living in poverty, or those without housing, education or a means to generate an income. For this reason, it is essential to ensure that mental health services and social sector services engage and collaborate in a very practical and meaningful way to provide holistic support. In many countries, great progress is already being made to diversify and integrate mental health services within the wider community. This approach requires active engagement and coordination with diverse services and community actors including welfare, health and judiciary institutions, regional and city authorities, along with cultural, sports and other initiatives. To permit such collaboration, significant strategy, policy and system changes are required not only in the health sector but also in the social sector. Scaling up mental health service networks This guidance demonstrates that scaling up networks of mental health services that interface with social sector services is critical to provide a holistic approach that covers the full range of mental health services and functions. In several places around the world, individual countries, regions or cities have developed mental health service networks which address the above social determinants of health and the associated challenges that people with mental health and psychosocial conditions face daily. Some of the showcased examples are well-established, structured and evaluated networks that have profoundly reshaped and reorganized the mental health system; others are networks in transition, which have reached significant milestones. The well-established networks have exemplified a strong and sustained political commitment to reforming the mental health care system over decades, so as to adopt a human rights and recovery- based approach. The foundation of their success is an embrace of new policies and laws, along with an increase in the allocation of resources towards community-based services. For instance, Brazil’s community-based mental health networks offer an example of how a country can implement services at large scale, anchored in human rights and recovery principles. The French network of East Lille further demonstrates that a shift from inpatient care to diversified, community-based interventions can be achieved with an investment comparable to that of more conventional mental health services. Technical package xvii Finally, the Trieste, Italy network of community mental health services is also founded upon on a human rights-based approach to care and support, and strongly emphasizes de-institutionalization. These networks reflect the development of community-based mental health services that are strongly integrated and connected with multiple community actors from diverse sectors including the social, health, employment, judiciary and others. More recently, countries such as Bosnia and Herzegovina, Lebanon, Peru, and others, are making concerted efforts to rapidly expand emerging networks, and to offer community-based, rights-oriented and recovery-focused services and supports at scale. A key aspect of many of these emerging networks is the aim of bringing mental health services out of psychiatric hospitals and into local settings, so as to ensure the full participation and inclusion of individuals with mental health conditions and psychosocial disabilities in the community. While more time and sustained effort is required, important changes are already materializing. These networks provide inspiring examples of what can be achieved with political will, determination and a strong human rights perspective underpinning actions in mental health. Key recommendations Health systems around the world in low-, middle- and high-income countries increasingly understand the need to provide high quality, person-centred, recovery-oriented mental health services that protect and promote people’s human rights. Governments, health and social care professionals, NGOs, organizations of persons with disabilities (OPDs) and other civil society actors and stakeholders can make significant strides towards improving the health and well-being of their populations by taking decisive action to introduce and scale up good practice services and supports for mental health into broader social systems while protecting and promoting human rights. This guidance presents key recommendations for countries and organizations, showing specific actions and changes required in mental health policy and strategy, law reform, service delivery, financing, workforce development, psychosocial and psychological interventions, psychotropic drugs, information systems, civil society and community involvement, and research. Crucially, significant effort is needed by countries to align legal frameworks with the requirements of the CRPD. Meaningful changes are also required for policy, strategy and system issues. Through the creation of joint policy and with strong collaboration between health and social sectors, countries will be better able to address the key determinants of mental health. Many countries have successfully used shifts in financing, policy and law as a powerful lever for mental health system reform. Placing human rights and recovery approaches at the forefront of these system reforms has the potential to bring substantial social, economic and political gains to governments and communities. In order to successfully integrate a person-centred, recovery-oriented and rights-based approach in mental health, countries must change and broaden mindsets, address stigmatizing attitudes and eliminate coercive practices. As such, it is critical that mental health systems and services widen their focus beyond the biomedical model to also include a more holistic approach that considers all aspects of a person’s life. Current practice in all parts of the world, however, places psychotropic drugs at the centre of treatment responses whereas psychosocial interventions, psychological interventions and peer support should also be explored and offered in the context of a person-centred, recovery and rights-based approach. These changes will require significant shifts in the knowledge, competencies and skills of the health and social services workforce. xviii Comprehensive mental health service networks More broadly, efforts are also required to create inclusive societies and communities where diversity is accepted, and the human rights of all people are respected and promoted. Changing negative attitudes and discriminatory practices is essential not just within health and social care settings, but also within the community as a whole. Campaigns raising awareness of the rights of people with lived experience are critical in this respect, and civil society groups can play a key strategic role in advocacy. Further, as mental health research has been dominated by the biomedical paradigm in recent decades, there is a paucity of research examining human rights-based approaches in mental health. A significant increase in investment is needed worldwide in studies examining rights-based approaches, assessing comparative costs of service provision and evaluating their recovery outcomes in comparison to biomedical-based approaches. Such a reorientation of research priorities will create a solid foundation for a truly rights-based approach to mental health and social protection systems and services. Finally, development of a human rights agenda and recovery approach cannot be attained without the active participation of individuals with mental health conditions and psychosocial disabilities. People with lived experience are experts and necessary partners to advocate for the respect of their rights, but also for the development of services and opportunities that are most responsive to their actual needs. Countries with a strong and sustained political commitment to continuous development of community- based mental health services that respect human rights and adopt a recovery approach will vastly improve not only the lives of people with mental health conditions and psychosocial disabilities, but also their families, communities and societies as a whole. Technical package xix What is the WHO QualityRights initiative? WHO QualityRights is an initiative which aims to improve the quality of care and support in mental health and social services and to promote the human rights of people with psychosocial, intellectual or cognitive disabilities throughout the world. QualityRights uses a participatory approach to achieve the following objectives: For more information visit the WHO QualityRights website Build capacity to combat stigma and discrimination, and to promote human rights and recovery. „ WHO QualityRights face to face training modules „ WHO QualityRights e-training on mental health and disability: Eliminating stigma and promoting human rights improve the quality of care and human rights conditions in mental health and social services. „ WHO QualityRights assessment toolkit „ WHO QualityRights module on transforming services & promoting rights Support the development of a civil society movement to conduct advocacy and influence policy-making. „ WHO QualityRights guidance module on advocacy for mental health, disability and human rights „ WHO QualityRights guidance module on civil society organizations to promote human rights in mental health and related areas Reform national policies and legislation in line with the Convention on the Rights of Persons with Disabilities and other international human rights standards. „ WHO guidance currently under development Create community-based and recovery-oriented services that respect and promote human rights. „ WHO guidance and technical packages on community mental health services: Promoting person-centred and rights-based approaches „ WHO QualityRights guidance module one-to-one peer support by and for people with lived experience „ WHO QualityRights guidance module on peer support groups by and for people with lived experience „ WHO QualityRights person-centred recovery planning for mental health and well-being self-help tool 1 2 3 4 5 xx Comprehensive mental health service networks About the WHO Guidance and technical packages on community mental health services The purpose of these documents is to provide information and guidance to all stakeholders who wish to develop or transform their mental health system and services. The guidance provides in-depth information on the elements that contribute towards the development of good practice services that meet international human rights standards and that promote a person-centred, recovery approach. This approach refers to mental health services that operate without coercion, that are responsive to people’s needs, support recovery and promote autonomy and inclusion, and that involve people with lived experience in the development, delivery and monitoring of services. There are many services in countries around the world that operate within a recovery framework and have human rights principles at their core – but they remain at the margins and many stakeholders including policy makers, health professionals, people using services and others, are not aware of them. The services featured in these documents are not being endorsed by WHO but have been selected because they provide concrete examples of what has been achieved in very different contexts across the world. They are not the only ones that are working within a recovery and human rights agenda but have been selected also because they have been evaluated, and illustrate the wide range of services that can be implemented. Showing that innovative types of services exist and that they are effective is key to supporting policy makers and other key actors to develop new services or transform existing services in compliance with human rights standards, making them an integral part of Universal Health Coverage (UHC). This document also aims to highlight the fact that an individual mental health service on its own, even if it produces good outcomes, is not sufficient to meet all the support needs of the many people with mental conditions and psychosocial disabilities. For this, it is essential that different types of community-based mental health services work together to provide for all the different needs people may have including crisis support, ongoing treatment and care, community living and inclusion. In addition, mental health services need to interface with other sectors including social protection, housing, employment and education to ensure that the people they support have the right to full community inclusion. The WHO guidance and technical packages comprise a set of documents including: • Guidance on community mental health services: Promoting person-centred and rights-based approaches – This comprehensive document contains a detailed description of person-centred, recovery and human rights-based approaches in mental health. It provides summary examples of good practice services around the world that promote human rights and recovery, and it describes the steps needed to move towards holistic service provision, taking into account housing, education, employment and social benefits. The document also contains examples of comprehensive, integrated networks of services and support, and provides guidance and action steps to introduce, integrate and scale up good practice mental health services within health and social care systems in countries to promote UHC and protect and promote human rights. Technical package xxi • Seven supporting technical packages on community mental health services: Promoting person- centred and rights-based approaches – The technical packages each focus on a specific category of mental health service and are linked to the overall guidance document. The different types of services addressed include: mental health crisis services, hospital-based mental health services, community mental health centres, peer support mental health services, community outreach mental health services, supported living services for mental health, and networks of mental health services. Each package features detailed examples of corresponding good practice services which are described in depth to provide a comprehensive understanding of the service, how it operates and how it adheres to human rights standards. Each service description also identifies challenges faced by the service, solutions that have been found and key considerations for implementation in different contexts. Finally, at the end of each technical package, all the information and learning from the showcased services is transformed into practical guidance and a series of action steps to move forward from concept to the implementation of a good practice pilot or demonstration service. Specifically, the technical packages: • showcase, in detail, a number of mental health services from different countries that provide services and support in line with international human rights standards and recovery principles; • outline in detail how the good practice services operate in order to respect international human rights standards of legal capacity, non-coercive practices, community inclusion, participation and the recovery approach; • outline the positive outcomes that can be achieved for people using good practice mental health services; • show cost comparisons of the good practice mental health services in contrast with comparable mainstream services; • discuss the challenges encountered with the establishment and operation of the services and the solutions put in place to overcome those challenges; and • present a series of action steps towards the development of a good practice service that is person- centred and respects and promotes human rights and recovery, and that is relevant to the local social and economic context. It is important to acknowledge that no service fits perfectly and uniquely under one category, since they undertake a multitude of functions that touch upon one or more of the other categories. This is reflected in categorizations given at the beginning of each mental health service description. These documents specifically focus on services for adults with mental health conditions and psychosocial disabilities. They do not include services specifically for people with cognitive or physical disabilities, neurological conditions or substance misuse, nor do they cover highly specialized services, for example, those that address eating disorders. Other areas not covered include e-interventions, telephone services (such as hotlines), prevention, promotion and early intervention programmes, tool-specific services (for example, advance planning), training and advocacy. These guidance documents also do not focus on services delivered in non-specialized health settings, although many of the lessons learned from the services in this document also apply to these settings. xxii Comprehensive mental health service networks How to use the documents Guidance on community mental health services: Promoting person-centred and rights-based approaches is the main reference document for all stakeholders. Readers interested in a particular category of mental health service may refer to the corresponding technical package which provides more detail and specific guidance for setting up a new service within the local context. However, each technical package should be read in conjunction with the broader Guidance on community mental health services document, which provides the detail required to also integrate services into the health and social sector systems of a country. These documents are designed for: • relevant ministries (including health and social protection) and policymakers; • managers of general health, mental health and social services; • mental health and other health and community practitioners such as doctors, nurses, psychiatrists psychologists, peer supporters, occupational therapists, social workers, community support workers, personal assistants, or traditional and faith based healers; • people with mental health conditions and psychosocial disabilities; • people who are using or who have previously used mental health and social services; • nongovernmental organizations (NGOs), and others working in the areas of mental health, human rights or other relevant areas such as organizations of persons with disabilities, organizations of users/survivors of psychiatry, advocacy organizations, and associations of traditional and faith- based healers; • families, support persons and other care partners; and • other relevant organizations and stakeholders such as advocates, lawyers and legal aid organizations, academics, university students, community and spiritual leaders. A note on terminology The terms “persons with mental health conditions and psychosocial disabilities” as well “persons using mental health services” or “service users” are used throughout this guidance and accompanying technical packages. We acknowledge that language and terminology reflects the evolving conceptualization of disability and that different terms will be used by different people across different contexts over time. People must be able to decide on the vocabulary, idioms and descriptions of their experience, situation or distress. For example, in relation to the field of mental health, some people use terms such as “people with a psychiatric diagnosis”, “people with mental disorders” or “mental illnesses”, “people with mental health conditions”, “consumers”, “service users” or “psychiatric survivors”. Others find some or all these terms stigmatizing or use different expressions to refer to their emotions, experiences or distress. The term “psychosocial disability” has been adopted to include people who have received a mental health-related diagnosis or who self-identify with this term. The use of the term “disability” is important in this context because it highlights the significant barriers that hinder the full and effective participation in society of people with actual or perceived impairments and the fact that they are protected under the CRPD. Technical package xxiii The term “mental health condition” is used in a similar way as the term physical health condition. A person with a mental health condition may or may not have received a formal diagnosis but nevertheless identifies as experiencing or having experienced mental health issues or challenges. The term has been adopted in this guidance to ensure that health, mental health, social care and other professionals working in mental health services, who may not be familiar with the term ‘psychosocial disability’, nevertheless understand that the values, rights and principles outlined in the documents apply to the people that they encounter and serve. Not all people who self-identify with the above terms face stigma, discrimination or human rights violations. a user of mental health services may not have a mental health condition and some persons with mental health conditions may face no restrictions or barriers to their full participation in society. The terminology adopted in this guidance has been selected for the sake of inclusiveness. It is an individual choice to self-identify with certain expressions or concepts, but human rights still apply to everyone, everywhere. Above all, a diagnosis or disability should never define a person. We are all individuals, with a unique social context, personality, autonomy, dreams, goals and aspirations and relationships with others.

11. introduction 2Comprehensive mental health service networks In several places around the world, individual countries, regions or cities have developed service networks which address the social determinants of health and the associated multiple challenges that people with mental health and psychosocial conditions face every day in all aspects of their lives. Crucially, these networks are making efforts to go a step further and work to rethink and reshape the relationships between services and the people who come to them for help. These networks of services have, in some cases, been explicitly inspired by a human rights agenda and have worked to establish recovery- oriented services. While they are focused on delivering a diversity of mental health services, they also recognize the importance of addressing key social determinants and actively collaborating with other sectors such as housing, education and employment. Many are also seeking to create the conditions for genuine partnerships with people with lived experience to ensure their expertise and requirements are integral to the services being provided. Several examples of mental health networks are provided in this section; some well-established, structured and evaluated networks that have profoundly reshaped and reorganized the mental health system, as well as some networks in transition, which have reached significant milestones. Showcasing these networks is not meant to imply that human rights standards are being met in all the network services at all times. This is not the case in any part of the world. However, these networks provide inspiring examples of what can be achieved with political commitment, determination and a strong human rights perspective underpinning actions in mental health. These examples are living proof that policy makers, planners and service providers can create a unique system of services that people with mental health conditions and psychosocial disabilities want to use and find helpful, and that produce good outcomes, protecting and promoting human rights. The service networks described in this technical package were chosen based on good practices known to the World Health Organization. The selection process was based on five human rights and recovery criteria, namely: respect for legal capacity, ending coercive practices, participation, community inclusion, and the recovery approach. The services described in this technical package are not intended to be interpreted as best practice, but rather to illustrate what can be done and to demonstrate the wider potential of community-based mental health services that promote a person-centred, rights- based, recovery approach. Providing community-based mental health services that adhere to human rights principles represents considerable shifts in practice for all countries and sets very high standards in contexts where insufficient human and financial resources are being invested in mental health. Some low-income countries may assume that the examples from high-income countries are not appropriate or useful, and equally, for high-income countries looking at the examples showcased from low-income countries. New types of services and practices may also generate a range of questions, challenges, and concerns from different stakeholders, be it policy makers, professionals, families and carers or individuals who use mental health services. The intention of this guidance is not to suggest that these services be replicated in their entirety, but rather to take and learn from those principles and practices that are relevant and transferrable to one’s own context in providing community-based mental health services that are person-centred and promote human rights and recovery. 32. Comprehensive mental health service networks – description and analysis 42.1 East Lille community mental health service network France Technical package 5 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS Context France operates with a sectorized mental health system, with approximately 850 sectors offering adult mental health services within population catchment areas of about 70,000 people. The East Lille sector is located in the Hauts-de-France region and serves only adults in an area with 88,000 inhabitants and six suburban towns. The area suffers from relatively high unemployment (15.6%) compared to the national average (11.1%) (1), and has the shortest life expectancy in France. The area is also is known to have an “under-resourced” health system (1). The Établissement Public de Santé Mentale (EPSM) Lille-Métropole, in Armentières, 25 km west of Lille, provides administrative management of the service on a day-to-day basis, and is also responsible for nine additional sectors, and a child and adolescent service that serves all these sectors. Since the 1970s, the mental health service in East Lille has undergone a series of major reforms and has promoted the concept of citizen psychiatry (psychiatrie citoyenne) which holds, as central elements, respect for the human rights of people who use mental health services and their empowerment. The first key phase of these reforms took place from 1970–1995, which saw a wide-scale shift of resources from institutions to the community. In the 1970s, the service mainly consisted of six inpatient units, based in the asylum at Armentières. These hosted over 300 long-term residents, and 98% of the budget was dedicated to their full-time hospitalization. An overseeing body was created in 1977, the Medico-Psycho-Social Association (Association Médico-Psycho-Sociale (AMPS)), to facilitate deinstitutionalization. It brought together the mental health service management, professionals, elected officials from the six towns in East Lille, and other groups that were interested in developing services in the sector. From the beginning, it was realized that reform could not only be about a reduction in the use of the asylum but would also require the inclusion of the wider community through educational work and a policy of integration. The next phase of reforms (1980–2010) involved the development of community- based mental health services alongside the integration of mental health into the health, social, and cultural services of the towns in the East Lille sector. There was also a movement towards the greater involvement of people with lived experience, family members, professional groups and elected officials, in the decisions of the mental health service. The following phase, from 2005 to 2014, witnessed the development of a large intensive mobile care team. From 2011, the emphasis moved towards creating the conditions for health democracy, in which all the stakeholders in the field of mental health (especially people with lived experience) would come together to develop and implement policy in a spirit of dialogue and consultation. Finally, from 2014 onwards, the primary task was to bring a recovery philosophy to the centre of the service. Since 2006, there have been important developments to sustain these achievements, including the replacement of AMPS in 2010 by a Local Mental Health Council (1), in line with changes in the rest of France (2). In East Lille, this local council is called the Intermunicipal Association for Health, Mental health and Citizenship (AISSMC), which is a forum where all the stakeholders from the six municipalities can meet, discuss and plan. It is chaired by the mayors of the municipalities and is co-led by the East Lille mental health service. As well as elected officials, managers and professionals, it involves people with lived experience, families and carers, residents, health and social services, general practitioners, social landlords, people from community centres, and people from the justice department. A general assembly is held every year. 6Comprehensive mental health service networks The AISSMC activities are organized according to four primary themes: • prevention – meetings on mental health issues, promotion of physical activity, cancer screening, and coordination of complex situations; • cultural actions – promotion of cultural and anti-stigma actions that make use of a fund of contemporary art, mixing pieces of art from people with and without mental health conditions; • housing issues – allocation, maintenance and planning of housing for people with mental health conditions in the municipalities; and • the local health contract – a national system which aims to define and coordinate mental health actions in the territories along the main regionally defined issues, which benefits from strong participation of elected officials in the negotiations. Description of the service The network of mental health care provided by the East Lille sector has been built over 40 years of reorganization and reform. The commitment from the head of the sector and the team has demonstrated that a shift from inpatient care to diversified, community-based interventions for people with mental health issues and/or psychosocial, intellectual and cognitive disabilities is possible, with a similar budget and epidemiological profile to other mental health sectors in France. The reforms have been made possible by the involvement of the municipalities, other stakeholders, people with lived experience, and their carers. The Local Mental Health Council (AISSMC) is the basis for actions to promote rights and information on mental health in East Lille. Such councils now operate across France, with 230 currently constituted. The concept of “citizen psychiatry” informs the entire East Lille mental health network, and is based on five pillars (3): 1. human rights are inalienable, and the presence of mental health conditions can never impede or prevent someone from accessing these rights and ensuring they are respected; justice and psychiatry, prison and hospital, seclusion and care must never be conflated; 2. society, and thus mental health services, need to adapt to people’s needs, and not the other way around; 3. there is a need to close medical and social institutions that effectively exclude residents from their communities; and 4. there is a need to fight stigma and discrimination based on mental health conditions. This includes challenging stereotypes about dangerousness and lack of capacity. On the basis of these values, the service in East Lille engages as a partner with other stakeholders, including people who use the service and their families, NGOs, elected officers in the municipalities, and others who are involved in the mental health field. Working in concert with these stakeholders, the various elements of the East Lille mental health system interrelate to form a coherent network. Technical package 7 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS Elements of the mental health service network Local medico-psychological centres (Services Médico-Psychologiques de Proximité (SMPP)) SMPPs represent the first point of contact for people with the mental health system, and provide comprehensive care and support. They are based in two dedicated ambulatory services of the EPSM which are integrated into 12 other health-related facilities. A person is referred to the SMPP by their general practitioner (GP), and can consult a range of professionals there: nurses, psychiatrists, psychologists, psycho-motor therapists,b social workers, peer-support workers, and an adapted sport coach. On arrival at the SMPP, a nurse performs an initial assessment of the person’s psychological and physical needs within 48 hours of the referral. This assessment is then discussed by a multi-disciplinary team that meets twice a week, and the team makes suggestions for care and plans future steps. The suggestions for care are always sent to the GP to ensure continuity of care and effective partnership. There are no waiting lists and all professionals working at the centre also have time allotted for home consultations. Consultations by the SMPP team can take place at a range of venues in the community, making it very accessible, including at a swimming pool and at a social and support centre for youths aged 16-25 (who may directly access services without being referred by a general practitioner). Mobile team (Soins intensifs intégrés dans la cité (SiiC)) The mobile crisis and home-treatment team is the largest in France, in terms of the number of people cared for. It provides crisis response and intensive care at home for up to 15 people at a time. It is a multi-disciplinary team which includes a health executive, day and night nurses, psychologists, special educators, a psychiatrist, psychomotor therapist; and peer health mediator, available 24 hours per day, seven days a week. The average length of time that people are cared for is 12 days; most interventions are for a few days but some last for weeks. In 2018, a total of 253 people were cared for at home, and 640 crisis interventions took place at home, avoiding hospitalization. The ratio of equivalent full-time workers to people being cared for is 0.96 (nearly one professional per person) (4). All workers in the service are sensitized to the recovery approach, the handling of crisis situations without coercion, and the human rights of service users. Jérôme Bosch Clinic General Hospital While the entire network is structured to prevent hospitalizations, when necessary, full time hospitalization can take place in the Jérôme Bosch Clinic which has 10 beds and is located next to Lille University Hospital. Its multidisciplinary team consists of a health executive, day and night nurses, a socio-cultural animator, a psychologist and Qualified Hospital Services Officers who are responsible for maintenance and hygiene. Processes are in place to avoid hospitalization, and especially forced admission. In 2018, there were 341 hospitalizations for a total of 222 people (some people had more than one episode of hospital care). At any time, an average of seven people are resident in the clinic, and the average length of stay is seven days ([Medical information service], [EPSM Lille Métropole], personal communication, [2020]). b Psychomotor therapy is defined as a method of treatment that uses body awareness and physical activities as cornerstones of its approach. It is widely used in a number of European countries, including France. 8Comprehensive mental health service networks When a person enters the clinic, information is provided about their rights and obligations both verbally and in written format, and they can name a trusted person as a supporter. The organization and architecture of the clinic is set up to ensure that people can maintain their right to privacy. All rooms are single occupancy and every person in the service has a key to their room and a safe in which they can keep their personal belongings. People staying in the hospital are free to enter and leave their rooms as they wish. The clinic relies on the close support network of the person using the service, in order to help with negotiation, safety and the avoidance of conflict. There is open visiting (5) and two rooms have a second bed for support people who can stay overnight at the clinic. An important emphasis is placed on the availability of health professionals in the clinic: the ratio of full- time workers to hospital beds is 3.1:1, with a minimum of three nurses during the day and two at night. There is also a nurse assistant, and a worker in the activity room who provides animations and artistic activities. On Sundays, external guests are invited, such as an artist or a sports coach, etc. Special needs workers (éducateurs spécialisés) are available daily to deal with social or administrative issues that a person using the service may encounter. Peer support workers who are employed by the EPSM come in each week to support people in hospital. These peer supporters have undertaken specific training to acquire a recognized national qualification. Throughout their hospital stay, the objectives of care and support are defined with the person using the service. Within 24 hours of arriving at the hospital, there is a consultation with a general practitioner to assess any physical health needs. Most importantly, social workers and special needs workers are involved from the beginning to help address the individual’s needs in terms of housing, protecting other human rights, and practical issues, such as caring for pets. An important aspect of the philosophy of the service is that hospitalization should never isolate a person from the rest of the outpatient system; all the ambulatory teams make visits to people who are in the hospital. The multi-disciplinary team meets daily to discuss care. All health professionals in the sector receive specific training to prevent instances of conflict and violence. The service also employs the services of an external security firm for situations where there is a risk of violence. These security agents can be called by the hospital staff, but otherwise do not interfere in the care offered to individuals. Their role is to help to create a climate of non-violence by reassuring professionals and people using the service that they are safe. In addition to general outpatient crisis plans, specific plans are also agreed upon to avoid any non- consensual interventions. The service does not have a dedicated seclusion area and seclusion is never practiced. While the use of any form of restraint is rare, coercive interventions are not entirely prohibited and physical restraint is used, exceptionally, on a time-limited basis. The clinic monitors the use of restraint and records all such instances and the duration of each. Between 2011 and 2019 physical restraint was used with an average of 1.77 persons per year, but since 2017 only one person per year has been subject to the use of physical restraint ([Medical information service], [EPSM Lille Métropole], personal communication, [2020]). The service has an internal goal of reducing such instances to zero. Chemical restraint is also rarely used and has recently received special attention. In 2019, nine cases of forced neuroleptic injection were reported. Each use of restraints is considered to be a major negative event in care and is subsequently investigated in order to ensure a continuous process of improving practices and reducing its use. Service users and their families are invited to participate in this. Technical package 9 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS The service places an emphasis on continuity of care as people transition out of the hospital. Families and trusted people are notified. An exit questionnaire is optionally completed by the service user, with support if needed (see Evaluation section below). A summary discharge letter is also given to the person who has used the service, with a copy for their GP. Therapeutic host families Staying with host families is another alternative to hospitalization. The goal of this service is to welcome a service user as a member of a family rather than being subject to a traditional patient/caregiver relationship. For this reason, the training of the host families does not focus on providing them with clinical caregiving skills; instead they receive training so that they understand how to support a person with a mental health condition or psychosocial disability within a recovery and human rights-based framework. They are also trained in preventing any form of mistreatment in the private homes, ways to help with agitation and crisis avoidance, and how to host a person as a family member. This host family service was used by 42 people in 2018, with an average length of stay of 32 days (4). The families involved were able to offer seven places at a time. In 2019 the availability of places decreased to two families who were able to offer four places. The host families receiving training and financial support from the EPSM for their service. There is supervision throughout the hosting period, and separate feedback meetings with all involved stakeholders. Peer group meetings are organized between the host families once or twice a year to discuss the challenges that they face. intersectoral family and systemic therapy centre The intersectoral family and network therapy centre (Don Jackson) is a specialized external consultation centre that delivers psychotherapeutic interventions for families and couples. Over 30 years, a total of 667 couples and 506 families have used these services. Although therapists from different backgrounds have worked at the centre, all have received additional training in the systemic approach to family and couples’ therapy over a four-year period. This has created a common, multidisciplinary, holistic perspective from which to consider therapy and support. Habicité Habicité is an Assertive Community Treatment (ACT) (6) team that provides long term intensive input to 80 persons with mental health conditions. This team is comprised of nurses, social workers, peer supporters, psychologists and an executive with a 1:8 professional to service user ratio (7). This service supports people in their personal recovery projects, allowing them to stay in their home and community. In addition, the service offers a range of communal housing; currently there are 13 apartments providing housing for 26 people. Access to this system has recently been democratized by including community representatives in the procedure, including elected representatives, experts with lived experience and social partners. Moreover, the service is now based on a “housing first” philosophy which means unconditional access to housing and unconditional support to make it work (8). Frontière$ Frontière$ is another element of the mental health service network, which is focused on increasing social inclusion and the general wellbeing of people using the service through physical, artistic, cultural, creative and professional activities. The team of Frontière$ comprises a nurse, a GP, an occupational 10 Comprehensive mental health service networks therapist, special needs educators, an artist, an adapted sports coach, a psychologist, psycho-motor educators, as well as five external people who organize the therapeutic activities and support people outside the service setting, through their connections with associations and other municipal bodies. Peer support workers currently at a training stage are also employed in the team and will continue to work with Frontière$ when they have completed their training. One of its services is to organize inclusion activities in ordinary leisure environments, with individualized, sustained support for people experiencing a mental health crisis, through the Service for activities of inclusion and integrated care in the community (Service d’activités d’insertion et de soins intégrés à la cite (SAISIC)). Further, its “Sagacités” system offers support to people who wish to attend activities with people outside the mental health service, also in an ordinary leisure and cultural environment. This support can either be very focused on specific activities or take the form of intensive coaching. Peer support groups can also be offered if people have a common project or interest. Lastly, this service offers support to facilitate access to and retention of employment through partnerships with local actors and stakeholders. An occupational therapist helps to define career and professional plans with service users, and a psychologist helps with motivation and evaluating vocational competencies. Network coordination and connections between services All mental health services in the East Lille network are connected and work together, which allows people to participate in one or more services: for example, people in Habicité can also be a part of Frontière$. By 2018, a total of 3513 people were receiving care from the service network ([Medical information service], [EPSM Lille Métropole], unpublished data, [2018]), and 75% of the professionals employed by the mental health service in East Lille were working in mobile teams and other community-based roles. This intensive community-based support was sufficient to keep the number of inpatient beds to 10, with a current average daily bed occupancy of seven ([Medical information service], [EPSM Lille Métropole], personal communication, [2020]). All East Lille mental health services work and operate as a network to create a coherent care pathway for each individual and are connected via an intranet network. All health professionals in the network have access to the information kept on the intranet about people using the service,c ensuring continuity and making coordination between different elements of the service possible (9). For example, in the SIIC, the intranet enables health professionals to rapidly identify the person’s medical and psychosocial background, and to refer them to the doctor, nurse or psychologist that they know best. The same file is used for outpatient and inpatient care in order to prevent loss of information. c In France, health information is subject to strict regulations regarding data access and storage. Information is stored on secure servers authorized to host health data and is accessible only to the healthcare team and to the person using the service, upon request. Access to medical files is under the strict control of an external institution, the Commission d’accès aux documents administratifs. As a general rule, people using the service can consult their file when they meet with professionals. Technical package 11 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS Core principles and values underlying the community-based mental health network Respect for legal capacity The service is committed to promoting respect for legal capacity by supporting initiatives and procedures that maximize independent and supported decision-making. However, the service does allow for involuntary admission and treatment. Out of the 222 people hospitalized in East Lille from 2013–2019, compulsory hospitalizations averaged 86.4 persons per year (39%), which is an average of 101.6 persons per 100,000 inhabitants per year. This high rate corresponds to the extensive use of these measures in France generally – in 2018 there were 82,000 compulsory admissions in the country – a rate of 122.6 per 100,000 (10). The mean length of stay in East Lille was 57 days, which is fairly close to the average for the Hauts-de-France region. The majority of these compulsory admissions are not organized by the staff from the East Lille sector, but by psychiatrists working in the general hospitals in Lille who see people in crisis who attend the Emergency departments of these hospitals. They arrange the admissions directly with the Jérôme Bosch clinic and effectively bypass the East Lille mobile crisis team (SIIC). The East Lille service does not have the authority to prevent this practice. However, once people are admitted to the clinic, plans are quickly made for discharge and the person’s status is converted to voluntary as soon as this is legally permissible. The average length of stay is only seven days. One of the major obstacles is that French law requires, in some cases, that the person no longer presents with a mental health condition, before the measure can be lifted. One of the new objectives in 2020 is to achieve a rate of zero hospitalizations without consent that last for more than 72 hours. To reinforce respect for legal capacity, the Users’ Commission (La Commission des Usagers (CDU)) – a branch of EPSM Lille-Métropole in charge of relations between users and professionals – organizes three legal advice sessions per month, in which people have access to external and independent lawyers, as well as advice from representatives of users and families. Every involuntary hospitalization is subject to judicial review, as provided by law, on the 12th day. Each person using the service is assisted by a lawyer at no cost to themselves. The East Lille network also uses advance planning as part of overall recovery plans, to discern and respect the will and preferences of individuals using services. These generic crisis plans are inspired by WRAP (11) and differ from the more specific plans used in the Jérôme Bosch clinic, which identify the triggers that might upset service users and list the interventions by professionals that they find helpful. These are used to anticipate and prevent conflict situations, and thus avoid coercive interventions. Advance plans are integrated using the online tool, Cariatides, to ensure that they are offered to the person in a user-friendly way and can be easily modified and followed-up throughout care. The target for the year 2018 was to ensure that every person going through the SIIC services is offered the opportunity to develop an advance plan. In 2018, around 300 people completed an advance plan, with a prioritization for those whose suicidal risk was high. Alternatives to coercive practices All the people working in the service receive training in de-escalation techniques, the recovery approach and in respecting patients’ rights, which helps to avoid and manage conflict situations. While great efforts are made to care for people outside hospital, and a range of concrete alternatives to hospitalization are 12 Comprehensive mental health service networks in place, forced admissions and forced treatment do sometimes occur. The rate of forced interventions is minimized in the Jérôme Bosch clinic through the use of crisis prevention plans. Even though these do not have legal status under French law, the service is fully committed to respecting a person’s prevention plan. In all cases following a crisis, the person is invited to review the plan with staff so that it can be improved and made to work better in the future. If a person refuses to take prescribed medication at the hospital, their wishes are respected. There is always a psychiatrist available to adjust the prescription as needed; they alone have the authority to make decisions regarding medication. If the providers think that a particular treatment would be beneficial, they negotiate (repeatedly, if needed) with the person who does not want to receive treatment, in order to reach informed consent. However, forced treatment still occurs at the clinic, even though every effort is made to avoid it. Failure to respect consent, and in particular the use of physical or chemical restraint (through forced injection of medication) is considered a failure of care, and all such episodes are analyzed by the service afterwards. Any forced use of medication is carefully tracked by the service, and service users and their families participate in the analysis and evaluation of these events. In 2019, there were 11 uses of medication without consent (two of these involved long-acting medication; nine cases involved punctual use) ([Medical information service], [EPSM Lille Métropole], personal communication, [2020]). Seclusion is never used in the hospital or other East Lille services. Community inclusion Community inclusion is the cornerstone and underlying philosophy of the network. Initiatives such as Habicité, Frontière$, the therapeutic host families, and the SMPP are examples of specialized support to promote community inclusion. Several support groups are also offered to service users to promote community inclusion and citizenship. The topics of those groups are based on needs identified by people using the service, such as: how to use public transport, how to access activities, how to protect rights, and how to manage one’s diet and “eat better, feel better” (particularly in relation to the effects of medication). These structured groups have a defined number of sessions and objectives and are led by various professionals. While they are subject to national regulations that require the presence of professionals, there are efforts to make these groups less “professional-dominated” with a greater emphasis on peer support and empowerment. Therapeutic and social inclusion activities are also integrated into public and ordinary community activities, through the Frontière$ service through an initiative called “hors-les-murs”, meaning outside of the facilities of the service. The East Lille sector has many partnerships with sports, cultural and social services to ensure participation of people with mental health conditions and psychosocial disabilities in ordinary community life. The aim is to use a person’s wishes and motivations as a starting point, to support participation administratively so that he or she can take part in community activities, and if necessary, to assist in attending the activity, but withdrawing from this role as soon as feasible. The East Lille service has established active links with many community-based services and organizations over the years, including with elected officials, social institutions, cultural institutions, user and family groups, and various health partners in the towns (GPs, pharmacists and private nurses etc.). It uses these links to help people using the service to re-establish their place in the community (1). Technical package 13 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS Participation In 2008, two self-help groups (Groupes d’Entraide Mutuelle) were established, which marked the starting point of real participation of people with lived experience in the organization of the service. These groups were funded by the Ministry of Health and were independent of the East Lille sector. Their objective was to promote peer support in daily life, leisure and social activities. The groups then became partners of the sector, as local and national users’ and carers’ associations. The creation of the Local Mental Health Council in 2010 (as discussed above) further emphasized participation of people with lived experience, along with their families and carers. In 2012, two peer support workers (Médiateurs de Santé-pairs) were hired as professionals in the mental health teams, which has now expanded to include five peer support workers. Also in 2012, a working group was created dedicated to the participation of people with lived experience – involving professionals, service user associations and peer support workers – which led to several innovations: a forum for people using the service in the form of a community workshop to discuss mental health and the organization of the service, communication tools, a suggestion form and a recovery charter drafted and signed by all stakeholders. In 2015, people using the service elected four representatives who participate directly in the management meetings of the service, to work on suggestions and complaints, and to organize the users’ forum. There are now six representatives who act as spokespersons for people using services in East Lille, who collect opinions and comments on the different network services through quarterly service user forums and suggestion boxes. They are also involved with investigating and reviewing the undesirable events forms that track use of coercive interventions, and participate in the sector’s steering committee meetings, management meetings and working groups. These representatives receive training on human rights and the recovery approach and have monthly meetings with professionals from the sector, to discuss current topics and complaints to be addressed by the service. One of the spokespersons has received the WHO QualityRights training (4). Feedback is also systematically collected at the hospital through exit questionnaires at the time of discharge, and through satisfaction questionnaires (12) that are completed by people using the full range of services. Suggestion boxes are available at all services, where anonymous comments or complaints can be made. This development has been recognized with the “Users Rights” award of the Regional Health Agency and has benefited from two grants, which were used for the training of spokespersons and the development of communication tools. In 2017, a training programme called “experts by experience” was developed, led by people with lived experience or members of service user and carer organizations. It provides training for professionals of the service on topics such as hearing voices, eating disorders, work and burn-out. These sessions happen every month and are aimed at informing the professionals about what is helpful (or not helpful) from the perspective of someone using the service (see next section). At the institutional level of the EPSM, the Commission of Service Users monitors the way in which the rights of those using the service are being respected and represents service users’ interests in the service decision-making bodies. Recovery approach The East Lille network has a steering group specifically on recovery and on promoting recovery-oriented tools in the sectors’ services. Since 2014, all services have been guided explicitly by the recovery 14 Comprehensive mental health service networks approach. In the East Lille sector, all professionals are trained in the recovery approach through presentations and workshops by experts on recovery-based practices, including by persons with lived experience and external guests. The training takes place annually in groups of 20–30 people, to ensure that everyone in the service receives the training. The East Lille mental health sector constantly explores new ways to support the recovery approach. For instance, one of the first tools used was called the Barometer, a recovery-based online platform. It aims to ensure that care not only concerns medication but focuses also on the person’s general quality of life, their social network, their achievements and their strengths. The person, and if desired a support person, can then work together to craft specific objectives that contribute to the person’s recovery, ensuring that progress is tracked consistently. This tool is used to encourage people to make advance plans and recovery plans which are formalized through their online medical file. The service further seeks to promote empowerment in many different ways; for example, training sessions for the professional staff are held by persons with lived experience every month. All these tools serve the same objective: to stay as close as possible to the needs that people identify for themselves, and, when needed, to help them articulate their own wishes and make their own decisions about care. Service evaluation The network of services in the East Lille sector keeps detailed audit figures for its activities, with annual objectives tracked monthly using well-defined and measurable indicators. An important achievement of this network is seen in the steadily decreasing rate of hospital admissions per year from 2002–2018 (from 497 to 341), despite a considerable increase in the number of people receiving care in the network (from 1677 to 3518 people). Furthermore, the length of stay at the in-patient unit decreased from 26 days to seven days over the same period ([Medical information service], [EPSM Lille Métropole], unpublished data, [2018]). In 2018, 34 people out of 222 completed the exit questionnaire at the Jérôme Bosch Clinic. On a scale of 1 to 10, the mean satisfaction rating was 8.06 (SD = 1.94), and 79.4% said that they felt better, or much better, compared to how they felt at the time of admission ([Medical information service], [EPSM Lille Métropole], unpublished data, [2018]). The local SMPP centres also track efficiency indicators which show that 80% of people have their initial assessment within 48 hours of contact. The quality of patient file completions showed between 80- 100% success in 2018, which demonstrates accurate and reliable monitoring ([Medical information service], [EPSM Lille Métropole], unpublished data, [2018]). In September 2018, an independent assessment team composed of eight members (including a psychiatrist, a quality director, a former hospital director, two lawyers, a psychologist, a family member and a service user), conducted the WHO QualityRights evaluationd in all the services of the East Lille sector. It was found that three themes were fully achieved: i) the enjoyment of the highest attainable standard of physical and mental health, ii) freedom from coercion, violence and abuse, and iii) the right to live independently in the community. The remaining two themes: iv) the right to an adequate standard of living and v) the right to legal capacity and personal liberty and security, were partially achieved (4). The existing legal framework was found to be an important barrier to the full achievement of these two themes. d These are the ratings for the five main themes, which are divided into 25 standards and 116 criteria. Full results and recommendations available on the QualityRights platform, see https://qualityrights.org/wp-content/uploads/ QualityRights-59G21-report-2019.docx. Technical package 15 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS The East Lille sector has changed dramatically over a period of four decades. Efficiency outcomes demonstrate that the network is well-run, organized, and cost-effective. The number of new people being cared for in the sector has increased steadily over the last decades, paralleling a decrease in the number of hospitalizations and demonstrating a real capacity of the network to provide community- based alternatives for care. The costs of the service are no higher than elsewhere in France and are actually lower than the cost of mental health services in surrounding sectors. The East Lille sector has been recognized by the French government and is being used as a model for further development of mental health policies in France. For example, the Roadmap for Mental Health and Psychiatry, published in 2018 (Feuille de Route Santé Mentale et Psychiatrie) (13) explicitly voices the government’s objective to integrate people with lived experience in mental health care, to promote the recovery approach to services, and to facilitate the inclusion of people with mental health conditions and/or psychosocial, intellectual and cognitive disabilities in the community. In April 2019 an inter- ministerial delegate was charged with its implementation and concurrently, the national budget for mental health was substantially increased (14). The East Lille sector was also mentioned positively in another recent parliamentary report (15). This national recognition demonstrates the East Lille approach is now becoming national policy. Costs and cost comparisons The service is entirely state-provided, and users of mental health services are completely covered by the national health care system. The average cost per person using the service decreased steadily from 2013–2017, from €3,131 (approximately US$ 3,684) in 2013 to €2,915 (approximately US$ 3,430)e in 2017 (4). These figures include costs associated with the whole care pathway, from the initial consultation to hospitalization. Overall in France, 61% of expenditure on mental health care is spent on hospitalization. However, in East Lille hospitalization represents only 28.5% of expenditure (4). The overall costs in East Lille are the lowest in the entire EPSM area. Challenges and solutions Challenging entrenched attitudes of stigma and discrimination One of the obstacles encountered in establishing the network was that stigma attached to people with mental health conditions (amongst professionals as well as in the wider community) meant that coercive practices and poor standards of care were seen as acceptable. People with mental health conditions were not seen as people who had the same rights as other people. They were generally seen as lacking the capacity to make decisions for themselves. To begin to address these pervasive attitudes, active engagement was necessary with the wider community about mental health and the rights of people who use services to overcome stigma, including bringing politicians and members of the community to visit psychiatric hospitals. The East Lille sector further addressed this issue through development of the philosophy of “citizen psychiatry”, which emphasizes the personal, social and cultural needs of people with mental health conditions and their entitlement to enjoy the same human rights as those of other citizens. Another e Conversion rate as of March 2021. 16 Comprehensive mental health service networks aspect that has helped to change entrenched ideas is the broadening of the network’s focus beyond health and widening of the scope of intervention to include social work, education and housing. The systematic involvement of service users and people with lived experience was also a critical aspect which helped slowly change perceptions and practices. Working within the limits of an outdated national legislative framework Another challenge faced by the East Lille network of services is that the presence of national legislation which allows for coercion continually serves to undermine the efforts of the mental health team to prevent it. Coercion is seen as the ‘easy option’ instead of something to be avoided at all costs. As a result, the network has encountered particular resistance to cultural change within mental health services themselves, in relation to coercive practices such as seclusion, restraint and forced treatment. Fortunately, the sectorization of services in France allowed the local mental health service in East Lille to use its finances to fund alternatives to hospitalization. The East Lille network has found that creating a system where the voice of the person using the service is genuinely heard, acts to counterbalance the drive towards coercive interventions. Having staff trained by people with lived experience also helps them to understand fully the importance of a human rights and recovery agenda. Finally, taking time to explore in some detail any instance when coercion has happened, means that it is less likely to happen again. Maintaining open communication among services Being decentralized, the network also faces the ongoing daily challenge of maintaining a permanent dialogue among the services, in which the notions of recovery and human rights are central to all the different stakeholders. One important action to address this challenge involves the ongoing training of professionals and other stakeholders on recovery and rights-based approaches to mental health. Another key aspect has been the creation of the Local Health Councils (AISSMC). The community-wide consultation structure involves a wide group of stakeholders including people using the service, their families, staff of the mental health service, social services staff, elected representatives, artists, other citizens, GPs, the police, the justice department and education sector, in order to improve communication and create buy-in from all parties. A further innovation supporting cross-sector communication was the establishment of quarterly service user forums which collects opinions and comments from users of all the network services. Key considerations for different contexts Key issues to consider for the establishment or expansion of this service in other contexts include: • uworking with the aim of achieving zero coercion and zero hospitalizations in the service if possible, pushing the service to provide “unconditional care”, characterized by availability and flexibility in working to the person’s own agenda; • systematically involving service users/people with lived experience in any new service development and in research and evaluation efforts; • supporting people with lived experience to have a “professional” status in the service and helping them to develop the skills to represent others in a genuine way; Technical package 17 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS • avoiding a narrow clinical agenda and seeking instead to identify the full range of a person’s personal, social and cultural needs (such as housing, education and employment, while working with other community stakeholders to respond to these issues; • evaluating the service using the WHO Quality Rights assessment Tool Kit provides a very helpful way of evaluating the service, and is the most comprehensive evaluation tool made by and for all the actors involved; • valuing the sense of pride that staff experience when they are able to provide care that is really responsive to the needs and demands of the people using the service; and • considering evaluation outcomes on a “whole system” level, including levels of coercion, suicide figures, rates of people cared for outside of hospital and the costs of the service. Additional information and resources: Website: https://www.epsm-lille-metropole.fr/recherche?field_tags=All&search_api_fulltext=G21 videos: Les SISM, c’est quoi ? Avril 2014, https://youtu.be/D7_1SQSiNb4 Contact: Jean-Luc Roelandt, Psychiatrist, Centre collaborateur de l’OMS pour la Recherche et la Formation en Santé mental, Etablissement Public de Santé Mentale (EPSM) Lille-Métropole, France. Email: jroelandt@epsm-lm.fr Simon Vasseur Bacle, Psychologue clinicien / Chargé de mission et des affaires internationales, Centre Collaborateur de l’Organisation Mondiale de la Santé (Lille, France), Etablissement Public de Santé Mentale (EPSM) Lille-Métropole et Sector 21, France. Email: svasseurbacle@epsm-lille-metropole.fr 18 2.2 Trieste community mental health service network Italy Technical package 19 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS Context Trieste is a city with a population of approximately 236,000 (16) and is the capital of the autonomous Friuli Venezia Giulia region in the north-east of Italy. A profound transformation of mental health services in Trieste began in the 1970s (17) with the closure of the old San Giovanni asylum, where 1200 people were being housed. Historically, the Italian reforms emerged within a social movement for the achievement of human rights across all Italian society. In Trieste, freedom and human rights became a central concern of mental health services, including the relocation of people from the institution to live in the community. The psychiatric institution was replaced by a network of community services which involved major changes in the allocation and spending of budgets (17-21). Today, the promotion of the citizenship of people with mental health conditions and psychosocial disabilities remains an essential feature and central tenet of the mental health service. In order to avoid fragmentation, all services are coordinated by the Department of Mental Health (DMH), which is responsible for the budgeting, planning and delivery of service (22). In 2020, a newly established health care agency, the Azienda Sanitaria Universitaria Giuliano Isontina, became the legal entity responsible for Trieste and the neighbouring territory of Gorizia.f While there is a common approach between both geographical areas the service description below focuses on Trieste as it developed up until the establishment of the wider organization in 2020. Description of the mental health service network Within the Trieste community mental health system, a “whole person, whole system, whole community” approach to mental health care has been developed, which places a major emphasis on working with the wider community to develop a fully integrated system of support with open doors and no restraint. People are supported as much as possible in their own homes and localities so that they are able to maintain links with their communities. There is an emphasis on human rights (including actions to promote social inclusion) and community participation, in order to avoid institutionalization and ensure people live their lives in their communities. This has been achieved through active engagement and collaboration with the health and welfare services, the juridical system, the cultural institutions, the regional and city authorities and other community organizations, in order to enhance the social capital of the city. The development of a broad partnership with peers, staff, trainees, volunteers, family members and social networks has also promoted a “whole life” approach. The Mental Health Department coordinates these partnerships, guided by key operational principles: • accepting responsibility for the mental health of the community • active engagement and responsiveness (there are no waiting lists) • high accessibility of the service • continuity of care • rapid responsiveness to crises in the community • comprehensive care • focus on teamwork and stakeholder participation (23). f Gorizia is a city of 140,000, including the area of Monfalcone. The asylum in Gorizia was the site of the first reforms in Italy in 1961, led by Franco Basaglia who moved to Trieste in the 1970s. 20 Comprehensive mental health service networks Elements of the mental health service network Community Mental Health Centres (CMHCs) Community mental health centres (CMHCs) are the primary point of entry into the mental health services and system. There are four CMHCs in the territory of Triesteg which form the heart of the service. Each serves a catchment area of 50,000 to 70,000 people. Each CMHC has a team of approximately 20-22 nurses and support workers, plus social workers, psychologists, rehabilitation specialists, and psychiatrists. Two members of staff are resident at night. The teams at the centres are multi-disciplinary and work in a flexible and highly mobile way. Staff are involved in delivering care, providing support for the coordination of services and fostering recovery by connecting people to the different initiatives, services and opportunities in the community. Their overarching goal is not only to provide treatment and care in a human rights framework, but also to promote social integration and inclusion (24). Each CMHC contains six beds (the exception is Monfalcone which has eight beds). They are open 24 hours a day and accept all referrals. People who stay overnight are called “guests”, rather than “patients” (24) and are encouraged to continue any involvement they may already have in ongoing activities in the community. They may host visitors as wished on an informal basis. The CMHCs also provide outreach activities for people requiring continuity of care and long-term support. Approximately 50% of the team’s work takes place in the centres, and 50% in the community. Between 08:00 and 20:00 the CMHCs operate a walk-in service. Anyone who enters or telephones a CMHC receives a swift response, usually within one to two hours. The staff members have a rota system, ensuring that a team member is always available. There is no waiting list. A typical day involves a meeting at 08:00 in which the team organizes the structure of the day, with scheduled activities as well as any new priorities that may have emerged. Time is allocated to the guests staying in the service. Daily activities include outpatient visits, administration of medication, informal contacts/talks, group meetings, and the sharing of lunch and dinner together. There is a morning meeting with guests (for information, orientation, reassurance and possible self-disclosure). Staff members who are not involved in the internal activities of the CMHC perform scheduled visits to homes in order to provide support, or to accompany people to the CMHC for day care. Some people are accompanied to medical appointments, and others, for example, to carry out daily life activities, such as collecting their pension, visiting the bank, going to the police station, or attending their workplace etc. In the afternoon, there is a shift change and the new staff members may re-arrange activities if new priorities emerge during the day. The primary aim is to create and maintain a therapeutic, but informal and friendly environment; the concepts of “doing with”, and “being with”, are the guiding principles for interactions between staff and guests. The intake assessment is problem-based, rather than diagnosis-based, and first-person narratives are used to understand people’s life story and circumstances. If a person using the service, or their carer, considers a problem to be urgent, it is dealt with as a priority. Formalities are kept to a minimum. The first contact with a person is frequently made in the community, most often in their own home. In this case, a key worker is appointed promptly, and contact is made with the family and the g There are a further two CMHCs in the territory of Gorizia (one in Gorizia and one in Monfalcone). Technical package 21 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS social network of the person. The team also works to mediate and to resolve any conflicts arising in the network, where possible, but the autonomy of the person is respected at all times. The rapid response to crises in the community results in very few hospital admissions in Trieste. A person in crisis, if unable to receive support at home, is able to spend a brief time at the CMHC as a short-term guest. The offer of ongoing support and care, and an emphasis on discussion and joint decision-making, usually means that involuntary interventions are avoided. Long term follow-up and support is always available. The CMHC centres and teams provide the following services (25): • overnight hospitality and care • day care • an outpatient service • home treatment via home visits • crisis intervention at home, in the community, or at the CMHC • individual and group therapy • medication • psychosocial support and work with social networks • psychosocial rehabilitation • support for group homes • support in accessing education, cultural activities, vocational training and work placements • social activities, self-help and leisure activities. General hospital psychiatric services and unit (GHPU) There is one general hospital mental health unit in Trieste (Servizio Psichiatrico di Diagnosi e Cura), which has six beds and provides a second point of entry to the mental health service. This unit covers the territory of both Trieste and Gorizia, a population of approximately 375,000. It is mainly used for emergencies at night. People usually stay for less than 24 hours and are referred to the CMHC in their own area as quickly as possible in order to transfer them to community-based care. The team based at the hospital includes two psychiatrists, one of whom is the Director of the unit, along with approximately 16 nurses. The team at the GHPU also provides a liaison service to the general hospital; most of their work is based in the emergency department. Community inclusion support services and initiatives The Trieste mental health service network has a comprehensive set of rehabilitation and residential support services working in partnership with a wide range of non-profit organizations, such as social cooperatives, volunteer and social promotion associations, including those of peers and carers, to provide a comprehensive set of interventions aimed at making sure that people are able to live their lives in freedom and with a sense of dignity. The rehabilitation and residential support services interface and collaborate with social cooperatives in order to ensure access to supported housing, including the Trieste recovery house and other types of housing, which is implemented through the personalized health care budget. The aim of these programmes is to ensure full community inclusion and participation for people with mental health conditions and psychosocial disabilities. 22 Comprehensive mental health service networks Personalized health care budget The personalized health care budget is designed mostly for people with complex needs as well as younger people thought to benefit most from a highly personalized programme. It addresses social factors and other challenges that might have a significant impact on people. A plan is developed, which includes a person’s identified goals, and is discussed and agreed upon in collaboration with the person and sometimes his or her family. The latter are only involved with the individual’s permission. Finance for the personalized health care budget programme comes from mental health and sometimes welfare budgets. Several co-ops contribute to the planning and delivery of care. Typically, the areas covered are housing, education, training, employment and social relations (26). The programme caters for approximately 160 people in Trieste every year. These “personal health budgets” (budget individuali di salute) support some of following programmes. Supported accommodation Supported accommodation is provided through several small residential flats, each of which caters for up to five people, or in people’s own homes. These schemes provide accommodation for 42 people at any given time, and approximately 100 people every year. Staff provided by the social cooperatives give flexible support as needed, including on a full-time basis. They operate in collaboration with the CMHCs in order to guarantee continuity of care and treatment and to ensure independent living. Trieste Recovery House opened in 2015 and is a residential project run through the health care budget programme as a collaboration between the Trieste Mental Health Department and a social cooperative. It has space for four to six people to stay, usually for a period of six months. It is open to people aged 18–35 who have had significant contact with the mental health service and who are interested in pursuing a recovery journey. Its essential operational principles are: 1. democracy, self-determination and emancipation (“nothing about me without me”); 2. asset- and strength-based approaches; 3. a whole person, whole life approach; 4. acknowledgment of the expert by lived experience; 5. trialogical meetings;h and 6. a shared learning environment (27). Social enterprises (cooperatives) The mental health service collaborates with a network of approximately 15 social cooperatives (28-32) in Trieste. Some cooperatives cater for the management of socio-health and educational services. They work closely with the staff from the CMHC teams and provide, for example, the previously mentioned supported accommodation. Other cooperatives carry out various activities (agricultural, industrial, commercial and service) and are mainly aimed at sustaining employment opportunities for people. In these social cooperatives at least 30% of the workers must be “disadvantaged people”, who are treated as equals with the other workers (33, 34). h Trialogues are meetings between people using services, their families and supporters and mental health professionals in which the goal is an open discussion of mental health problems, their consequences and ways forward (see: https://www.intervoiceonline.org/tag/trialogical-approach). Technical package 23 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS These cooperatives offer job opportunities and educational/ vocational training, employing approximately 800 people in Trieste. In 2018, there were 292 trainees receiving work-grants (35). Over the years the work has covered a wide range of activities such as cleaning; building maintenance; transport; cafeteria work; catering; hotel and restaurant services; management of a beach resort; gardening; handicrafts; photo, video and radio production; computer services; serigraph printing; administrative services and personal services (23). An example is the Tritone Hotel in Trieste, which is a residence overlooking the sea – entirely managed by a social cooperative, mostly comprising users of services of the Trieste Mental Health Department. Other examples include Strawberry Fields Café (Il Posto delle Fragole), a busy restaurant managed by users of mental health services. The cafes at the Opera House in Trieste, the public radio station, a historical bathhouse, and all museums and public gardens, employ at least one-third of their staff through contract with the social cooperatives of mental health service users (30, 32, 36, 37). As well as the core services described above, Trieste also has several targeted programmes delivered in tandem with the other health district teams of the main health care agency, Azienda Sanitaria Universitaria Giuliano Isontina. These include: • a service for children and adolescents encompassing crisis care, through a day centre with therapeutic groups, psychoeducation, social activities and home visits; • an early intervention service for psychosis in adolescents and young people; • a service for young people with eating disorders; • coordinated care for persons with physical, as well as psychosocial, disabilities; • coordination of care for elderly persons in need of home assistance and in nursing homes (people with cognitive impairments and dementia); • close support for family doctors in providing care to people experiencing mental distress or who have received a diagnosis of a mental health condition; • improving care for persons with mental health and substance use conditions (coordinated through joint personalized care plans); • work in prisons and with the Tribunal for persons who are on trial, or have been convicted; and • work with families (a psychoeducational programme with 10 meetings/modules, self-help groups, and training course for a local carer association). Other activities implemented through the Rehabilitation and Residential Support Services Additional activities are organized across a number of locations through the Rehabilitation and Residential Support Services, with the aim of promoting social participation. Activities are run by volunteer associations, including organizations of peers and carers, and focus on defined areas such as wellbeing, physical health and sport, social participation, self-help and peer support, art expression and anti-stigma initiatives, gender programmes including culture, and work training and placement. Activities are organized in social spaces in the city and are in the style of clubs. Four of the organized activities/clubs, including a gym, are provided by the Department of Mental Health, with activities co- produced by the associations. Four other organized activities/clubs are run directly by the associations 24 Comprehensive mental health service networks themselves. Personalized health care budgets can be used to organize a very individualized programme of activities to suit the specific needs of a person. Core principles and values underlying the service Respect for legal capacity From the very beginning of the reforms in the 1970s, the focus in Trieste has been on promoting autonomy, independence and a respect for the person’s capacity to make their own decisions. This is reflected in the emphasis on the “rights of citizenship” (23). There is an explicit commitment to a right to informed consent as well as other commitments in a Bill of Rights, introduced by the service in 1995. People working in the Department of Mental Health do not wear uniforms and work to minimize barriers and hierarchies between themselves and the people they provide care and support for. All services have an open-door policy, and people can go in and out without physical barriers such as locks, keys or codes. Services in Trieste and Gorizia use the concept of “hospitality”. This means that the person using the service is encouraged to stay in contact with their normal life as much as is possible while they are staying in the CMHC, and can also participate in the on-going daily activities of the centre, if they wish. CMHC staff, people who work in the cooperatives, volunteers, carers and peers are all present in the centre during the day, and anyone staying can socialize and interact as much as they wish. “Guests” who are in crisis in one of the CMHCs are made aware that they have a right to leave the service should they so desire, to go out to cafés or for a walk. Although there are no specific rules about this, guests are asked to let the staff know where they are going and what time they will return. The staff members negotiate with the person as to whether she or he is able to go on their trip unaccompanied or whether they require active support from staff or from a relative, a volunteer or a peer. There is an emphasis on discussion regarding decisions about everything; the day-to-day care plan is adjusted according to personal needs, will and preferences. However, if guests who are experiencing a severe crisis wish to leave and abandon all forms of care, the staff negotiate and seek an agreed plan around safety. This can lead eventually to a legal decision to apply for involuntary treatment as last resort, after several attempts and offers of alternatives. People using the service on a routine basis self-administer their own medication whenever possible. A number of people collect their medication at the centre and take it at home. They, along with carers or supporters, can attend discussion groups and training events related to the treatments used. The effects and side-effects of the various medications are carefully explained. Written information is also provided through leaflets. Thus, people are assisted to make informed decisions about medication and other interventions (38). Personalized care plans are developed with the active participation of the person and their network. Apart from clinical interventions, these are based on the individual circumstances of the person’s life and can cover all relevant needs, from the person’s living situation, including home repairs, maintenance, cleaning, or looking for more appropriate accommodation, to personal finances – such as the need for cash subsidies, use of the centre’s safe, temporary daily money management, or support to maintain tenancies. The personalized care plan also covers aspects related to personal hygiene such as laundry, personal cleanliness and hairdressing, as well as purposeful activities, education, vocational training, work opportunities (such as simple tasks at the CMHC or job placements in a work cooperative or in an Technical package 25 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS open market setting) and leisure, including workshops in drama, art, music and needlework, gym visits, day trips, holidays, parties, cinema and theatre trips (24). These plans also cover the best ways to avoid relapse, and the person’s wishes in times of crisis, including where they would like to receive care. It is usually recommended that the person should keep in contact with the service, and phone immediately when in need (such as during a stressful event). These plans also include a negotiated account of the medication the person is going to take. Formalized advance directives (39) are not routinely used. Furthermore, if a person is considered to have impaired decision-making capacity, the provisions of the Law 6/2004 covering legal agency apply, and a support administrator (or legal proxy: usually a trusted person, a relative or a friend) can be appointed by a tutelary judge. This does not equate to supported decision making as this person may take on a more of a guardianship role and make decisions for the person in a substituted manner. Alternatives to coercive practices The service aims to avoid all forms of institutionalization (such as psychiatric hospitalization, or incarceration in jail, forensic units and nursing homes for the elderly) and all types of coercive, compulsory interventions. However, involuntary treatment (trattamento sanitario obbligatorio) is sometimes used as prescribed by Italian law. The vast majority of treatment, care and support is voluntary and average lengths of stay in either the CMHC or in the GHPU are short (an average of 13.8 days for the former; 1.7 days for the latter (40)). However, in the CMHCs, the “hospitality” extended to guests is informal and flexible, and sometimes lasts for weeks or months if needed until another solution or accommodation is possible. There is an explicit policy of “open door - no restraint” in both the CMHCs and the GHPU (16, 23, 41) and staff are trained in the use of dialogue, de-escalation strategies and the provision of personal support to guests under stress in order to avoid confrontation and the use of coercion. The various places in the CMHC: kitchen, garden, personal rooms are all used in de-escalation; seclusion has not been used since the psychiatric hospital was closed. In 2019, the rate of involuntary treatment was 8.11 per 100,000 population in Trieste (42) compared to 15 per 100,000 in 2017 for Italy as a whole (43). Notably, Italy has the lowest rate of involuntary hospitalization of all countries surveyed in Europe (44). In situations where involuntary treatment is used according to the law, when all attempts to provide care with consent have failed, it must be requested by two psychiatrists and endorsed by the mayor, who is the highest authority in the town, responsible for public health. These compulsory admissions last initially for seven days. As a particularity of Trieste (and its region), these happen mainly in the CMHCs, where the “open door” principle continues to apply. Involuntary treatment may be extended by periods of seven days for several extensions but can also be withdrawn after few days (33) if consent to care is achieved. When a person is receiving compulsory treatment, more staff are deployed in the CMHC, so that there are always two or three people available (mainly staff but also social cooperative support workers, peers, carers or volunteers) to meet the needs of a person in crisis. Close, personalized (one-to-one) care is therefore practiced. Family members may also be involved so that the person retains as much connection as possible to their daily life. The person may even continue to take trips into town if this is negotiated but, in the context of compulsory treatment, there is always someone to accompany the individual. The service aims to respond to the needs of the person, rather than acting in a “guarding” capacity. 26 Comprehensive mental health service networks In a limited number of cases, the police are involved to help and co-manage a situation, which is a legal requirement where immediate risk and a need for the protection of safety and health are considered to be at issue. Forensic hospitals were closed in Italy in 2015 (41); however, Trieste had not sent anyone to these facilities for 40 years. After they were closed, “residential facilities for security measures” (45) replaced them. In the Friuli Venezia Giulia region, a decision was made to locate two secure beds in three locations (Trieste, Udine and Pordenone Provinces), rather than have a single unit. However, from 2015, only one person from Trieste has been hosted in such a facility. Community inclusion The service in Trieste has achieved a significant level of integration of mental health with other community-based services including housing, employment and education. The Department of Mental Health works closely with all health and welfare services and directly funds a wide series of independent partners in the not-for-profit sector, such as social enterprises, cooperatives and volunteer associations. Even when in crisis, people staying at the CMHC are actively encouraged to maintain their usual daily community activities. For people with complex needs, the personalized plans that come with a personal health care budget can be used creatively to help with autonomy and community inclusion. Through a series of programmes developed in the community, people using the service are offered opportunities for engagement with a wide range of activities including sports, leisure, wellness, writing, films, museums and other cultural pursuits. Different educational and training courses are organized by associations and cultural agencies, in language, self-care, social identity and various aspects of community life. Through these various activities people are able to experience reciprocal relationships and new social roles. This is also achieved through job training and placement, and work in the social cooperatives. Participation The reforms in Trieste have always been concerned with the empowerment of people who are recipients of services, and users of the service are involved in planning, delivering and evaluating services (23). Group meetings of peers are actively encouraged and take place regularly in the CMHCs. Peer facilitators of these groups are paid for their work. A designated office within the health care agency receives feedback and complaints from people using services, and people can also request to meet the Director of the Mental Health Service. There is also a Participatory Committee which represents the views of service users and carers along with their associations, and a social cooperatives’ representative. Recovery approach The Trieste service network has sought to be responsive to the “whole life” needs of the person, rather than simply focusing on their diagnosis, and has sought to promote freedom, particularly from institutional residence or detention, as a therapeutic principle. A focus on personal autonomy, citizenship and human rights are basic elements of the “whole person, whole system, whole community” approach used in Trieste (46). Technical package 27 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS The personalized care plans developed with people using the service incorporate explicit recovery goals (26) and allow people to explore their aspirations as a basis for an individual programme or a whole “life project”. They can be assisted with money, work, training, education, living places, activities and relationships when necessary. The Trieste mental health service network recovery approach is based on the following ideals. • Holistic: services focus on values and principles rather than on diagnostic classifications and intervention techniques. Services attempt to respond to the “whole person” and their various needs, not simply their diagnostic label. • Whole life/whole system-oriented: attention is directed towards contextual issues and the services seek to engage with the person’s family and social network when appropriate. Much effort is spent on the promotion of social inclusion and cultural participation. • Rights-based: attention is paid to citizenship, participation and civil rights (both legal and social), such as the right to socially meaningful work (33). Over the past decade there has been a sustained effort to incorporate an overt philosophy of recovery into every aspect of the service. A Recovery Research Group produced a Recovery Charter in 2014 (47), which emerged from focus groups with people in all four CMHCs in Trieste and involved approximately 100 people, the majority of whom were people with lived experience (48). Service evaluation The changes in Trieste have been substantial since the reforms were initiated in the 1970s. From 1971 to 2018 (49) the number of beds was reduced from 1160 to 219 (40), while the number of people treated by the service has risen from 1160 to 4800 over the same period (35).i The suicide rate has also fallen from 25 per 100,000 population in the period 1971–1994, to 13 per 100,000 in 2015 (46). The number of people subjected to involuntary treatment each year dropped from 150 in 1971 to 18 in 2019 – a rate of 8.11 per 100,000 population (40). The number of people in forensic hospitals in Trieste has fallen from 15 in 1977 (49) to zero in 2006 (46) and onwards. Several studies have evaluated the network of mental health services in Trieste and the transition from asylum to community-based care in the city. The first follow-up study after the reform law (conducted from 1983–1987) showed better outcomes for 20 patients with a diagnosis of schizophrenia in Trieste and Arezzo compared to 18 other Italian centres (50). Further, a study of 27 “high priority users”j found that there was a high rate of social recovery at five-year follow up. A significant reduction of symptoms was also found, of about 20%, and a marked improvement of social functioning (score increased by 50%). Nine people secured competitive jobs, 12 achieved independent living, and a measure of unmet needs dropped from 75% to 25%. There was also a 70% reduction of days of admission, and only one person dropped out (51). Other studies over the years have also demonstrated important outcomes for the services in Trieste. A national survey carried out in 13 centres showed that the crisis care provided by the CMHCs open i Excluding small accommodations. j The people studied were selected by the team. Each had at least six of the following characteristics: high family burden, absence of a social network, isolation, frequent drop out from services, repeated failure of previous forms of treatment, episodes of involuntary treatment, imminent risk of serious social drift, imminent risk of committing crimes, use of illegal psychotropic substances. 28 Comprehensive mental health service networks 24 hours a day, seven days per week, resulted in a faster crisis resolution, the prevention of future relapses, and better clinical and social outcomes at two-year follow-up (52-54). This also emphasized the importance of trusting therapeutic relationships, continuity and flexibility of care, and service comprehensiveness. A 50% reduction in emergency presentations at the General Hospital Casualty Department was also reported from 1984 to 2005 (24). Adherence to antipsychotic medication was 75% (55); this was ascribed to the comprehensive care approach with the development of good therapeutic relationships, social network involvement, and the attention to contextual factors associated with the “whole person, whole system, whole community” philosophy (38, 55). Qualitative research has also been used to study the service network in Trieste, based on the analysis of recovery stories from a narrative point of view (56). An international research group pointed to the important interconnections between recovery, social inclusion and lived citizenship (57-61). High rates of service user satisfaction were reported in the early years of reform (62) and a survey carried out for a university dissertation pointed to satisfaction levels of 83% with the work of the CMHCs ([Zanello LE],[Università degli Studi di Trieste], unpublished observations, [2006]). Costs and cost comparisons The budget of the mental health service is heavily weighted towards community interventions (94%) and only a small proportion goes to the GHPU (6%). It is estimated that the annual cost of the service in Trieste in 2018 was approximately €80 per capita (23) (US$ 94)k which amounted to €16.7 million (approximately US$ 19.6 million).j It is calculated that in 2019, the cost of the Mental Health Department amounted to 37% of the cost of the old psychiatric hospital (35). This represents about 4% of the overall health care budget in Trieste. The service is paid for by the national health service which is publicly funded. A regional budget provided to the health care agency is then passed on to the Mental Health Department, based on historical expenditures. This is negotiated according to assigned and agreed objectives. As in all of Italy, private care is available to people who have insurance or who can pay for this directly themselves. Care is also offered free of charge by private accredited providers and is reimbursed by the national health service. However, all private care in Trieste is “office-based” (consultation, psychotherapy, medication) and there are no private hospitals. Challenges and solutions Overcoming the legacy of institutionalization Since the early 1970s, developments in the Trieste mental health service have been driven by a desire to overcome the legacy of institutionalization (19). One of the obstacles to deinstitutionalization was the predominant view of “out of sight, out of mind” leading to the dominance of the psychiatric hospital, and associated power imbalances, human rights violations and social exclusion. From the beginning, the political support of local and regional authorities and their policies was very important in the Trieste context. Other influential factors (63) in the Trieste approach included: the alliance of professionals, administrators, people using the service and their supporters and carers k Conversion rate as of March 2021. Technical package 29 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS as well as multiple actors from outside the institution (volunteers, artists, active citizens, families, intellectuals, non-profit groups); the empowerment of service users in the service and the involvement of families (64). The development of a multi-professional team approach with task-sharing, and a stress on the importance of flexibility in terms of professional roles and inputs were also important factors influencing the professional workforce, along with investing in a comprehensive approach that serves to overcome resistance to change, and investing heavily in training, motivation, and professional development of staff (23). Further, Trieste adopted a multisectoral approach with social care, addressing personal and daily life needs (e.g. housing, income, education, social inclusion etc) and social determinants of mental health. Some of the most important factors, however, involve working actively to prevent admissions to hospitals; adopting a person-centred approach integrating health and social care (36); and adopting a defined organizational model based on a network of services, which has as its main point of reference the services at the 24-hour Mental Health Centres, equipped with very few beds and managed by a single comprehensive team. Since Trieste was designated as a WHO pilot centre for deinstitutionalization in 1973 (18), it has continued to innovate and develop, and has been hugely influential across the world (16, 65-68). It now has established links with countries and services in all continents and there are study visits by approximately 1000 people every year to the city (23). The Parliamentary Commission on the State of the Italian National Health System (69) and the Italian Fellowship of Mental Health Associations has since identified this as a model for the whole of Italy to adopt (41). Changing institutional culture and power relations The mental health system was built on a system of hierarchies. Working to overcome the institutional culture required challenging these hierarchies and the power relations that sustained them. Progress was made with persistent efforts to democratize the world of mental health by broadening discussions and decision-making processes to include all the stakeholders. Initially, daily assemblies were held in the psychiatric hospital in an effort to achieve this. Involving the families of people with mental health conditions and the wider community also helped to counteract the forces of social exclusion that had sustained the central position of the psychiatric hospital. Finally, developing ways for the voices of people using the service to be heard and acted upon created opportunities for people to take back their authority and independence for their own care. Challenging the disease-centred ideology The ideology associated with a disease-centred approach acted to silence the voice of the people using the service and meant that little attention was paid to their personal, social and cultural needs. The establishment of new forms of collective leadership and a whole new set of practices in the mental health system aimed at supporting people to lead a full life in the community was extremely important. Progress was also made through the development of associations and social cooperatives to nurture a new focus on the “whole person”, rather than solely the biomedical model and a narrow disease-centred ideology. 30 Comprehensive mental health service networks Sustaining progress made The Trieste mental health network faces a continual threat of slipping into new forms of institutionalization, or simply service “inertia”. Further, there is an ever-present danger that paternalism, and even different forms of abusive behaviour, might emerge. Being aware of the problems and actively engaging with them helps avoid these risks. Supporting staff through periods of change Without the easy fallback of reliance on clinical models, the Trieste staff were pushed to use their own personal resources to relate to people using the service. This sometimes led to burnout and conflict because this was a new approach which was less structured and had more uncertainties. One of the solutions found was to create a culture of “sharing the burden”, so that no staff member is left alone to carry all the worry and concern about a particular individual or family. Another organizational solution involved efforts to create a genuine democracy within the organization so that both people using the service and staff members feel that their voices are being heard and that their concerns are listened to. Key considerations for different contexts Key issues to consider for the establishment or expansion of this service in other contexts include: • nurturing critical thinking and reflection within the service as a vital ingredient of creating and sustaining the positive impact of your service; • shifting from a clinical understanding of mental health conditions to a ‘whole person-whole life’ philosophy; • investing heavily in staff training and development; • creating opportunities for staff members, people using the service, their families and people from the wider community to meet and discuss the vision of the service; and • recognizing that clinical outcomes (as measured by rating scales) are not as important as outcomes relating to the citizenship of the people using the services, such as the levels of coercion used by the services; and • evaluating networks of services using an approach and measures that capture the overall working and outcomes of the network rather than just the individual services and interventions provided. Technical package 31 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS Additional information and resources: Website: www.triestementalhealth.org videos: BBC News, Trieste’s mental health revolution: “It’s the best place to get sick”; https://www.youtube.com/watch?v=5v0jki3GaBw&feature=youtu.be Episode 8 - Lived experience in Trieste, a mental health system without psychiatric hospitals, with Marilena and Arturo: https://www.spreaker.com/user/apospodcast/episode-8-lived-experience-in-trieste-a- Roberto Mezzina, 2013; https://youtu.be/UnMSHQDrByI Contacts: Elisabetta Pascolo Fabrici, Director, Mental Health Department of Trieste and Gorizia, WHO CC for Research and Training – Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), Italy. Email: elisabetta.pascolofabrici@asugi.sanita.fvg.it Roberto Mezzina, Psychiatrist, Former Director, Mental Health Department of Trieste and Gorizia, WHO CC for Research and Training – Azienda Sanitaria Universitaria Giuliano, Isontina (ASUGI), Italy. Email: romezzin@gmail.com; who.cc@asuits.sanita.fvg.it 32 2.3 Brazil community mental health service network a focus on Campinas Technical package 33 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS Context Brazil is a federal republic, the world’s fifth-largest country by area with 27 federative units and 5570 municipalities. It is the sixth most populous country in the world, with over 211 million people (70). It is an upper-middle-income country, but with high levels of social inequality (71). Universal healthcare is a constitutional right in Brazil provided under the country’s Unified Health System (Sistema Único de Saúde (SUS)). Brazil’s mental health network is provided under the SUS. The mental health network in Brazil today is a reflection of the significant psychiatric reform that has taken place in Brazil since the late 1970s. Originating as a civil society movement, psychiatric reform took place through shifting from institutionalized care to care in the community and the development of a supporting legal framework, service regulations and rights-based mental health policy. Institutional structures and practices have been replaced by a community-based network of services through incremental resource reorientation (72, 73). Of the federal financial resources allocated to mental health in 2002, psychiatric hospitals accounted for almost 80% of expenditure, with community-based mental health services accounting for the remaining 20%. By 2013, in contrast, nearly 80% of mental health budgeting was invested in community-based services while 20% was hospital expenses (74). In 2017, though, psychiatric hospitals were again formally included in the mental health network (following a change in mental health policy in 2016) and federal government investment in the implementation of community-based services also decreased (75, 76). However, due to a level of autonomy at municipality and state level in the implementation of public policy and strong foundations in psychiatric reform from institutions, legal, financial and civil society, this shift did not automatically lead to a cessation in implementation of community-based services, nor the closure of psychiatric hospitals across municipalities (77). All community-based mental health services in Brazil follow the main guiding principles of the mental health network in Brazil: • promotion of equity; • guarantee of open access to services; • rights-driven, quality services offering comprehensive care based on a person-centred recovery plan and multi professional input; • person-centred and needs-focused care and actions; • respect for human rights; • promotion of people’s autonomy, social inclusion and participation, rights of citizenship and freedom; • community-based approach with participation of people with lived experience; • combating stigma and prejudice; and • joint actions with other sectors, such as housing, work, education and culture, and the development of capacity building strategies (78). The community-based mental health network is implemented throughout all regions in Brazil; how each element of the network is implemented and what people may experience though, varies. For the purpose of describing the network, a good practice example of a local (municipality level) network was selected to provide practical insight into its workings. The municipality of Campinas was selected for 34 Comprehensive mental health service networks the following reasons: it is a municipality with an entirely community-based mental health network, having closed the city’s psychiatric hospital in 2017; it does not refer individuals to psychiatric hospitals outside of the municipality, for example, to regional hospitals; it has a comprehensive integrated network of services that work well together at the local level; and evaluation data is available. Campinas – Profile Campinas has a population of approximately 1.2 million people. In 2010, 30% of the population had monthly earnings less than half the national minimum wage. A total of 39% of the population had formal employment, with 72% aged between 15 to 64 years old (79). When the transformation of the Campinas mental health network began in 1990, there were 1200 psychiatric beds across five hospitals in Campinas. The first step in this process was the deinstitutionalization of the psychiatric hospital, Sanatório Dr. Cândido Ferreira. From the 2000s onwards, substitute services such as those described in this document began to be implemented and in parallel, a progressive and agreed closing of the psychiatric hospital beds and the deinstitutionalization of the people who lived there. In 2017 the Sanatório Dr. Cândido Ferreira psychiatric hospital was finally closed. Description of the mental health service network in Brazil, with examples from Campinas The services described below work together to provide continuous community mental health care and support that meets the needs of both the individual and the community. Mental health forums in Campinas provide an opportunity for community-based service professionals, the individuals who use the service and family members to come together to discuss and address common issues related to services and regional needs. The mental health network links with the general health network in addition to other relevant sectors and services (for example, employment, culture, sports) through the community-based mental health centres. Elements of the mental health service network Community-based mental health centres Community-based mental health centres, known as Centro de Atenção Psicosocial (CAPS), are the cornerstone of the community-based mental health network in Brazil. CAPS provide continuous, tailored and comprehensive community-based mental health care to individuals with severe or persistent mental health conditions and/or psychosocial disabilities, including during challenging and crisis situations. CAPS have a rights-centred and people-centred approach. Their primary goals are providing psychosocial care, promotion of autonomy, addressing power imbalances and increased social participation. As a principle, CAPS do not refer users to psychiatric hospitals. CAPS are active both within the confines of the centre itself and in the community. The number and type of CAPS in a region depends on the population and the unique needs of that region. CAPS services are classified according to catchment area and target population. CAPS I serve the adult population in catchment areas of over 15,000 people and CAPS II in areas of over 70,000. CAPS III servicesl cater for adults as well as children and adolescents in areas of over 150,000, and l A more in-depth description of a CAPS III is provided separately in this guidance using the example of CAPS III Brasilândia in the technical package, Community mental health centres: Promoting person-centred and rights-based approaches. Technical package 35 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS are open 24 hours a day, seven days per week, providing overnight accommodation if needed. CAPSi serve children and adolescents, and CAPS ad provide support for problems and needs associated with substance use. Alternative configurations are also possible: for example, while CAPS I and CAPS II services mainly serve the adult population, they may also provide care and support to children and adolescents to ensure access to community-based support where a CAPSi is not available. Different types of CAPS can also be combined to meet the needs of the community. For example, In December 2017 new legislation established the creation of a new CAPS type: CAPS ad IV, focused on people with problems and needs associated with substance use in areas with over 500,000 people. The staffing of each CAPS varies according to the type of CAPS, population needs, hours of operation and specific demands. Minimum staffing levels for each type of CAPS are prescribed by law as shown below; however, municipalities may fund staffing beyond these minimum levels. The staffing requirements refer to various staff categories. University level educated professionals include psychologists, social workers, occupational therapists, pedagogues, physical educators, speech therapists or other professionals as required for service users’ needs. Mid-level professionals include nursing technicians and/or assistants, administrative technicians, educators and “artisans”. The minimum staffing levels for CAPS services are as follows. CAPS I – a physician with training in mental health, a nurse, three university level educated professionals and four mid-level professionals. CAPS II – a psychiatrist, a nurse with training in mental health, four university level educated professionals and six mid-level professionals. CAPS III – two psychiatrists, a nurse with training in mental health, five university level educated professionals, eight mid-level professionals. For the night shift: three nursing technicians under the supervision of the nurse and a mid-level professional. CAPS ad – a psychiatrist, a nurse with training in mental health, a clinical physician responsible for screening, evaluating and monitoring clinical complications, four university level educated professionals and six mid-level professionals. CAPSi – a psychiatrist, neurologist or paediatrician with training in mental health, a nurse, four university level educated professionals and five mid-level professionals. Among all of the CAPS modalities, CAPS III is considered a key strategic service to have in a mental health network. In operating 24 hours a day, seven days per week, and with the availability of a dorm facility, a network with a CAPS III can provide continuous care in the community to its users at all times but also to other CAPS in the network where a user would benefit from continuous (day and night) support. For smaller municipalities without a CAPS III, service users may be referred to a CAPS III in another city or region. CAPS III dorms are not considered nor used as traditional mental health beds. They can be accessed for respite, to take time away from difficult situations, during challenging and crisis situations, or any other situation when an individual feels that they may benefit from additional, constant support (78). People can stay for up to 14 consecutive days during which the CAPS proactively support the user in addressing the factors that led them to require overnight support. The dorms aim to provide a similar environment to that of being at home. There are no rules or requirements in terms of using this service. 36 Comprehensive mental health service networks Operational principles All CAPS services follow three guiding principles. 1. Open door policies – To access a CAPS a person can simply walk in without an appointment to have a first meeting about using the centre. A person may also be referred by another service, or can be visited at home. The CAPS physical structure aims to provide a welcoming and comfortable homely environment that helps people to feel at ease and encourages active participation and interaction (80). There is no involuntary admission or forced use of CAPS. No individual is refused access to the centre, including if they present in a crisis or challenging situation. A mental health diagnosis is not required to attend the centre. 2. Wide reaching community engagement – For CAPS, being community-based is not limited to being a service that is available in the community, rather this principle requires full engagement with and understanding of the community, as well as the individuals who live there. CAPS team members talk to people in the community to understand the social dynamics and to map the common problems that most impact people’s lives and mental health to gain a better understanding of possible mental health and psychosocial needs. At CAPS, team members identify and activate community resources and create partnerships with people and services to carry out mental health care initiatives. CAPS also engage with the community on mental health and psychosocial disability topics such as promotion of rights of individuals with psychosocial disabilities, and initiatives to reduce stigma and prejudice. 3. Deinstitutionalization – As CAPS were designed to replace psychiatric hospitals and other institutionalization structures (81), all CAPS have capacity and responsibility to attend to complex, challenging and crisis situations, offering care and support with community-based practices. CAPS interpret this role as requiring more than acting as a physical alternative to traditional institutional services, but also deinstitutionalizing services, practices and attitudes. At an individual level, this can mean therapeutic support based on recognition of an individual’s human rights, respect for different ways of life, practicing validation and empowerment of the user and respecting that the user has knowledge about themselves and their recovery process. At a service level, no doors in the centre are locked and the individuals who use the service can enter or leave any room in the centre at any time. Neither involuntary admission nor seclusion are used in a CAPS. The use of restraint goes against the core principles of the CAPS model. Operational practices While each CAPS can shape its practices to best meet the needs of service users and the wider community, there are important commonalities in operational practices across all CAPS services (80). Development of a person-centred recovery plan • A wide-ranging person-centred recovery plan for all service users (Projeto Terapêutico Singular (PTS)), is co-developed by the individual and a team member. It includes personal history, an individual’s wants and needs, social relationships, current life context, challenges, strengths and goals. Individuals are encouraged to reflect about the future and take risks. There is also a focus on promoting an individual’s rights and enjoying these rights. The plan also defines care strategies with shared responsibilities. Developing a PTS is seen as a strategy to empower people to take charge of their own recovery process. The PTS is reviewed and updated on an ongoing basis. All activities in a CAPS reflect the PTS of its users (82). Technical package 37 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS Empowerment actions • CAPS seek to recognize and address power imbalances within the service (for example, team members recognize differences in power and seek to redistribute power in relationships). • Staff create positive opportunities for dialogue, negotiation and exercising rights. For example, service users receive practical support for engaging with and participating in the community (such as making a purchase in the local market), support for managing finances and mediating conflicts. • CAPS centres hold periodic assemblies with participation of the individuals who use the service, family members and staff. The assemblies provide opportunities to participate in discussions regarding daily life and activities of the CAPS, as well as debates on broader topics that affect CAPS users, such as poverty and stigma. In the assemblies, everyone participates on an equal basis and all are responsible for the discussions and decisions taken. • Service users are encouraged to engage in management councils, mental health conferences and mental health service forums. Needs-focused meetings between team members and CAPS users • At a first welcoming meeting (Acolhimento), the aim is to create a welcoming and positive dynamic, and meet an individual’s needs in that specific moment. The welcoming team member explains the service and together they begin the process of identifying whether the centre is the right service for that individual. Team members listen to understand the needs and wants of the individual, their personal history, their social and support network and general mental health. Information from the first meeting is recorded, and the service user has access to this information at any time. Standardized mental health screening tools or assessment tools are not used. • All subsequent individual meetings (including therapeutic activities) maintain the same approach; team members actively listen to and recognize the individual’s needs in that moment in time rather than focus on mental health diagnosis, personal history or past discussions. Group activities • CAPS services provide group activities both at the centre and in the community. Group activities provide opportunities to socialize and build relationships, and promote co-existence and a sense of belonging. Each CAPS defines which activities it will carry out depending on users’ PTS and the resources available in the CAPS and in the community. Types of activities include self-care, art, theater, dance, social activities, cooking and gardening, amongst others. • Some group activities are not limited to registered users of CAPS but may also have wider engagement and participation. These activities can provide broader opportunities to socialize, increase community participation and reduce stigma. Home visits • Individuals can be visited at home both for a first meeting about potentially using a CAPS or for further needs. This ensures that individuals who have difficulties reaching or accessing the centre can still access its support. Family support • CAPS services develop individual and collective care strategies for family members. The objective is to identify and meet the demands of family members in order to support their role and co-responsibility for care. 38 Comprehensive mental health service networks Providing a space to be and to participate • CAPS offer the possibility for users to spend the day and/or night (if a CAPS III) in the service. Users can participate in activities that are happening and give their opinion on the service’s practices and, together with others, remodel them. They have a chance to be with other people and progressively create new social relationships, a sense of belonging and a space to be and participate. Crisis support • Individuals in acute crisis are welcomed and supported, and there is no involuntary admission or forced use of the centre. An individual in crisis is never referred to another service where coercive practices could be used. • In a CAPS, crises are understood as moments in a person’s life and recovery during which the individual needs to be supported based on their stated wishes, needs and preferences. Support is based on the principles of Open Dialogue (for more information see Mental Health Crisis services: Promoting person-centred and rights-based approaches). • Team members are available to listen to individuals, understand and mediate possible conflicts. Support can be provided at the service itself, at the individual’s home or in community spaces. Psychosocial rehabilitation • Psychosocial rehabilitation is one of the most important aspects and activities of CAPS. These activities reflect the unique needs and life history of each individual and their PTS. Practices can include team members accompanying an individual as support in their daily activities, mediating relationships or conflicts with family members or their support network, or providing individual or group activities that contribute to an individual’s recovery. • A key focus of psychosocial rehabilitation is ensuring active citizenship. This may include, for example, accompanying an individual and providing support to navigate bureaucracies so that a person can have documentation and be formally recognized as a citizen; or to create opportunities so that a person can study or work, and in doing so, increasing that person’s social participation. • Psychosocial rehabilitation also involves creating and developing initiatives with community resources. Rehabilitation strategies are developed in the areas of housing, social life and work, creating opportunities to enable an individual’s social participation and enhance autonomy. • These actions also aim to build new social places of belonging for the individuals who access CAPS services, in that people can be increasingly recognized by society and have an active citizen role. Network coordination and cohesion • CAPS offer support to other mental health and general health services, including independent living facilities, primary health centres, emergency services and hospital services, and to other networks and institutions. The aim of this support is to promote collaboration in the co-management and co- responsibility of the various services and service networks to fulfil their role in each service user’s PTS. • As a strategic service in the mental health network, CAPS also develop and implement strategies to create links and partnerships with other services in the health, education, justice and social assistance network, as well as with community resources, with the aim of promoting and guaranteeing rights. Technical package 39 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS A typical day and night at a CAPS iii – Campinas In a CAPS lll in Campinas, an average of 60 people (service users and team members) are at the service on any given day. The day at CAPS III is lively with diverse activities that promote well-being, self-care, social exchanges and the strengthening of relationships between the individuals who access the service, team members and the community. Generally the CAPS III has designated team members to ensure that the day at the CAPS flows, offering support in organizing meals for people coming to the service, listening and meeting the unexpected demands of the day, proposing activities and creating opportunities for social exchange. The individuals who use the CAPS come and go during the day. It is common for individuals to go to the CAPS during the day to watch a movie, talk, meet people, bake a cake, play games, read a newspaper together or water the plants for example. In addition, CAPS III activities take place in the community. CAPS team members go to other community mental health services, such as the Núcleo de Atenção à Saúde da Família teams and independent living facilities, to provide support to Family Health Teams and to visit and provide support to independent living facility residents. Team Members also go out with CAPS III service users to accompany them in their activities, putting into practice the activities of psychosocial rehabilitation and actions in the community. For example, an individual and a team member might take public transport together to go somewhere (which involves planning the destination, separating the right amount of money to pay for the bus ticket, and selecting the right bus to take) or they may choose to take a walk around the neighbourhood (which involves leaving home, getting to know the neighbourhood, being around and relating to other people). Team members also support individuals to participate in other services, such as community-based “Coexistence Centres” and other city services such as cultural centres, and support activities to generate work and income. At night, individuals are supported by professionals and activities are organized to meet the needs of people in the service at that time. A welcoming environment is created that enables people to experience a crisis in a safe, caring environment. The average duration of overnight stays in a CAPS III in Campinas is 6.7 days (in 2020). While CAPS centres provide a key and strategic service in the community-based mental health network in Brazil, other services within the network play just as essential complimentary roles. Community Based Health Centres Community Based Health Centres (CBHC) (Unidade Básica de Saúde) are considered the first contact point for people to enter the Brazilian public health system (83). CBHCs provide basic community care across general practice, paediatrics, gynaecology, nursing and dentistry. Family Health Teams situated within the CBHC, provide an important link between the CBHC and the community. One of the key responsibilities of the Family Health Teams is to ensure every family in their catchment area is registered with their respective CBHC, to monitor each family’s general health and living conditions and to provide health care. The Family Health Teams key practitioners are Community Health Workers (Agentes Comunitários de Saúde) who are basic level professionals with an understanding and knowledge of the community they work in, the people that live there, and the community’s unique dynamics and challenges. 40 Comprehensive mental health service networks Community Based Health Centres – Campinas There are 66 CBHCs in Campinas (approximately one for every 20,000 inhabitants). All CBHCs in Campinas are linked with and receive support from a CAPS service. The typical staffing of a CBHC in Campinas varies, however minimum staffing includes: a coordinator, physicians (including specialists in paediatrics, gynaecology and obstetrics), nurses, a dentist, nursing assistants, dental assistants, and support staff. About a third of CBHCs have mental health professionals, including psychiatrists, psychologists and occupational therapists. Small CBHCs in Campinas have between 16-20 individuals in professional roles, in addition to the support staff described above. Medium sized CBHCs are made up of approximately 47 professionals in addition to support staff, with large CBHCs having 84 professionals, plus support staff. All CBHCs in Campinas have Family Health Teams and there are a further 146 Family Health Teams in Campinas. The minimum staffing of a Family Health Team includes: a physician, a nurse, two nursing technicians and community health agents. In addition, most Family Health Teams have other support professionals, including paediatricians, gynaecologists, nutritionists, psychologists, occupational therapists, physiotherapists, social workers, dentists and dental assistants. Núcleo de Atenção à Saúde da Família (NASF) teams NASF are multidisciplinary expert teams providing direct general support to Family Health Teams at the CBHCs. These teams are not mental health specific, but include mental health expertise. NASF teams typically comprise a social worker, psychologist, occupational therapist, nutritionist, physical education professional, pharmacist, physiotherapist and speech and language therapist, and usually a physician. NASFs provide support by discussing clinical cases, doing shared consultations with the Family Health Teams and CBHC teams, collaborating in the development of PTS plans, and delivering prevention and health promotion activities. NASFs are also involved in capacity building for professionals in CBHCs in their specialist areas, and provide care and support to individuals with less severe or less complex mental health needs. When a NASF can successfully support CBHCs to meet these needs, it allows CAPS in the region to focus on providing care and support to individuals with more complex mental health needs. This can help to prevent excessive demand on a CAPS service. NASFs follow the same human rights principles as CAPS and link and engage with CAPS as needed. They do not practice or promote the use of seclusion, restraint or any other coercive practices. NASFs are particularly important in municipalities with less than 15,000 inhabitants. These municipalities, which represent about 60% of Brazilian municipalities and account for approximately 12% of the total Brazilian population, are not large enough to qualified for a CAPS. Therefore within these municipalities, the actions of community-based health centres at primary health care level are the main care and support strategy for the mental health needs of the population they serve (73). NASFs – Campinas Campinas has a total of five NASFs. Their staffing levels reflect the unique needs and demands of the services they support and the communities they serve. All NASFs in Campinas typically include as a minimum: a psychiatrist, psychologist and occupational therapist, with additional professionals as needed. Technical package 41 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS Street Outreach Teams Street Outreach Teams (Equipes de Consultório na Rua) are part of the CBHC and are focused on the homeless population. They provide support, health care, protection against the risks to which this population is exposed (such as greater risk of urban violence, lack of financial income, absence of social support network, risks associated with drug use), and take actions to protect and promote the rights of this community. Teams provide mental health care to the homeless population in general but also to people with mental health conditions, psychosocial disabilities and problems associated with substance use. Street Outreach Teams map out the areas or regions frequented by individuals who may be able to benefit from their service, go directly to these areas to offer help and support, and provide referrals to health and social services. Street Outreach Teams are in constant dialogue and develop partnerships with CBHCs, Family Health Teams and CAPS in order to best meet the needs of the population and individuals they serve (78). The services share relevant information about the person and their recovery process, and identify actions or support required to meet the person’s needs. Street Outreach Teams can also help to facilitate access to CAPS, including for individuals who use drugs. Teams consist of between four and seven members. Teams may include a nurse, psychologist, social worker, occupational therapist, doctor, social agent with lived experience, nursing assistant and dental health technician. Larger teams also include a physician. Street Outreach Teams do not refer or otherwise direct people to psychiatric hospitals or other services where coercion, restraint or seclusion may be used. Street Outreach Teams – Campinas There are two Street Outreach Teams in Campinas, who provided support to approximately 476 individuals per month in 2020. The typical staffing of a Street Outreach Team in Campinas includes: • 1.75 medical professionals (equivalent to 70 hours, provided by 1 psychiatrist and 3 physicians) • 2 nurses • 1 occupational therapist • 1 psychologist • 1 social worker • 3 harm reduction professionals • 3 nursing technicians • 1 administrative assistant • 2 drivers • 1 coordinator. The Street Outreach Teams meet at the beginning of each working day to plan the day’s activities. The teams provide an outreach service in areas of the city that have been mapped as places where people in vulnerable situations live, generally public squares. Each day, the Street Outreach Team travel to these designated areas, set up a tent from which they work and begin consultations (for example, nursing and social assistance assessments, referral to other services and social activities). In providing health care to the homeless population in Campinas, cultural activities such as music and capoeira (a dance-like martial art of Brazil) exist side-by-side with medical, nursing and mental health practices. Once assessed by the Street Outreach Team, a person can be referred to the primary care network 42 Comprehensive mental health service networks and/or to a CAPS where their mental health needs and/or any issues regarding substance use can be identified. The services then work closely together in an integrated manner to support and meet the needs of the individual. The Street Outreach Teams in Campinas also work very closely with individuals who are homeless and pregnant. This includes identifying individuals who may need support, monitoring prenatal care and providing referrals to shelters and maternity hospitals. In 2020, Campinas Street Outreach Teams supported 100 women who were pregnant and homeless, allowing the baby to stay with the mother or extended family and avoiding the child being taken into care. The Street Outreach Team’s relationship with the wider network, especially in terms of social assistance and public security, is crucial in the care of this population. Of the people supported each month by the street outreach service, an average of 20 individuals are accompanied to attend a CAPS for adults and 65 individuals are accompanied to attend the CAPS ad. Both CAPS and the Street Outreach Teams are responsible for the care of this population. independent living facilities Independent living facilities (Serviços Residenciais Terapêuticos (SRT)) are houses located in the community designed for people with a history of long-term hospitalization (two years or more uninterrupted) who have been discharged from psychiatric hospitals or custody hospitals. For individuals who do not have a family or support network available, or there is no possibility to return to the family home, an SRT provides the individual with an independent accommodation option in the community. This service is part of the deinstitutionalization strategy of the Brazilian psychiatric reform process. An SRT can accommodate up to ten residents, with houses exclusively for women, exclusively for men, and mixed houses (81). Each residence has five caregivers per work shift and one nursing technician. Residents of SRTs are also CAPS users. Using each individual’s PTS, psychosocial rehabilitation is provided through a close partnership between the individual, the SRT and the CAPS, with the objective of promoting autonomy, social inclusion and guaranteeing rights. A person can live indefinitely in an SRT. They are seen as a person’s home, rather than a health or social service and fall outside regulatory or inspection activities. As a principle, seclusion, coercion and restraint are not used in an SRT. independent living facilities – Campinas Campinas has 20 SRTs with a total available capacity of 160 spaces. Currently SRTs in Campinas are housing 139 people. The typical staffing of an SRT in Campinas includes a housing assistant, a monitor and a nursing technician, depending on the needs of the individuals in the SRT. Each house has its own unique configuration, also according to the needs of the people resident there. In the day-to-day life of an SRT, residents may engage in various activities in the community – for leisure, religious observance, activities at the CAPS – or be at home pursuing their interests or having visitors. In each SRT there is a weekly discussion during which the residents decide on the menu for the week. The residents then go out to buy the necessary groceries, with the support of caregivers as needed. The residents also manage household chores; however, in the case of houses with people with more serious clinical conditions and with a greater need of support, there is a cleaning team. Technical package 43 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS The SRT houses are located in different neighbourhoods across Campinas. All SRTs are linked with a CAPS III and there is continuous dialogue and engagement between SRTs and CAPS services. A CAPS team member visits the SRT daily to check-in on the daily life at the residence, for example, to check if the shopping needs for the house are up to date, if anyone needs to make any personal purchases, and if all residents are well. The linking of SRTs with CAPS is particularly important as the same professionals who provide care at the CAPS are also involved in the psychosocial rehabilitation process in the community. This in turn, facilitates the overall development and oversight of the individual’s care plan (PTS) at both a service and community level. However each SRT resident participates in the community’s mental health services network according to their wishes and needs. Going Back Home Programme The Going Back Home Programme (Programa De Volta Para Casa) is a deinstitutionalization strategy that consists of a transfer of financial resources to people who have been discharged from long-term psychiatric hospitalization (two or more years uninterrupted) (84). The aim of the programme is to promote psychosocial rehabilitation by strengthening a person’s contractual power by ensuring that the person has an income to be able to make choices, for example, about what to buy and where to go. The monthly amount paid at federal level was 412 Brazilian Real (R$) (approximately US$ 72)m in 2020. Going Back Home Programme – Campinas In Campinas, a total of 139 individuals are currently recipients under the Going Back Home Programme, with a cost of R$ 57,268 (approximately US$ 10,070)m per month. Mental health beds in general hospitals Mental health beds in general hospitals (Leitos de saúde mental em Hospitais Gerais) provide health care for people with mental health conditions, psychosocial disabilities, and problems and needs associated with substance use. Access to mental health beds in general hospitals is coordinated through a centralized bed management system. Admission is based on clinical criteria and hospitalizations must be of short duration (that is, until the clinical stability of the individual allows discharge). To access a bed, a mental health network service, such as a CAPS, must request the use of the bed; this ensures that only those people who have a specific need to use the bed will in fact use it, preventing the inappropriate use of hospital beds and avoiding unnecessary hospitalizations. CAPS may refer people to mental health beds at a general hospital, for example when an individual who uses that CAPS has co-morbidities, or difficulties or needs associated with their general health that requires secondary level care. Mental health beds in general hospitals can also act as a barrier to admissions to psychiatric hospitals in a region. The mental health beds may be ring-fenced beds reserved by the hospital in the event an individual with mental health needs is admitted or they may be part of a mental health unit or ward. The number of mental health beds in a general hospital cannot exceed 15% of the total number of beds, up to a maximum of 25 beds. There is a minimum of four mental health beds in a general hospital. m Conversion rate as of March 2021. 44 Comprehensive mental health service networks As part of the mental health network in Brazil, these beds follow the same principles as the previously listed services. However, at the time of writing no evaluation data was available on the use of coercive practices in these services. Anecdotal information suggests that coercive practices (namely the use of mechanical and chemical restraints) may be used and that this practice varies across hospitals. A further challenge is the effective integration of this service with other services in the network in order to guarantee the continuity of an individual’s care across services. Mental health beds in general hospitals – Campinas There are 36 mental health beds in the two general hospitals in Campinas. One hospital, Complexo Hospitalar Mayor Edvaldo Orsi, has 20 mental health beds and the other, Hospital das Clínicas da UNICAMP has a total of 14 such beds. The mental health beds are located in a designated ward in both hospitals. To illustrate the staffing levels in one of these wards, the staffing at the mental health ward of the general hospital Complexo Hospitalar Mayor Edvaldo Orsi includes: • 1 psychiatrist (service coordinator with medical responsibilities) • 1 medical supervisor • 1 nurse supervisor • 1 psychiatrist on call • 1 nurse • 5 nurse technicians • 1 occupational therapist • 1 psychologist • 1 social worker. In Campinas, hospitalization is generally used for support during a crisis situation, based on the severity of the crisis and the needs of an individual. An individual may also be referred to one of these beds to remove them from their current environment, or because of the existence of a clinical comorbidity that requires psychiatric care and other medical specialties. These beds may also be used for the purpose of diagnosis (more common in the care of CAPS ad service users) and protection purposes, especially in the vulnerable underage population. Mental health beds in a general hospital may also be considered when the CAPS and general hospital considers that an individual may benefit from it. For example, the hospital may provide a more appropriate environment for some individuals than the busy active environment of a CAPS, and also provide an alternative if there are no dorm vacancies within a CAPS III in the network. If an individual is admitted to a mental health bed in a general hospital in Campinas, the hospital team and the team from the reference service of that person (for example, a CAPS) work to continue the PTS of that individual. They will discuss the user’s recovery plan and any adjustments that may be needed during their time in hospital. Visits by professionals to the individual, for example, from CAPS, are common and encouraged during the hospitalization period. Technical package 45 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS Engagement between the services and team members is ongoing throughout the time an individual is using one of these beds. The general hospital team also goes to CAPS to attend meetings and to discuss shared strategies to better serve the individuals who access these services. The care provided by a general hospital follows the same principles of the mental health network and CAPS. In a crisis situation, both verbal and medication approaches are used, but medication is used only with the consent of the individual. The network reported, however, that restraints may still be used in extreme circumstances and this is important to change. Mental health beds in general hospitals are important in the Campinas network for their role not only in providing additional support to individuals experiencing a crisis situation, but also for their ability to link and work with all the municipal mental health services. Emergency and urgent services Urgent and emergency care services associated with the mental health network are part of the emergency services network of the general health system, including mobile emergency services, emergency care units (standalone emergency care-specific services) and hospital emergency rooms. As a general guideline, the urgent and emergency care services work together with CAPS when an individual with mental health needs presents at one of these services. On arrival, the emergency service contacts the relevant CAPS for that individual. Once contact is made, the CAPS has shared responsibility for the individual’s care, including for example, discussing the individual’s needs, following up emergency service actions, resuming the person’s PTS in the community upon discharge from the emergency service, etc. Other mental health network services Reception Units (Unidade de Acolhimento) are community-based residential services, designed to provide support to CAPS centres in the health care of people with problems and needs associated with substance use who are in situations of social vulnerability and/or when a more intense presence and monitoring for a transitory period of time is required. This service is not described in more detail as substance use services were beyond the scope of this document. Cross-network initiatives A strength of the network in Brazil is not only that these services co-exist to meet the evolving needs of the community, but also in its cross-network initiatives that are transformative in terms of the individual and community. Such initiatives have been instrumental in widening the perception of and engagement with mental health and psychosocial disability at a community level. Coexistence Centres Coexistence Centres (Centro de Convivência (CECO)) are community-based centres open to all members of the community, and the participation of people with psychosocial disabilities, cognitive disabilities, older adults, and children and adolescents with social vulnerabilities is highly encouraged. The primary goal of CECOs is the mediation and promotion of opportunities for coexistance, promoting social inclusion and belonging. While CECOs are considered part of the national mental 46 Comprehensive mental health service networks health policy, they are currently only implemented in some regions of Brazil. CECOs are funded at state and municipality level. Coexistence Centres – Campinas There are five Coexistence Centres (CECOs) across Campinas each with a service capacity of between 120 and 300 people per month. The typical staffing at a CECO in Campinas includes: two professionals (psychologist, occupational therapist, group leader, physical educator or nurse), a monitor, cleaning assistant and coordinator. The CECOs of Campinas were established as part of local public policy before CECOs were recognized at a national policy level, and are funded at a local level. CECOs are usually located in public parks or green areas and link health, sport, culture, education and the environment from a psychosocial rehabilitation, prevention and health promotion perspective. CECO activities reflect two main themes – coexistence (group activities, public meetings, promoting understanding and tolerance of differences between people) and partnerships (with public institutions and civil society) that can contribute to the inclusion and autonomy of individuals accessing the CECO. For example, a literacy programme for young people and adults was developed by the CECO in partnership with the educational sector, in which both CAPS users and residents of SRTs may participate. Each CECO has its own schedule of activities published monthly. Activities include literacy, guitar lessons, English, capoeira, zumba, painting and craft activities, garden activities, a cinema workshop and cooking, among others. All activities are free, open to the community and often rely on the active participation of volunteers. CECOs also link directly to mental health services. For example, if a CAPS identifies that a CECO can enhance the PTS of an individual (in the sense that participating in some CECO activity could be beneficial to the person) a referral can be made. Likewise a CECO can also identify if someone who attends its activities could potentially benefit from a CAPS service and facilitate a referral. Work and income generation services and initiatives Work and income generation initiatives aim to guarantee the right to work and to provide training and qualifications for work. These initiatives promote social inclusion and autonomy, increasing power and improving people’s living conditions. They are also a psychosocial rehabilitation strategy for strengthening the protagonism of individuals who access the mental health network. Some of the initiatives carried out in different regions include cooking, craft products, clothing production, agriculture, recycling, stamping, rendering of services, sales, among others. These initiatives are based on the solidarity economy perspective (85). Work and income generation services and initiatives – Campinas Campinas has two services focused on the Solidarity Economy and the generation of work and income – Workshops House (Casa das Oficinas) and the Centre for Workshops and Work (Núcleo das Oficinas e Trabalho). Both of these services develop activities focused on guaranteeing the right to work, promoting autonomy, fostering social inclusion through work, and participation in social associations and cooperatives. They develop collective and participative training activities and Technical package 47 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS income and work generation activities, in a variety of areas. A further entity focuses on commercializing products, Workshops Warehouse (Armazém das Oficinas). Casa das Oficinas is staffed by a coordinator, psychologist, occupational therapist, monitors, administrative assistant and cleaning assistant. It has seven work and income generation initiatives in the areas of cooking, stationary and sewing (Gira Mundo), handicrafts, printing, bread making and mosaics. Approximately 50 people per month access this service. Nucleo de Oficinas e Trabalho is staffed by a coordinator and administrative assistants. Each of the work and income generation initiatives has a separate coordinator who may be an occupational therapist, psychologist, social worker or architect, and monitors. The organization has 12 work and income generation initiatives in the areas of: recycled paper, joinery, metalwork, mosaics, events, agricultural, culinary and restaurant, printing, flat stained glass, religious stained glass, sewing and hydraulic/ceramic tile. Approximately 300 people per month access this service. To access one of these services, a person is referred by one of the municipality’s mental health services, for example, a CAPS. After being informed of all the options for work and income generation projects and workshops, a person can then choose the initiative or activity in which they would like to participate. All participants are remunerated as a result of the production and sale of the products. The total sale value is divided among the participants according to the performance evaluation of each person. This monthly assessment is made by a group that includes the service coordinator, a monitor of the project or workshop and the individual, considering criteria such as attendance, punctuality, responsibility, initiative and creativity. The network in Campinas reported the number of people who manage to participate in the formal job market is however, still very small. An alternative employment avenue has been developed with employment directly by Serviço de Saude Dr. Cândido Ferreira. As of September 2020, 34 people had gained employment through this initiative. Cultural initiatives – Campinas The mental health network in Campinas also has a number of collective and cross-network projects that include the participation of individuals who use mental health services, professionals and family members from different CAPS, SRTs, CECOs and beyond. Examples of initiatives include: Rádio Maluco Beleza, a radio programme that brings together individuals who use mental health services, family members, social projects, employees and people from the community. It is on air 24 hours a day with a variety of programmes that address different themes; Jornal Candura, a bimonthly publication covering news and events related to mental health services, addressing issues of social inclusion and citizenship; and Coletivo de esportes, a sports initiative responsible for InterCAPS, an event that brings together the CAPS of the city of Campinas and region in a football championship and celebration of the 18 May, the national day on which the civil society social movement celebrates and demands advances on psychiatric reform. Coletivo de esportes is also responsible for the Inclusion Cup, a weekly football championship among the CAPS in Campinas. This initiative promotes weekly meetings between employees, the individuals who use the service and family members through sports activities in mental health services and in community spaces. 48 Comprehensive mental health service networks Core principles and values underlying the service Respect for legal capacity Respect for the legal capacity of individuals who access mental health services is embedded in the principles of the community-based mental health network in Brazil. At a service level, this is reflected in person-led recovery plans, the absence of involuntary admission or treatment, proactive addressing of power imbalances and support of individuals to exercise and enjoy their legal capacity both within the service and in their communities. The Going Back Home Programme (Volta Para Casa) and SRTs support individuals with a history of institutionalization with a supported, person-led return to exercising their legal capacity in society. Alternatives to coercive practices The use of coercive practices is against the principles of the community-based mental health network in Brazil. Services instead emphasize the practice of negotiation and mediation in conflicting and challenging situations. In addressing power imbalances and recognizing an individual’s own knowledge of their experiences, needs, wants, preferences, and person-led recovery plans, services develop a permanent dialogue and relationships of trust with service users, shifting service dynamics away from coercive practices. There were no reports of the use of coercive practices in NASF, CBHC, SRT or Street Outreach Teams in 2020. The occurrence of coercive practices in CAPS rare and considered an unacceptable practice by the service and its team members. The use of coercive practices (physical and chemical restraints) in general hospitals, however, was identified as being variable from hospital to hospital. This is an area that requires constant attention and efforts to change. Nevertheless, the network in Brazil illustrates the emphasis on and success of building relationships to prevent the use of coercive practices. Community inclusion At an individual level, a person is supported by the network to participate in their community according to their needs and preferences, guided by their person-centred recovery plan (PTS). Proportionate support is available, reflecting the needs of the individual, for examples through SRTs. The mental health network is active in the community, reflecting the collective nature of inclusion, and that it is through collective actions with people in the community that possibilities for social inclusion are created and in the process, the community and its relationships are transformed. Practices such as CAPS activities, CECOs and cultural initiatives that are open to the wider public promote community inclusion, diversity and reduced stigma. Partnerships between services and the practice of continuous care carried out between services increases people’s access to and inclusion in the community across diverse areas including health, mental health, employment, sport and culture. Participation Strategies of collective dialogue, such as the CAPS assemblies, are actively used in the network. Users participate in the design and implementation of the service network, including network and service practices. This occurs daily through social exchanges within the services, in formal structures such as mental health forums, and also through the civil organization in the social movement for psychiatric reform. Technical package 49 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS Recovery approach The community-based mental health network principles are consistent with the recovery approach, including promoting autonomy, social participation, community inclusion and equal rights. The use of individual person centred recovery plans (PTS) across services is consistent with the recovery approach, encouraging each individual to identify their own hopes, goals and aspirations and lead in their own recovery journey. The focus of each service and the structure of the network, in particular cross network initiatives, lend to a whole-person and holistic approach including essential recovery elements such as access to community participation, employment, education, culture and sports. Service evaluation Due to the size and complexity of the network in Brazil, the following is not a comprehensive description of all studies pertaining to the community-based mental health network in Brazil. This section includes evaluation data of the mental health network of different Brazilian municipalities and regions (divided into general network studies and CAPS-oriented studies). Studies are also presented from the case study municipality of Campinas. The evaluation data reviewed for the purpose of this document supports that the network can offer high quality services and support to the individual and community. Community-based mental health network, Brazil Several studies have evaluated the community-based mental health network in Brazil. A 2015 systematic review of studies on the mental health services in Brazil reported satisfaction with the services that were developed as a substitute to institutionalization (e.g. CAPS) in relation to welcoming and humanizing attitudes, breaking with social isolation, establishing connections, improvement in clinical conditions, quality of life and support with mental health (86). It also reported improvement in self-confidence, emotional health, quality of sleep and the capacity to handle difficult situations. In comparing psychiatric hospitals and community-based mental health services and strategies that replaced psychiatric hospitals, community-based mental health services were found to be more effective and efficient. A 2019 study demonstrated a correlation between increasing CAPS and primary health centre coverage with decreased psychiatric hospitalization rates (87). In a study of CAPS II linking with primary health care teams, quality of care increased in crisis situations in the community, preventing escalation and use of coercive practices such as police actions, use of physical force, involuntary conduct for emergencies and hospitalization (88). The role of the NASF has also been found to be effective in supporting mild and moderate mental health needs, preventing excess demand on specialist services such as CAPS, in municipalities who have clear policies and practices to support this practice (89, 90). The implementation of NASF teams in a rural area was also found to increase individual engagement with activities proposed by the health services and health needs were more comprehensively attended to (91). Residential services such as the SRT have been found to support individuals who had experienced long term hospitalization to increase an individual’s own sense of power and autonomy, to establish relationships and increase social participation (92, 93). Similar findings support the role of financial programmes such as Going Back Home to support individuals’ return and life in the community after extensive periods of hospitalization (91, 94). However, studies have also identified that challenges exist in the networks, for example, the integration of services, the effectiveness of mental health actions provided by the network in supporting community-based health centres (CBHCs) and capacity building of SRT caregivers to manage residents’ complex demands and needs (90, 95). These studies highlight the scope for variance in the network in how well it can work together to meet the needs of the communities it serves and the importance of integration in a network infrastructure. 50 Comprehensive mental health service networks CAPS Studies have identified high levels of satisfaction by both individuals who use CAPS and family members. When measuring level of satisfaction (on a scale of 1–5), a 2018 study reported a measure of 4.6. Questions relating to professional competence, needs-focused first meeting and care provided, and being treated with respect and dignity recorded the highest levels of satisfaction (96). CAPS were also found to favour the expansion of individuals’ autonomy, co-responsibility in recovery, and protagonism (97, 98). Family members also reported satisfaction with the service, the quality of care and the support that they receive (99, 100). In a prospective cohort study from 2010 with 1888 users of CAPS, the study found that CAPS practices were effective in supporting users in challenging and crisis situations (101). After attending CAPS, 24% of users reported absence of crisis, 60% had crises less frequently and 70% reported less intensity. The longer the time attending the CAPS, the greater the time elapsed since the last psychiatric hospitalization. The implementation of CAPS has also been found to reduce the risk of suicide by 14% (102). In a 2018 cross-sectional study, 917 CAPS users from four municipalities were interviewed. Results show that “in all cities, less than 10% of users had a psychiatric hospital admission after treatment at the CAPS was started” (103). Community-based mental health network, Campinas Studies from Campinas have demonstrated the effectiveness of the network at both system and individual level. Long-term users of CAPS III in the city of Campinas showed a reduction in crisis occurrence, in medication use and number of psychiatric hospitalizations. Non-intensive CAPS users experienced reduced medication. Both individuals who used the service and family members reported high levels of confidence in the service at a time of crisis and in terms of psychosocial rehabilitation (104). Specific CAPS practices have also been positively received, in particular the availability and trust in the overnight accommodation facility of CAPS III and the allocation of a “reference practitioner” for all CAPS users (105, 106). In a cross-sectional study, 95% of CAPS users interviewed reported not having had any psychiatric hospitalization after starting to attend the CAPS; 73% reported seeking CAPS in a crisis situation and 0% reported seeking a psychiatric hospital. This study supports the premise of the community-based network in Campinas as a replacement to psychiatric hospitals (103). The positive integration between the mental health network and general health network was also identified as important, allowing the networks to share knowledge and experience, and allowing greater continuity of care (107). Costs and cost comparisons The mental health network is part of a wider health network of services and is delivered under the Unified Health System (SUS). This universal health system is financed at federal, state and municipal level, sustained through a public tax system. There is no direct cost for the population to access and use any service in the network. Technical package 51 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS Costs of the Campinas network The annual health budget in Campinas in 2019 was approximately R$ 1.2 billion (roughly US$ 213 million).n The community-based mental health network was allocated 6.6% of this total budget, equivalent to R$ 80 million (approximately US$ 14 million). (This figure does not include the costs of mental health beds in the general hospitals, nor the wider CBHC non-mental health costs.) This equates to a cost of approximately R$ 67 (US$ 12) per capita in Campinas per year (based on an approximate population of 1.2 million). Challenges and solutions increasing poor health coverage An early challenge in establishing the community-based mental health network in Campinas was the absence of a public health system to address coverage of general health, including mental health. The first steps toward overcoming this issue were taken in the 1980s when Brazil recognized and established health (and mental health) as a constitutional right with the implementation of its universal public health system (SUS) in 1988. Challenging the predominance of the biomedical model and psychiatric hospitals A major obstacle to establishing the community-based network in Campinas was the predominance of the biomedical model and psychiatric hospitals, leading to human rights violations, social exclusion and denial of power to people with mental health problems. The establishment of a human rights-based national mental health policy which focused on deinstitutionalization and freedom first principles and aimed at promoting continuous care at the community in all levels of health system began the process of deinstitutionalization. Other approaches were sought at various levels and included: showcasing and promoting deinstitutionalization experiences including successes in closing psychiatric hospitals and developing community-based services; establishing a programme to continually evaluate progress towards reducing the size of psychiatric hospitals and expansion of community-based services; and further, a powerful lever of reform involved the redirecting of financing from psychiatric hospitals towards the development of community-based services using an incremental, phased approach. Finally, open dialogue and articulation of experiences from other countries helped to change mindsets and show possible paths forward. Dissolving political resistance to deinstitutionalization Another serious challenge faced by the network was the presence of local political resistance to deinstitutionalization and closure of psychiatric beds, at the municipality and community level. Other sectors and systems also held attitudes and practices that favoured institutionalization, including the legal system. n Conversion as of March 2021. 52 Comprehensive mental health service networks A major aspect that helped overcome this barrier was the enacting of laws to guarantee the rights of people with mental health problems and establish service regulation norms to implement community- based mental health services. Further, holding mental health conferences at national and municipal levels to encourage debates and democratize decision making amongst service users, family members and staff from the mental health network to discuss mental health policy and deinstitutionalization practices also helped address this political resistance. The network has been negotiated and debated by stakeholders at all levels of the mental health system, which created a level of buy-in and commitment. Finally, civil society movements remain active in pushing the progressiveness of the network forward. Addressing poor workforce knowledge of human rights Another ongoing challenge is the lack of knowledge and understanding of human rights in newly recruited professionals working in community-based mental health services. Engaging in continuous dialogue with all stakeholders including in different sectors, to address any concerns, and provide practical support to solve challenges at the local level has helped improve understanding of human rights in the mental health context. An additional effective solution has been the organizing of CAPS placements for people training in academic programmes and residency programmes that emphasize multidisciplinary approaches. Key considerations for different contexts Key issues to consider for the establishment or expansion of this service in other contexts include: • engaging continuously at all levels in the system, in particular with those who access mental health services, their families and civil society movements to identify the network services that are needed and wanted; • embracing a whole person-centred approach to meet the entire range of needs of the individual (for example, mental, physical, employment, education, community participation); • considering tiered services to meet the range of mental health needs in an appropriate setting (i.e. primary health centres through the support of NASFs able to meet low complexity needs, CAPS meeting high complexity needs); and • establishing an overall coordinating body (CAPS and CBHC in the Brazilian context) that guide the mental health network in each area. Technical package 53 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS Additional Information and resources: Website: https://www.gov.br/saude/pt-br http://www.saude.campinas.sp.gov.br/ videos: Morar em Liberdade: Retratos da Reforma Psiquiátrica Brasileira - FIOCRUZ (Portuguese)/ Living in Freedom: Portraits of the Brazilian Psychiatric Reform - FIOCRUZ (English) https://www.youtube.com/channel/UCD2xLN_GIeJRWqOs8yWLDPQ/videos Memórias da reforma psiquiátrica no Brasil - FIOCRUZ (Portuguese)/Memories of psychiatric reform in Brazil - FIOCRUZ (English) http://laps.ensp.fiocruz.br/ Rádio ‘Maluco Beleza’ – Campinas (Portuguese)/Radio ‘Maluco Beleza’ – Campinas (English) https://www.youtube.com/watch?v=ujRDWeL_cnM Contact: Coordination of the Area of Mental Health, Alcohol and other Drugs, Brazil. Email: saudemental@saude.gov.br Coordination of the Technical Area of Mental Health, Municipal Health Secretariat, Campinas, Brazil. Email: dptosaude@campinas.sp.gov.br Serviço de Saúde Dr. Candido Ferreira, Campinas, Brazil. Email: contato@candido.org.br

3. Moving forward: from concept to good practice comprehensive mental health service network 56 Comprehensive mental health service networks The purpose of this section is to provide readers with some key practical steps and recommendations that will facilitate the process of conceptualizing, planning and piloting the setting up or transformation of a network of services. It is not meant as a comprehensive and complete plan for undertaking this since many context-specific factors, including socio-cultural, economic and political factors play important roles in this process. Further detail on integrating the service into health and social sectors is provided in the guidance and action steps section in Guidance on community mental health services: Promoting person-centred and rights-based approaches. Action steps for setting up/transforming a network of services: • Set up a group of different stakeholders whose expertise is crucial for setting up or transforming the network of services in your social, political and economic context. These stakeholders can include but are not limited to: » policymakers and managers from health and social sectors, people with lived experience and their organizations, general health and mental health practitioners and associated organizations, legal experts, politicians, NGOs, OPDs, academic and research representatives and community gatekeepers such as local chiefs, traditional healers, leaders of faith-based organizations, carers and family members. • Provide the opportunity for all stakeholders to thoroughly review and discuss the good practice services and networks outlined in all the technical packages to get an in-depth understanding of the respective services and networks. This is the opportunity to identify the values, principles and features you would like to see incorporated into your network given the social, political and economic context. • Establish contact with the management/providers of the service(s) and networks that you are interested in to get information and advice on setting up/transforming a network in your context and to understand the nuances of their network. Ask specific questions about how the services and network operate keeping in mind the local context in which they would be developed. This can be done via a site visit to the good practice service/service network and/or video conference. • Provide training and education on mental health, human rights and recovery to the groups who will be most relevant for setting up/transforming the network and individual services using WHO QualityRights face-to-face training materials (https://www.who.int/publications/i/item/who- qualityrights-guidance-and-training-tools) and e-training platform. Changing the attitudes and mindsets of key stakeholders is crucial to reduce potential resistance to change and to develop attitudes and practices in line with the human rights-based approach to mental health. • Discuss and agree on the roles and responsibilities of the health and social sectors required to comprehensively address the support needs of people with mental health conditions and psychosocial disabilities that were identified in your stakeholder discussions, including but not limited to housing, employment, access to education and to adequate health services for overall health not just mental health. Technical package 57 3 | M O V IN G FO R W A R D : FR O M C O N C E P T TO G O O D P R A C T IC E C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K Questions specific for setting up/transforming a network of services: • What gaps have you identified in your network of services that need to be addressed (for example, in relation to the availability of crisis response services, community mental health centres, hospital-based services, community outreach services, peer support services and living support services, and in relation to how they operate in respecting rights and promoting recovery)? • What existing community-based mental health services are you aiming to transform in your network of services (see services showcased in the other six technical packages)? • What new community-based mental health services need to be created to fill any gaps in service provision (see for example, the services showcased in the other six technical packages)? • Are there opportunities to build these service reforms into policies and strategies under development in the areas of mental health, general health, disability and other related areas? • What treatments/interventions are you planning to provide through the network and within each category of service included in the network? For example: » interventions explicitly related to community inclusion (see community inclusion section below) » assessments of support needs and diagnosis if agreed by a person » trauma informed therapy » person-centred recovery planning » psychotherapy, e.g. Cognitive Behavioural Therapy » problem solving and behavioural activation/activity scheduling » individual and group-based supportive counselling/therapy » psychotropic and other medication (including prescribing medication, as well as support for withdrawing safely from medication) » dialogue/meetings with families, friends and supporters (with the agreement of the person using the service) » transitional support for people returning to their home and community » crisis hotline phone-in » peer support » other. • How will your service assess, provide for or refer people for any physical health conditions they may have? • What additional human resources will be required (doctors including psychiatrists, general practitioners and others, psychologists, nurses, social workers, peer support workers, occupational therapists, outreach workers, community/lay workers, administrative staff, etc.) and what new skills and training will be required for them to provide quality and evidence-based service in line with human rights? 58 Comprehensive mental health service networks • What will be the interrelationship between all the services and supports within the network and with other services and resources in the community, including upward and downward referral systems? • What will be the overall coordinating mechanism for the network of services? • What mechanism or forums will be required to support the operation of the network, in particular integration of services and consistency of principles and values across services in the network? • What strategies and training will be put in place to realize legal capacity, non-coercive practices, participation, community inclusion and recovery orientation?o „Legal capacity • How will you ensure that mechanisms for supported decision making are in place in each service in the network to make sure that decisions are made based on the will and preference of the person? • How will you ensure a consistent human rights-oriented approach to informed consent by service users in relation to treatment decisions across all services in your network? • How will all network services ensure that people are: » able to make informed decisions and choices about different options for their treatment and care; and » provided with all critical information relating to medication and other treatment including on their efficacy and on any potential side effects? • How will you ensure network services have processes in place to systematically support people to develop advance plans? • How will you ensure network services have processes in place to respect each individual’s advance plan? • What kind of mechanisms will network services put in place to ensure that people can make a complaint if they need to? • How will network services facilitate access to legal advice and legal representation by its users in need of this type of service, e.g. pro bono legal representation? „ Non-coercive practices • How will you ensure the systematic training of all staff on non-coercive responses and de- escalation of tense and conflictual situations throughout the service network? • Will the service network support people to write individualized plans to explore and respond to sensitivities and signs of distress? • How will you create a “saying yes” and “can do” culture in which every effort is made to say “yes” rather than “no” in response to a request from people who are using the service, throughout the service network? o For more information see section 1.3 in Guidance on community mental health services: Promoting person- centred and rights-based approaches. Technical package 59 3 | M O V IN G FO R W A R D : FR O M C O N C E P T TO G O O D P R A C T IC E C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K • How will the service network incorporate comfort rooms and response teams that operate in alignment with human rights principles? • How will the service network incorporate human rights and recovery-oriented community- based responses to individuals experiencing crisis or challenging situations? „ Participation • How will people with lived experience be an integral part of the team within services and the service network as staff, volunteers or consultants? • How will people with lived experience be represented in the high-level decision-making in the different services and also at the network level? • How will feedback be systematically collected from service users and integrated into the services of the network? • How will the services in the network link people using the service to peer networks in the community? „Community inclusion • How will the service network support people to find work and income generation, for example through a transitional employment programme, supported employment programme or through independent employment as appropriate? • How will the service network facilitate access to housing services? • How will the service network facilitate supported education and assistance in accessing community-based education opportunities and resources to continue education? • How will the service network facilitate access to social protection benefits? • How will the service network facilitate access to social, cultural and recreational programmes, initiatives and events? • How will the service network support deinstitutionalization and the return of individuals back to the community, including people who have been long term residents of institutions? „Recovery • How will the service network ensure that persons will be considered in the context of their entire life and experiences and that care and support will not solely focus on treatment, diagnosis and symptom reduction? • How will the service network ensure that the five dimensions of recovery: (1) connectedness, (2) hope and optimism, (3) identity, (4) meaning and purpose and (5) self-empowerment, are integral components of service provision? • How will people throughout the service network be supported to develop recovery plans in order to think through and document their hopes, goals, strategies for dealing with challenging situations, managing distress, strategies for keeping well, etc.? • How will people throughout the service network be supported to review and update their recovery plans on a regular basis? 60 Comprehensive mental health service networks • Will the service network provide training and support activities regarding the human rights- based approach in mental health to other stakeholders and in the community? » Will the service network provide training and support to organizations in the community, including civil society groups? » Will it provide training and support to staff of other health and social services, including non-specialized health services? • Awareness-raising and advocacy » Will the service network undertake awareness-raising on mental health and human rights, including with families, schools, employers, local organizations and other community settings? » Will the service network undertake advocacy actions on mental health and human rights for the rights of people with mental health conditions and psychosocial disabilities and create positive opportunities for individuals to engage in the community with the ultimate aim of creating a community whereby individuals can live autonomously? This includes actions to reduce stigma around mental health and creating positive opportunities for community engagement. • What actions will the service network undertake to understand the social dynamics of the local community and to map the frequent problems that most impact people’s lives and mental health (for example, police violence, threats related to drug trafficking, economic hardship)? Technical package 61 3 | M O V IN G FO R W A R D : FR O M C O N C E P T TO G O O D P R A C T IC E C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K • Prepare a proposal/concept note that covers process issues, detailing the steps for setting up the service network, the vision and operation of the service network based on the full range of services that will be provided, covering the following: » human resource, training and supervision requirements; » how this service relates to other local mental health and social services; » strategies to ensure that human rights principles of legal capacity, non-coercive practices, community inclusion and participation will be implemented, along with a recovery approach; » details about the monitoring and evaluation of the service; and » information on costs of the service and how this compares with the previous services in place. • Secure the required financial resources to set up or transform the service network, exploring all options including government health and social sectors, health insurance agencies, NGOS, private donors etc. • Use financing mechanisms to support the transformation or creation of the good practice service network that adheres to a human rights-based approach and is sustainable. • Set up and provide the service network in accordance with administrative, financial and legal requirements. • Monitor and evaluate the different services within the service network on a continual basis and publish research using measures of service user satisfaction, quality of life, community inclusion criteria (employment, education, income generation, housing, social protection) recovery, symptom reduction, assessment of quality and human rights conditions (for example using the QualityRights assessment toolkit), and rates of coercive practices (involuntary treatment, mechanical, chemical and physical restraints). • Establish dialogue and ongoing communication with key stakeholders and members of the public by holding public forums and hearings with these groups where people can openly express their views, ideas and concerns about the overall service network and the individual services within it, and to address these concerns. • Advocate and promote the service network with all relevant stakeholder groups (politicians, policy makers, health insurance agencies, media, people with lived experience, families, NGOs, OPDs and the community at large). 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70 Policy, Law and Human Rights Department of Mental Health and Substance Use World Health Organization Avenue Appia 20 1211 Geneva 27 Switzerland

Technical package i Technical package Comprehensive mental health service networks Promoting person-centred and rights-based approaches

Comprehensive mental health service networks Promoting person-centred and rights-based approaches Technical package Comprehensive mental health service networks: promoting person-centred and rights-based approaches (Guidance and technical packages on community mental health services: promoting person-centred and rights-based approaches) ISBN 978-92-4-002584-4 (electronic version) ISBN 978-92-4-002585-1 (print version) © World Health Organization 2021 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization (http://www.wipo.int/amc/en/mediation/rules/). Suggested citation. Comprehensive mental health service networks: promoting person-centred and rights-based approaches. Geneva: World Health Organization; 2021 (Guidance and technical packages on community mental health services: promoting person-centred and rights-based approaches). Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CiP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. 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 WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Design and layout by Genève Design. Photo credit: Cover photo: UN Photo/Martine Perret. Page 4: East Lille/ Nathalie Paulis. Page 18: Trieste/Massimo Silvano. Campinas mental health service network. The accompanying guidance document and technical packages are available here. Technical package iii Contents Foreword . . . . . . . . . . . . . .iv Acknowledgements . . . . . . . . . . . . v Executive summary . . . . . . . . . . . xiii What is the WHO QualityRights initiative? . . . . . . xix About the WHO Guidance and technical packages on community mental health services . . . . . . . . . . xx 1. Introduction ......................................................1 2. Comprehensive mental health service networks – description and analysis ................................3 2.1 East Lille community mental health service network France . . . . . . . . . . . . . . 4 2.2 Trieste community mental health service network Italy . . . . . . . . . . . . . . 18 2.3 Brazil community mental health service network a focus on Campinas. . . . . . . . . . 32 3. Moving forward: from concept to good practice comprehensive mental health service network .. 55 References . . . . . . . . . . . . . 62 iv Comprehensive mental health service networks Foreword Around the world, mental health services are striving to provide quality care and support for people with mental health conditions or psychosocial disabilities. But in many countries, people still lack access to quality services that respond to their needs and respect their rights and dignity. Even today, people are subject to wide-ranging violations and discrimination in mental health care settings, including the use of coercive practices, poor and inhuman living conditions, neglect, and in some cases, abuse. The Convention on the Rights of Persons with Disabilities (CRPD), signed in 2006, recognizes the imperative to undertake major reforms to protect and promote human rights in mental health. This is echoed in the Sustainable Development Goals (SDGs) which call for the promotion of mental health and wellbeing, with human rights at its core, and in the United Nations Political Declaration on universal health coverage. The last two decades have witnessed a growing awareness of the need to improve mental health services, however, in all countries, whether low-, medium- or high-income, the collective response has been constrained by outdated legal and policy frameworks, and lack of resources. The COVID-19 pandemic has further highlighted the inadequate and outdated nature of mental health systems and services worldwide. It has brought to light the damaging effects of institutions, lack of cohesive social networks, the isolation and marginalization of many individuals with mental health conditions, along with the insufficient and fragmented nature of community mental health services. Everywhere, countries need mental health services that reject coercive practices, that support people to make their own decisions about their treatment and care, and that promote participation and community inclusion by addressing all important areas of a person’s life – including relationships, work, family, housing and education – rather than focusing only on symptom reduction. The WHO Comprehensive Mental Health Action Plan 2020–2030 provides inspiration and a framework to help countries prioritize and operationalize a person-centred, rights-based, recovery approach in mental health. By showcasing good practice mental health services from around the world this guidance supports countries to develop and reform community-based services and responses from a human rights perspective, promoting key rights such as equality, non-discrimination, legal capacity, informed consent and community inclusion. It offers a roadmap towards ending institutionalization and involuntary hospitalization and treatment and provides specific action steps for building mental health services that respect every person’s inherent dignity. Everyone has a role to play in bringing mental health services in line with international human rights standards – policy makers, service providers, civil society, and people with lived experience of mental health conditions and psychosocial disabilities. This guidance is intended to bring urgency and clarity to policy makers around the globe and to encourage investment in community-based mental health services in alignment with international human rights standards. It provides a vision of mental health care with the highest standards of respect for human rights and gives hope for a better life to millions of people with mental health conditions and psychosocial disabilities, and their families, worldwide. Dr Ren Minghui Assistant Director-General Universal Health Coverage/Communicable and Noncommunicable Diseases World Health Organization Technical package v Acknowledgements Conceptualization and overall management Michelle Funk, Unit Head, and Natalie Drew Bold, Technical Officer; Policy, Law and Human Rights, Department of Mental Health and Substance Use, World Health Organization (WHO), Geneva, Switzerland. Strategic direction Strategic direction for the WHO documents was provided by: Keshav Desiraju, Former Health Secretary, New Delhi, India Julian Eaton, Mental Health Director, CBM Global, London, United Kingdom Sarah Kline, Co-Founder and Interim Chief Executive Officer, United for Global Mental Health, London, United Kingdom Hernan Montenegro von Mühlenbrock, PHC Coordinator, Special Programme on Primary Health Care, WHO, Geneva, Switzerland Michael Njenga, Executive Council Member, Africa Disability Forum, Chief Executive Officer, Users and Survivors of Psychiatry in Kenya, Nairobi, Kenya Simon Njuguna Kahonge, Director of Mental Health, Ministry of Health, Nairobi, Kenya Soumitra Pathare, Director, Centre for Mental Health Law and Policy, Indian Law Society, Pune, India Olga Runciman, Psychologist, Owner of Psycovery Denmark, Chair of the Danish Hearing Voices Network, Copenhagen, Denmark Benedetto Saraceno, Secretary General, Lisbon Institute Global Mental Health, CEDOC/NOVA, Medical School, Lisbon, Portugal Alberto Vásquez Encalada, President, Sociedad y Discapacidad (SODIS), Geneva, Switzerland Writing and research team Michelle Funk and Natalie Drew Bold were lead writers on the documents and oversaw a research and writing team comprising: Patrick Bracken, Independent Psychiatrist and Consultant, West Cork, Ireland; Celline Cole, Consultant, Department of Mental Health and Substance Use, WHO, Aidlingen, Germany; Julia Faure, Consultant, Policy, Law and Human Rights, Department of Mental Health and Substance Use, WHO, Le Chesnay, France; Emily McLoughlin, Consultant, Policy, Law and Human Rights, Department of Mental Health and Substance Use, WHO, Geneva, Switzerland; Maria Francesca Moro, Researcher and PhD candidate, Department of Epidemiology, Mailman School of Public Health Columbia University, New York, NY, United States of America; Cláudia Pellegrini Braga, Rio de Janeiro Public Prosecutor’s Office, Brazil. Afiya House – Massachusetts, USA: Sera Davidow, Director, Wildflower Alliance (formerly known as the Western Massachusetts Recovery Learning Community), Holyoke MA, USA Atmiyata – Gujarat, india: Jasmine Kalha, Program Manager and Research Fellow; Soumitra Pathare, Director (Centre for Mental Health Law and Policy, Indian Law Society, Pune, India). Aung Clinic – Yangon, Myanmar: Radka Antalikova, Lead Researcher, Thabyay Education Foundation, Yangon, Myanmar; Aung Min, Mental health professional and Art therapist, Second team leader, Aung Clinic Mental Health Initiative, Yangon, Myanmar; Brang Mai, Supervisor Counsellor and Evaluation Researcher (team member), Aung Clinic Mental Health Initiative, YMCA Counselling Centre, Yangon, Myanmar; Polly Dewhirst, Social Work and Human Rights Consultant/ Trainer and Researcher of Case Study Documentation, Aung Clinic Mental Health Initiative, Yangon, Myanmar; San San Oo, Consultant Psychiatrist and EMDR Therapist and Team Leader, Aung Clinic Mental Health Initiative, Yangon, Myanmar; Shwe Ya Min Oo, Psychiatrist and Evaluation Researcher (team member), Aung Clinic Mental Health Initiative, Mental Health Hospital, Yangon, Myanmar. vi Comprehensive mental health service networks BET Unit, Blakstad Hospital, vestre viken Hospital Trust – viken, Norway: Roar Fosse, Senior Researcher, Department of Research and Development, Division of Mental Health and Addiction; Jan Hammer, Special Advisor, Department of Psychiatry, Blakstad Division of Mental Health and Addiction; Didrik Heggdal, The BET Unit, Blakstad Department; Peggy Lilleby, Psychiatrist, The BET Unit, Blakstad Department; Arne Lillelien, Clinical Consultant, The BET Unit, Blakstad Department; Jørgen Strand, Chief of staff and Unit manager, The BET Unit, Blakstad Department; Inger Hilde Vik, Clinical Consultant, The BET Unit, Blakstad Department (Vestre Viken Hospital Trust, Viken, Norway). Brazil community-based mental health networks – a focus on Campinas: Sandrina Indiani, President, Directing Council of the Serviço de Saúde Dr. Candido Ferreira, Campinas, Brazil; Rosana Teresa Onocko Campos, Professor, University of Campinas, Campinas, Brazil; Fábio Roque Ieiri, Psychiatrist, Complexo Hospitalar Prefeito Edivaldo Ors, Campinas, Brazil; Sara Sgobin, Coordinator, Technical Area of Mental Health, Municipal Health Secretariat, Campinas, Brazil. Centros de Atenção Psicossocial (CAPS) iii – Brasilândia, São Paulo, Brazil: Carolina Albuquerque de Siqueira, Nurse, CAPS III – Brasilândia, São Paulo, Brazil; Jamile Caleiro Abbud, Psychologist, CAPS III – Brasilândia, São Paulo, Brazil; Anderson da Silva Dalcin, Coordinator, CAPS III – Brasilândia, São Paulo, Brazil; Marisa de Jesus Rocha, Ocupational Therapist, CAPS III – Brasilândia, São Paulo, Brazil; Debra Demiquele da Silva, Nursing Assistant, CAPS III – Brasilândia, São Paulo, Brazil; Glaucia Galvão, Supporter Management of Network and Services, Mental Health, Associação Saúde da Família, São Paulo, Brazil; Michele Goncalves Panarotte, Psychologist, CAPS III – Brasilândia, São Paulo, Brazil; Cláudia Longhi, Coordinator, Technical Area of Mental Health, Municipal Health Secretariat, São Paulo, Brazil; Thais Helena Mourão Laranjo, Supporter Management of Network and Services, Mental Health, Associação Saúde da Família, São Paulo, Brazil; Aline Pereira Leal, Social Assistant, CAPS III – Brasilândia, São Paulo, Brazil; Iara Soares Pires Fontagnelo, Ocupational Therapist, CAPS III – Brasilândia, São Paulo, Brazil; Igor Manoel Rodrigues Costa, Workshop Professional, CAPS III – Brasilândia, São Paulo, Brazil; Douglas Sherer Sakaguchi, Supervisor Técnico, Freguesia do Ó, Brasilândia, São Paulo, Brazil; Davi Tavares Villagra, Physical Education Professional, CAPS III – Brasilândia, São Paulo, Brazil; Alessandro Uemura Vicentini, Psychologist, CAPS III – Brasilândia, São Paulo, Brazil. East Lille network of mental health services – France: Antoine Baleige, Praticien hospitalier, Secteur 59G21, Centre Collaborateur de l’Organisation mondiale de la Santé (Lille, France); Alain Dannet, Coordonnateur du GCS, Centre Collaborateur de l’Organisation mondiale de la Santé (Lille, France); Laurent Defromont, Praticien hospitalier, Chef de pôle, Secteur 59G21, Centre Collaborateur de l’Organisation mondiale de la Santé (Lille, France); Géry Kruhelski, Chief Nurse Manager, Secteur 21, Centre Collaborateur de l’Organisation mondiale de la Santé (Lille, France); Marianne Ramonet, Psychiatrist, Sector 21, Centre Collaborateur de l’Organisation mondiale de la Santé (Lille, France); Jean-Luc Roelandt, Psychiatrist, Centre collaborateur de l’OMS pour la Recherche et la Formation en Santé mentale, Etablissement Public de Santé Mentale (EPSM) Lille-Métropole, France; Simon Vasseur Bacle, Psychologue clinicien /Chargé de mission et des affaires internationales, Centre Collaborateur de l’Organisation mondiale de la Santé (Lille, France), Etablissement Public de Santé Mentale (EPSM) Lille-Métropole et Secteur 21, France. Friendship Bench – Zimbabwe: Dixon Chibanda, Chief Executive Officer; Ruth Verhey, Program Director (Friendship Bench, Harare, Zimbabwe). Hand in Hand supported living – Georgia: Eka Chkonia, President of the Society of Georgian Psychiatrists, Associate Professor at Tbilisi State Medical University, Clinical Director at the Tbilisi Mental Health Center, Tbilisi, Georgia; Amiran Dateshidze, Founder, NGO-Hand in Hand, Tbilisi, Georgia; Giorgi Geleishvili, Director of Evidence Based Practice Center, Psychiatrist at Tbilisi Assertive Community Treatment Team, Individual Member of International Association for Analytical Psychology, Tbilisi, Georgia; Izabela Laliashvili, Manager, NGO-Hand in Hand, Tbilisi, Georgia; Tamar Shishniashvili, Director, NGO-Hand in Hand, Tbilisi, Georgia; Maia Shishniashvili, Founder, NGO-Hand in Hand, Tbilisi, Georgia. Technical package vii Hearing voices support groups: Gail Hornstein, Professor of Psychology, Mount Holyoke College, South Hadley, MA, USA; Olga Runciman, Psychologist, Owner of Psycovery Denmark, Chair of the Danish Hearing Voices Network, Copenhagen, Denmark. Home Again – Chennai, india: Vandana Gopikumar, Co-Founder, Managing Trustee; Lakshmi Narasimhan, Consultant Research; Keerthana Ram, Research Associate; Pallavi Rohatgi, Executive Director (The Banyan, Chennai, India). Nisha Vinayak, Co-lead for Social Action and Research, The Banyan Academy, Chennai, India. Home Focus – West Cork, ireland: Barbara Downs, Rehabilitative Training Instructor, Home Focus Team; Kathleen Harrington, Area Manager; Caroline Hayes, Recovery Development Advocate, Home Focus Team; Catriona Hayes, Clinical Nurse Specialist/Community Mental Health Nurse, Home Focus Team; Maura O’Donovan, Recovery Support Worker, Home Focus Team; Aidan O’Mahony, Rehabilitative Training Instructor, Home Focus Team; Jason Wycherley, Area Manager (National Learning Network, Bantry, Ireland). KeyRing Living Support Networks: Charlie Crabtree, Marketing and Communications Manager; Sarah Hatch, Communications Coordinator; Karyn Kirkpatrick, Chief Executive Officer; Frank Steeples, Quality Assurance Lead; Mike Wright, Deputy Chief Executive Officer (KeyRing Living Support Networks, London, United Kingdom). Kliniken Landkreis Heidenheim gGmbH – Heidenheim, Germany: Martin Zinkler, Clinical Director, Kliniken Landkreis Heidenheim gGmbH, Heidenheim, Germany. Link House – Bristol, United Kingdom: Carol Metters, Former Chief Executive Officer; Sarah O‘Leary, Chief Executive Officer (Missing Link Mental Health Services Bristol, United Kingdom). Nairobi Mind Empowerment Peer Support Group, USP Kenya: Elizabeth Kamundia, Assistant Director, Research, Advocacy and Outreach Directorate, Kenya National Commission on Human Rights, Nairobi, Kenya; Michael Njenga, Executive Council Member, Africa Disability Forum, Chief Executive Officer, Users and Survivors of Psychiatry in Kenya, Nairobi, Kenya. Naya Daur – West Bengal, india: Mrinmoyee Bose, Program Coordinator; Sarbani Das Roy, Director and Co-Founder; Gunjan Khemka, Assistant Director; Priyal Kothari, Program Manager; Srikumar Mukherjee, Psychiatrist and Co-Founder; Abir Mukherjee, Psychiatrist; Laboni Roy, Assistant Director (Iswar Sankalpa, Kolkata, West Bengal, India). Open Dialogue Crisis Service – Lapland, Finland: Brigitta Alakare, Former Chief Psychiatrist; Tomi Bergström, Psychologist PhD, Keropudas Hospital; Marika Biro, Nurse and Family Therapist, Head Nurse, Keropudas Hospital; Anni Haase, Psychologist, Trainer on Psychotherapy; Mia Kurtti, Nurse, MSc, Trainer on Family and Psychotherapy; Elina Löhönen, Psychologist, Trainer on Family and Psychotherapy; Hannele Mäkiollitervo, MSc Social Sciences, Peer Worker, Unit of Psychiatry; Tiina Puotiniemi, Director, Unit of Psychiatry and Addiction Services; Jyri Taskila, Psychiatrist, Trainer on Family and Psychotherapy; Juha Timonen, Nurse and Family Therapist, Keropudas Hospital; Kari Valtanen, Psychiatrist MD, Trainer on Family and Psychotherapy; Jouni Petäjäniemi, Head Nurse, Keropudas Hospital Crisis Clinic and Tornio City Outpatient Services (Western-Lapland Health Care District, Lapland, Finland) Peer Support South East Ontario – Ontario, Canada: Todd Buchanan, Professor, Loyalist College, Business & Operations Manager, Peer Support South East Ontario (PSSEO), Ontario, Canada; Deborrah Cuttriss Sherman, Peer Support for Transitional Discharge, Providence Care, Ontario, Canada; Cheryl Forchuk, Beryl and Richard Ivey Research Chair in Aging, Mental Health, Rehabilitation and Recovery, Parkwood Institute Research/Lawson Health Research Institute, Western University, London, Ontario, Canada; Donna Stratton, Transitional Discharge Model Coordinator, Peer Support South East Ontario, Ontario, Canada. Personal Ombudsman – Sweden: Ann Bengtsson, Programme Officer, Socialstyrelsen, Stockholm, Sweden; Camilla Bogarve, Chief Executive Officer, PO Skåne, Sweden; Ulrika Fritz, Chairperson, The Professional Association for Personal Ombudsman in Sweden (YPOS), Sweden. viii Comprehensive mental health service networks Phoenix Clubhouse – Hong Kong Special Administrative Region (SAR), People’s Republic of China: Phyllis Chan, Clinical Stream Coordinator (Mental Health) - Hong Kong West Cluster, Chief of Service - Department of Psychiatry, Queen Mary Hospital, Honorary Clinical Associate Professor - Department of Psychiatry, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, People’s Republic of China; Anita Chan, Senior Occupational Therapist, Occupational Therapy Department, Queen Mary Hospital, Hong Kong SAR, People’s Republic of China; June Chao, Department Manager, Occupational Therapy Department, Queen Mary Hospital, Hong Kong SAR, People’s Republic of China; Bianca Cheung, Staff of Phoenix Clubhouse, Phoenix Clubhouse/ Occupational Therapy Department, Queen Mary Hospital, Hong Kong SAR, People’s Republic of China; Eileena Chui, Consultant, Department of Psychiatry, Queen Mary Hospital, Hong Kong SAR, People’s Republic of China; Joel D. Corcoran, Executive Director, Clubhouse International, New York, NY, USA; Enzo Lee, Staff of Phoenix Clubhouse, Phoenix Clubhouse/ Occupational Therapy Department, Queen Mary Hospital, Hong Kong SAR, People’s Republic of China; Francez Leung, Director of Phoenix Clubhouse, Occupational Therapist, Phoenix Clubhouse/ Occupational Therapy Department, Queen Mary Hospital, Hong Kong SAR, People’s Republic of China; Eric Wong, Staff of Phoenix Clubhouse, Phoenix Clubhouse/ Occupational Therapy Department, Queen Mary Hospital, Hong Kong SAR, People’s Republic of China; Mimi Wong, Member of Phoenix Clubhouse, Hong Kong SAR, People’s Republic of China; Eva Yau, Honorary member of Friends of Phoenix Clubhouse, Faculty Member of Clubhouse International, Founding Director of Phoenix Clubhouse, Hong Kong SAR, People’s Republic of China. Shared Lives – South East Wales, United Kingdom: Emma Jenkins, Shared Lives for Mental Health Crisis Manager, South East Wales Shared Lives Scheme, Caerphilly CBC, United Kingdom; Martin Thomas, Business Manager, South East Wales Shared Lives Scheme, Caerphilly CBC, United Kingdom; Benna Waites, Joint Head of Psychology, Counselling and Arts Therapies, Mental Health and Learning Disabilities, Aneurin Bevan University Health Board, United Kingdom; Rachel White, Team Manager, Home Treatment Team, Adult Mental Health Directorate, Aneurin Bevan University Health Board, United Kingdom. Soteria – Berne, Switzerland: Clare Christine, Managing Director, Soteria Berne, Berne, Switzerland; Walter Gekle, Medical Director, Soteria Berne, Head Physician and Deputy Director, Center for Psychiatric Rehabilitation, University Psychiatric Services, Berne, Switzerland. Trieste Community Mental Health Network of Services – italy: Tommaso Bonavigo, Psychiatrist, Community Mental Health Centre 3 – Domio, Mental Health Department of Trieste and Gorizia, WHO Collaborating Centre for Research and Training – Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), Trieste, Italy; Mario Colucci, Psychiatrist, Head of Community Mental Health Centre 3 – Domio, Mental Health Department of Trieste and Gorizia, WHO Collaborating Centre for Research and Training – Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), Trieste, Italy; Elisabetta Pascolo Fabrici, Director, Mental Health Department of Trieste and Gorizia, WHO Collaborating Centre for Research and Training – Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), Trieste, Italy; Serena Goljevscek, Psychiatrist, Community Mental Health Centre 3 – Domio, Mental Health Department of Trieste and Gorizia, WHO CC for Research and Training – Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), Trieste, Italy; Roberto Mezzina, International Mental Health Collaborating Network (IMHCN), Italy, Former Director, Mental Health Department of Trieste and Gorizia, WHO Collaborating Centre for Research and Training – Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), Trieste, Italy; Alessandro Saullo, Psychiatrist, Community Mental Health Centre of Gorizia, Mental Health Department of Trieste and Gorizia, WHO Collaborating Centre for Research and Training – Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), Trieste, Italy; Daniela Speh, Specialized Nurse, Coordinator for Training, Mental Health Department of Trieste and Gorizia, WHO Collaborating Centre for Research and Training - ASUGI Corporate Training and Development Office – Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), Trieste, Italy; Marco Visintin, Psychologist, Community Mental Health Centre of Gorizia, Mental Health Department of Trieste and Gorizia, WHO Collaborating Centre for Research and Training – Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), Trieste, Italy. Tupu Ake – South Auckland, New Zealand: Janice McGill, Peer Development Lead; Ross Phillips, Business Operations Manager (Pathways, Auckland, New Zealand). Technical package ix Mental health networks from Bosnia and Herzegovina, Lebanon and Peru Bosnia and Herzegovina: Dzenita Hrelja, Project Director, Mental Health / Association XY, Sarajevo, Bosnia and Herzegovina. Lebanon: Rabih El Chammay, Head; Nayla Geagea, Legislation and Human Rights Advisor; Racha Abi Hana, Service Development Coordinator (National Mental Health Programme, Ministry of Public Health, Lebanon). Thurayya Zreik, QualityRights Project Coordinator, Lebanon. Peru: Yuri Cutipe, Director of Mental Health, Ministry of Health, Lima, Peru. Technical review and written contributions Maria Paula Acuña Gonzalez, Former WHO Intern (Ireland); Christine Ajulu, Health Rights Advocacy Forum (Kenya); John Allan, Mental Health Alcohol and Other Drugs Branch, Clinical Excellence Queensland, Queensland Health (Australia); Jacqueline Aloo, Ministry of Health (Kenya); Caroline Amissah, Mental Health Authority (Ghana); Sunday Anaba, BasicNeeds (Ghana); Naomi Anyango, Mathari National Teaching & Referral Hospital (Kenya); Aung Min, Aung Clinic Mental Health Initiative (Myanmar); Antoine Baleige, Centre Collaborateur de l‘Organisation Mondiale de la Santé, Lille (France); Shantha Barriga, Disability Rights Division, Human Rights Watch (Belgium); Peter Bartlett, School of Law and Institute of Mental Health, University of Nottingham (United Kingdom); Marie Baudel, Laboratoire DCS - Droit et changement social, Université de Nantes (France); Frank Bellivier, Ministry of Health (France); Alison Brabban, Tees, Esk & Wear Valleys NHS Foundation Trust (United Kingdom); Jonas Bull, Mental Health Europe (Belgium); Peter Bullimore, National Paranoia Network (United Kingdom); Raluca Bunea, Open Society Foundations (Germany); Miroslav Cangár, Social Work Advisory Board (Slovakia); Mauro Giovanni Carta, Department of Medical Science and Public Health, University of Cagliari (Italy); Marika Cencelli, Mental Health, NHS England (United Kingdom); Vincent Cheng, Hearing Voices, (Hong Kong); Dixon Chibanda, Friendship Bench (Zimbabwe); Amanda B. Clinton, American Psychological Asscociation (USA); Jarrod Clyne, International Disability Alliance (Switzerland); Joel D. Corcoran, Clubhouse International (USA); Alain Dannet, Centre Collaborateur de l‘Organisation Mondiale de la Santé, Lille (France); Bhargavi Davar, Transforming Communities for Inclusion – Asia Pacific (TCI–AP) (India); Adv. Liron David, Enosh - The Israeli Mental Health Association (Israel); Sera Davidow, Wildflower Alliance (formerly known as the Western Massachusetts Recovery Learning Community) (USA); Larry Davidson, Program for Recovery and Community Health, School of Medicine, Yale University (USA); Gabriela B. de Luca, Open Society Foundations (USA); Laurent Defromont, Centre Collaborateur de l‘Organisation Mondiale de la Santé, Lille (France); Keshav Desiraju, Former Health Secretary (India); Julian Eaton, CBM Global (United Kingdom); Marie Fallon- Kund, Mental Health Europe (Belgium); Julia Faure, WHO Consultant (France); Silvana Galderisi, University of Campania „Luigi Vanvitelli“ (Italy); Rosemary Gathara, Basic Needs Basic Rights Kenya (Kenya); Walter Gekle, Soteria Berne (Switzerland); Piers Gooding, Melbourne Social Equity Institute, University of Melbourne (Australia); Ugne Grigaite, NGO Mental Health Perspectives (Lithuania); Ahmed Hankir, Institute of Psychiatry, Psychology and Neuroscience, King‘s College London (United Kingdom); Sarah Harrison, International Medical Corps (Turkey); Akiko Hart, National Survivor User Network (United Kingdom); Hee-Kyung Yun, WHO Collaborating Centre for Psychosocial Rehabilitation and Community Mental Health, Yong-In Mental Hospital (Republic of Korea); Helen Herrman, Orygen and Centre for Youth Mental Health, The University of Melbourne (Australia); Mathew Jackman, Global Mental Health Peer Network (Australia); Florence Jaguga, Moi Teaching & Referral Hospital (Kenya); Jasmine Kalha, Centre for Mental Health Law and Policy, Indian Law Society (India); Olga Kalina, European Network of (Ex)Users and Survivors of Psychiatry (Denmark); Elizabeth Kamundia, Kenya National Commission on Human Rights (Kenya); Clement Kemboi Cheptoo, Kenya National Commission on Human Rights (Kenya); Tim Kendall, Mental Health, NHS England (United Kingdom); Judith Klein, INclude-The Mental Health Initiative (USA); Sarah Kline, United for Global Mental Health (United Kingdom); Humphrey Kofie, Mental Health Society of Ghana (Ghana); Martijn Kole, Lister Utrecht Enik Recovery Center (Netherlands); Géry Kruhelski, Centre Collaborateur de l‘Organisation Mondiale de la Santé, Lille (France); Kimberly Lacroix, Bapu Trust for Research on Mind and Discourse (India); Rae Lamb, Te Pou o te Whakaaro Nui (New Zealand); Marc Laporta, Douglas Hospital Research Centre, The Montreal PAHO/WHO Collaborating Centre for Reference and Research in Mental Health, Montréal xComprehensive mental health service networks (Canada); Tuncho Levav, Department of Community Mental Health, University of Haifa (Israel); Konstantina Leventi, The European Association of Service Providers for Persons with Disabilities (Belgium); Long Jiang, Shanghai Mental Health Centre, Shanghai Jiao Tong University, WHO Collaborating Centre for Research and Training in Mental Health (China); Florence Wangechi Maina, Kenya Medical Training College, Mathari Campus (Kenya); Felicia Mburu, Validity Foundation (Kenya); Peter McGovern, Modum Bad (Norway); David McGrath, David McGrath Consulting (Australia); Roberto Mezzina, International Mental Health Collaborating Network (IMHCN), Italy, Former Director, Mental Health Department of Trieste and Gorizia, WHO Collaborating Centre for Research and Training – Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), Trieste, Italy; Matilda Mghoi, Division of Mental Health, Ministry of Health (Kenya); Jean-Dominique Michel, Pro Mente Sana (Switzerland); Tina Minkowitz, Center for the Human Rights of Users and Survivors of Psychiatry (USA); Faraaz Mohamed, Open Society Foundations (USA); Andrew Molodynski, Oxford Health NHS Foundation Trust (United Kingdom); Maria Francesca Moro, Department of Epidemiology, Mailman School of Public Health, Columbia University (USA); Marina Morrow, Realizing Human Rights and Equity in Community Based Mental Health Services, York University (Canada); Joy Muhia, QualityRights Kenya, Division of Mental Health, Ministry of Health (Kenya); Elizabeth Mutunga, Alzheimers and Dementia Organization (Kenya); Na-Rae Jeong, WHO Collaborating Centre for Psychosocial Rehabilitation and Community Mental Health, Yong-In Mental Hospital (Republic of Korea); Lawrence Nderi, Mathari National Teaching & Referral Hospital (Kenya); Mary Nettle, Mental Health User Consultant (United Kingdom); Simon Njuguna Kahonge, Ministry of Health (Kenya); Akwasi Owusu Osei, Mental Health Authority (Ghana); Cláudia Pellegrini Braga, Rio de Janeiro Public Prosecutor‘s Office, Brazil; Sifiso Owen Phakathi, Directorate of Mental Health and Substance Abuse Policy, Department of Health (South Africa); Ross Phillips, Pathways (New Zealand); Dainius Puras, Human Rights Monitoring Institute/ Department of Psychiatry, Faculty of Medicine, Vilnius University (Lithuania); Gerard Quinn, UN Special Rapporteur on the rights of persons with disabilities (Ireland); Marianne Ramonet, Centre Collaborateur de l‘Organisation Mondiale de la Santé, Lille (France); Julie Repper, Nottinghamshire Healthcare Trust, University of Nottingham (United Kingdom); Pina Ridente, Psychiatrist, Italy; Jean- Luc Roelandt, Centre collaborateur de l‘OMS pour la Recherche et la Formation en Santé mentale, Etablissement Public de Santé Mentale (EPSM) Lille-Métropole (France); Grace Ryan, Centre for Global Mental Health, London School of Hygiene and Tropical Medicine (United Kingdom); San San Oo, Aung Clinic Mental Health Initiative (Myanmar); Benedetto Saraceno, Lisbon Institute Global Mental Health, CEDOC/NOVA, Medical School (Portugal); Natalie Schuck, Department of Transboundary Legal Studies, Global Health Law Groningen Research Centre, University of Groningen (Netherlands); Seongsu Kim, Mental Health Crisis Response Center, New Gyeonggi Provincial Psychiatric Hospital (Republic of Korea); Dudu Shiba, Directorate of Mental Health and Substance Abuse Policy, Department of Health (South Africa); Mike Slade, Faculty of Medicine & Health Sciences, University of Nottingham (United Kingdom); Alexander Smith, WAPR/Counseling Service of Addison County (USA); Gregory Smith, Mountaintop, Pennsylvania (USA); Daniela Speh, Mental Health Department of Trieste and Gorizia, WHO CC for Research and Training - ASUGI Corporate Training and Development Office – Azienda Sanitaria Universitaria Giuliano Isontina (Italy); Ellie Stake, Charity Chy -Sawel (United Kingdom); Peter Stastny, International Network Towards Alternatives and Recovery (INTAR)/Community Access NYC (USA); Sladjana Strkalj Ivezic, Community Rehabilitation Center, University psychiatric Hospital Vrapče (Croatia); Charlene Sunkel, Global Mental Health Peer Network (South Africa); Sauli Suominen, Finnish Personal Ombudsman Association (Finland); Orest Suvalo, Mental Health Institute, Ukrainian Catholic University (Ukraine); Kate Swaffer, Dementia Alliance International, Alzheimer‘s Disease International (Australia); Tae-Young Hwang, WHO Collaborating Centre for Psychosocial Rehabilitation and Community Mental Health, Yong-In Mental Hospital (Republic of Korea); Bliss Christian Takyi, St. Joseph Catholic Hospital, Nkwanta (Ghana); Katelyn Tenbensel, Alfred Health (Australia); Luc Thibaud, Users‘ Advocat (France); Tin Oo, Ministry of Health and Sports, Mental Health Department, University of Medicine (Myanmar); Samson Tse, Faculty of Social Sciences, Department of Social Work & Social Administration, The University of Hong Kong (Hong Kong); Gabriel Twose, Office of International Affairs, American Psychological Association (USA); Roberto Tykanori Kinoshita, Federal University of São Paulo (Brazil); Katrin Uerpmann, Directorate General of Human Rights and Rule of Law, Bioethics Unit, Council of Europe (France); Carmen Valle Trabadelo, Inter-Agency Standing Committee (IASC) on Mental Health and Psychosocial Support Technical package xi (MHPSS) Reference Group (Denmark); Alberto Vásquez Encalada, Sociedad y Discapacidad (SODIS), Switzerland; Simon Vasseur Bacle, Centre Collaborateur de l‘Organisation Mondiale de la Santé (Lille, France), Etablissement Public de Santé Mentale (EPSM) Lille-Métropole (France); Ruth Verhey, Friendship bench (Zimbabwe); Lakshmi Vijayakumar, Society for Nutrition, Education & Health Action, Voluntary Health Services (India); Benna Waites, Psychology, Counselling and Arts Therapies, Aneurin Bevan University Health Board (United Kingdom); Ian Walker, Mental Health, NCDs and UKOT Programme, Global Public Health Division, Public Health England (United Kingdom); Petr Winkler, Department of Public Mental Health, National Institute of Mental Health (Czech Republic); Stephanie Wooley, European Network of (Ex-) Users and Survivors of Psychiatry (France); Alexandre Willschleger, Mental Health, Hôpitaux Universitaires Genève (Switzerland); Peter Badimark Yaro, BasicNeeds Ghana (Ghana); Yifeng Xu, Shanghai Mental Health Centre, Shanghai Jiao Tong University, WHO Collaborating Centre for Research and Training in Mental Health (China); Luk Zelderloo, The European Association of Service Providers for Persons with Disabilities, Zero Project (Belgium); Maximilien Zimmerman, Féderation Handicap International – Humanity & Inclusion (Belgium); Martin Zinkler, Kliniken Landkreis Heidenheim gGmbH, Heidenheim (Germany). WHO Headquarters, Regional and Country Office contributions Nazneen Anwar (WHO/SEARO); Șebnem Avșar Kurnaz (WHO/Turkey); Florence Baingana (WHO/ AFRO); Fatima Batool (WHO/HQ); Andrea Bruni (WHO/AMRO); Kenneth Carswell (WHO/HQ); Vanessa Cavallera (WHO/HQ); Claudina Cayetano (WHO/AMRO); Daniel Hugh Chisholm (WHO/EURO); Neerja Chowdhary (WHO/HQ); Alarcos Cieza (WHO/HQ); Catarina Magalhães Dahl (WHO/AMRO); Tarun Dua (WHO/HQ); Alexandra Fleischmann (WHO/HQ); Stéfanie Freel (WHO/HQ); Brandon Gray (WHO/HQ); Fahmy Hanna (WHO/HQ); Mathew Jowett (WHO/HQ); Tara Mona Kessaram (WHO/Indonesia); Dévora Kestel (WHO/HQ); Kavitha Kolappa (WHO/HQ); Jason Ligot (WHO/WPRO); Aiysha Malik (WHO/HQ); Maria del Carmen Martinez Viciana (WHO/AMRO); Hernan Montenegro von Mühlenbrock (WHO/ HQ); Melita Murko (WHO/EURO); Brian Ogallo (WHO/Sudan); Sally-ann Ohene (WHO/Ghana); Renato Oliveira E Souza (WHO/AMRO); Khalid Saeed (WHO/EMRO); Giovanni Sala (WHO/HQ); Alison Schafer (WHO/HQ); Nicoline Schiess (WHO/HQ); Katrin Seeher (WHO/HQ); Chiara Servili (WHO/HQ); Julie Storr (WHO/HQ); Shams B. Syed (WHO/HQ); Mark Van Ommeren (WHO/HQ); Martin Vandendyck (WHO/WPRO); Jasmine Vergara (WHO/Philippines); Edwina Zoghbi (WHO/Lebanon). WHO administrative, editorial and other support Administrative support: Patricia Robertson, Assistant to Unit Head, Policy, Law and Human Rights, Department of Mental Health and Substance Use, WHO, Geneva, Switzerland; Editing of the Guidance on community mental health services: Promoting person-centred and rights- based approaches: Alexandra Lang Lucini (Switzerland); Editing of the Technical packages on community mental health services: Promoting person-centred and rights-based approaches: Tatum Anderson (United Kingdom) and Alexandra Lang Lucini (Switzerland); Drafting of initial summaries of the 25 good practice services: Elaine Fletcher, Global Policy Reporting Association (Switzerland); Tatum Anderson (United Kingdom); Graphic Design: Jillian Reichenbach-Ott, Genève Design (Switzerland); Other support: Casey Chu, Yale School of Public Health (USA); April Jakubec Duggal, University of Massachusetts (USA); Adrienne W.Y. Li, Toronto Rehabilitation Institute, University Health Network (Canada); Izabella Zant, EmblemHealth (USA). Financial support WHO would like to thank Ministry of Health and Welfare of the Republic of Korea for their continuous and generous financial support towards the development of the Guidance and Technical packages on community mental health services: Promoting person-centred and rights-based approaches. We are also grateful for the financial support received from Open Society Foundations, CBM Global, and the Government of Portugal. xii Comprehensive mental health service networks Special thanks Aung Clinic – Yangon, Myanmar would like to thank the study participants of the evaluation research for the Aung Clinic Mental Health Initiative, service users and their families, and networks and partnerships of local and international organizations/people; and the peer support workers and peer group of Aung Clinic Mental Health Initiative for advocacy and coordinating initiatives for people with psychosocial and intellectual disability. East Lille network of mental health services – France would like to acknowledge the support to their service of the following individuals: Bernard Derosier, Eugéne Regnier, Gérard Duchéne (deceased), Claude Ethuin (deceased), Jacques Bossard, Françoise Dal, Alain Rabary, O. Verriest, M. Février, Raghnia Chabane and Vincent Demassiet. BET Unit, Blakstad Hospital, vestre viken Hospital Trust – viken, Norway would like to acknowledge Øystein Saksvi (deceased) for his mentorship, inspiration and important contribution to BET Unit. Shared Lives – South East Wales, United Kingdom would like to acknowledge the following people for their key role in the development of their service: Jamie Harrison, Annie Llewellyn Davies, Diane Maddocks, Alison Minett, Perry Attwell, Charles Parish, Katie Benson, Chris O’Connor, Rosemary Brown, Ian Thomas, Gill Barratt, Angela Fry, Martin Price, Kevin Arundel, Susie Gurner, Rhiannon Davies, Sarah Bees, and the Newport Crisis Team and Newport In-patient Unit, Aneurin Bevan University Health Board (ABUHB); and in addition, Kieran Day, Rhian Hughes and Charlotte Thomas- Johnson, for their role in evaluation. Peer Support South East Ontario – Ontario, Canada would like to acknowledge the support of Server Cloud Canada, Kingston, Ontario, Canada, to their website for the statistical data required for their service (https://www.servercloudcanada.com). Technical package xiii Executive summary Mental health has received increased attention over the last decade from governments, nongovernmental organizations (NGOs) and multilateral organizations including the United Nations (UN) and the World Bank. With increased awareness of the importance of providing person-centred, human rights-based and recovery-oriented care and services, mental health services worldwide are striving to provide quality care and support. Yet often services face substantial resource restrictions, operate within outdated legal and regulatory frameworks and an entrenched overreliance on the biomedical model in which the predominant focus of care is on diagnosis, medication and symptom reduction while the full range of social determinants that impact people’s mental health are overlooked, all of which hinder progress toward full realization of a human rights-based approach. As a result, many people with mental health conditions and psychosocial disabilities worldwide are subject to violations of their human rights – including in care services where adequate care and support are lacking. To support countries in their efforts to align mental health systems and services delivery with international human rights standards, including the Convention on the Rights of Persons with Disabilities (CRPD), the WHO Guidance on community mental health services: Promoting person-centred and rights-based approaches calls for a focus on scaling up community-based mental health services that promote person-centred, recovery- oriented and rights-based health services. It provides real-world examples of good practices in mental health services in diverse contexts worldwide and describes the linkages needed with housing, education, employment and social protection sectors, to ensure that people with mental health conditions are included in the community and are able to lead full and meaningful lives. The guidance also presents examples of comprehensive, integrated, regional and national networks of community-based mental health services and supports. Finally, specific recommendations and action steps are presented for countries and regions to develop community mental health services that are respectful of peoples’ human rights and focused on recovery. This comprehensive guidance document is accompanied by a set of seven supporting technical packages which contain detailed descriptions of the showcased mental health services 1. Mental health crisis services 2. Hospital-based mental health services 3. Community mental health centres 4. Peer support mental health services 5. Community outreach mental health services 6. Supported living for mental health 7. Comprehensive mental health service networks xiv Comprehensive mental health service networks Introduction Reports from around the world highlight the need to address discrimination and promote human rights in mental health care settings. This includes eliminating the use of coercive practices such as forced admission and forced treatment, as well as manual, physical or chemical restraint and seclusiona and tackling the power imbalances that exist between health staff and people using the services. Sector-wide solutions are required not only in low-income countries, but also in middle- and high-income countries. The CRPD recognizes these challenges and requires major reforms and promotion of human rights, a need strongly reinforced by the Sustainable Development Goals (SDGs). It establishes the need for a fundamental paradigm shift within the mental health field, which includes rethinking policies, laws, systems, services and practices across the different sectors which negatively impact people with mental health conditions and psychosocial disabilities. Since the adoption of the CRPD in 2006, an increasing number of countries are seeking to reform their laws and policies in order to promote the rights to community inclusion, dignity, autonomy, empowerment and recovery. However, to date, few countries have established the policy and legislative frameworks necessary to meet the far-reaching changes required by the international human rights framework. In many cases, existing policies and laws perpetuate institutional-based care, isolation as well as coercive – and harmful – treatment practices. a Strategies to end seclusion and restraint. WHO QualityRights Specialized training. Course guide. Geneva: World Health Organization; 2019 (https://apps.who.int/iris/bitstream/handle/10665/329605/97892 41516754-eng.pdf). Key messages of this guidance • Many people with mental health conditions and psychosocial disabilities face poor- quality care and violations of their human rights, which demands profound changes in mental health systems and service delivery. • in many parts of the world examples exist of good practice, community-based mental health services that are person-centred, recovery-oriented and adhere to human rights standards. • in many cases these good practice, community-based mental health services show lower costs of service provision than comparable mainstream services. • Significant changes in the social sector are required to support access to education, employment, housing and social benefits for people with mental health conditions and psychosocial disabilities. • it is essential to scale up networks of integrated, community-based mental health services to accomplish the changes required by the CRPD. • The recommendations and concrete action steps in this guidance provide a clear roadmap for countries to achieve these aims. Technical package xv Providing community-based mental health services that adhere to the human rights principles outlined in the CRPD – including the fundamental rights to equality, non-discrimination, full and effective participation and inclusion in society, and respect for people’s inherent dignity and individual autonomy – will require considerable changes in practice for all countries. Implementing such changes can be challenging in contexts where insufficient human and financial resources are being invested in mental health. This guidance presents diverse options for countries to consider and adopt as appropriate to improve their mental health systems and services. It presents a menu of good practice options anchored in community-based health systems and reveals a pathway for improving mental health care services that are innovative and rights-based. There are many challenges to realizing this approach within the constraints that many services face. However, despite these limitations, the mental health service examples showcased in this guidance show concretely – it can be done. Examples of good practice community mental health services In many countries, community mental health services are providing a range of services including crisis services, community outreach, peer support, hospital-based services, supported living services and community mental health centres. The examples presented in this guidance span diverse contexts from, for example, the community mental health outreach service, Atmiyata, in India, to the Aung Clinic community mental health service in Myanmar and the Friendship Bench in Zimbabwe, all of which make use of community health care workers and primary health care systems. Other examples include hospital-based services such as the BET unit in Norway, which is strongly focused on recovery, and crisis services such as Tupu Ake in New Zealand. This guidance also showcases established supported living services such as the KeyRing Living Support Networks in the United Kingdom and peer-support services such as the Users and Survivors of Psychiatry groups in Kenya and the Hearing Voices Groups worldwide. While each of these services is unique, what is most important is that they are all promoting a person- centred, rights-based, recovery approach to mental health systems and services. None is perfect, but these examples provide inspiration and hope as those who have established them have taken concrete steps in a positive direction towards alignment with the CRPD. Each mental health service description presents the core principles underlying the service including their commitment to respect for legal capacity, non-coercive practices, community inclusion, participation and the recovery approach. Importantly, each service presented has a method of service evaluation, which is critical for the ongoing assessment of quality, performance and cost-effectiveness. In each case, service costs are presented as well as cost comparisons with regional or national comparable services. These examples of good practice mental health services will be useful to those who wish to establish a new mental health service or reconfigure existing services. The detailed service descriptions in the technical packages contain practical insights into challenges faced by these services as they evolved, and the solutions developed in response. These strategies or approaches can be replicated, transferred or scaled up when developing services in other contexts. The guidance presents practical steps and recommendations for setting up or transforming good practice mental health services that can work successfully within a wide range of legal frameworks while still protecting human rights, avoiding coercion and promoting legal capacity. xvi Comprehensive mental health service networks Significant social sector changes are also required In the broader context, critical social determinants that impact people’s mental health such as violence, discrimination, poverty, exclusion, isolation, job insecurity or unemployment, and lack of access to housing, social safety nets, and health services, are factors often overlooked or excluded from mental health discourse and practice. In reality, people living with mental health conditions and psychosocial disabilities often face disproportionate barriers to accessing education, employment, housing and social benefits – fundamental human rights – on the basis of their disability. As a result, significant numbers are living in poverty. For this reason, it is important to develop mental health services that engage with these important life issues and ensure that the services available to the general population are also accessible to people with mental health conditions and psychosocial disabilities. No matter how well mental health services are provided though, alone they are insufficient to support the needs of all people, particularly those who are living in poverty, or those without housing, education or a means to generate an income. For this reason, it is essential to ensure that mental health services and social sector services engage and collaborate in a very practical and meaningful way to provide holistic support. In many countries, great progress is already being made to diversify and integrate mental health services within the wider community. This approach requires active engagement and coordination with diverse services and community actors including welfare, health and judiciary institutions, regional and city authorities, along with cultural, sports and other initiatives. To permit such collaboration, significant strategy, policy and system changes are required not only in the health sector but also in the social sector. Scaling up mental health service networks This guidance demonstrates that scaling up networks of mental health services that interface with social sector services is critical to provide a holistic approach that covers the full range of mental health services and functions. In several places around the world, individual countries, regions or cities have developed mental health service networks which address the above social determinants of health and the associated challenges that people with mental health and psychosocial conditions face daily. Some of the showcased examples are well-established, structured and evaluated networks that have profoundly reshaped and reorganized the mental health system; others are networks in transition, which have reached significant milestones. The well-established networks have exemplified a strong and sustained political commitment to reforming the mental health care system over decades, so as to adopt a human rights and recovery- based approach. The foundation of their success is an embrace of new policies and laws, along with an increase in the allocation of resources towards community-based services. For instance, Brazil’s community-based mental health networks offer an example of how a country can implement services at large scale, anchored in human rights and recovery principles. The French network of East Lille further demonstrates that a shift from inpatient care to diversified, community-based interventions can be achieved with an investment comparable to that of more conventional mental health services. Technical package xvii Finally, the Trieste, Italy network of community mental health services is also founded upon on a human rights-based approach to care and support, and strongly emphasizes de-institutionalization. These networks reflect the development of community-based mental health services that are strongly integrated and connected with multiple community actors from diverse sectors including the social, health, employment, judiciary and others. More recently, countries such as Bosnia and Herzegovina, Lebanon, Peru, and others, are making concerted efforts to rapidly expand emerging networks, and to offer community-based, rights-oriented and recovery-focused services and supports at scale. A key aspect of many of these emerging networks is the aim of bringing mental health services out of psychiatric hospitals and into local settings, so as to ensure the full participation and inclusion of individuals with mental health conditions and psychosocial disabilities in the community. While more time and sustained effort is required, important changes are already materializing. These networks provide inspiring examples of what can be achieved with political will, determination and a strong human rights perspective underpinning actions in mental health. Key recommendations Health systems around the world in low-, middle- and high-income countries increasingly understand the need to provide high quality, person-centred, recovery-oriented mental health services that protect and promote people’s human rights. Governments, health and social care professionals, NGOs, organizations of persons with disabilities (OPDs) and other civil society actors and stakeholders can make significant strides towards improving the health and well-being of their populations by taking decisive action to introduce and scale up good practice services and supports for mental health into broader social systems while protecting and promoting human rights. This guidance presents key recommendations for countries and organizations, showing specific actions and changes required in mental health policy and strategy, law reform, service delivery, financing, workforce development, psychosocial and psychological interventions, psychotropic drugs, information systems, civil society and community involvement, and research. Crucially, significant effort is needed by countries to align legal frameworks with the requirements of the CRPD. Meaningful changes are also required for policy, strategy and system issues. Through the creation of joint policy and with strong collaboration between health and social sectors, countries will be better able to address the key determinants of mental health. Many countries have successfully used shifts in financing, policy and law as a powerful lever for mental health system reform. Placing human rights and recovery approaches at the forefront of these system reforms has the potential to bring substantial social, economic and political gains to governments and communities. In order to successfully integrate a person-centred, recovery-oriented and rights-based approach in mental health, countries must change and broaden mindsets, address stigmatizing attitudes and eliminate coercive practices. As such, it is critical that mental health systems and services widen their focus beyond the biomedical model to also include a more holistic approach that considers all aspects of a person’s life. Current practice in all parts of the world, however, places psychotropic drugs at the centre of treatment responses whereas psychosocial interventions, psychological interventions and peer support should also be explored and offered in the context of a person-centred, recovery and rights-based approach. These changes will require significant shifts in the knowledge, competencies and skills of the health and social services workforce. xviii Comprehensive mental health service networks More broadly, efforts are also required to create inclusive societies and communities where diversity is accepted, and the human rights of all people are respected and promoted. Changing negative attitudes and discriminatory practices is essential not just within health and social care settings, but also within the community as a whole. Campaigns raising awareness of the rights of people with lived experience are critical in this respect, and civil society groups can play a key strategic role in advocacy. Further, as mental health research has been dominated by the biomedical paradigm in recent decades, there is a paucity of research examining human rights-based approaches in mental health. A significant increase in investment is needed worldwide in studies examining rights-based approaches, assessing comparative costs of service provision and evaluating their recovery outcomes in comparison to biomedical-based approaches. Such a reorientation of research priorities will create a solid foundation for a truly rights-based approach to mental health and social protection systems and services. Finally, development of a human rights agenda and recovery approach cannot be attained without the active participation of individuals with mental health conditions and psychosocial disabilities. People with lived experience are experts and necessary partners to advocate for the respect of their rights, but also for the development of services and opportunities that are most responsive to their actual needs. Countries with a strong and sustained political commitment to continuous development of community- based mental health services that respect human rights and adopt a recovery approach will vastly improve not only the lives of people with mental health conditions and psychosocial disabilities, but also their families, communities and societies as a whole. Technical package xix What is the WHO QualityRights initiative? WHO QualityRights is an initiative which aims to improve the quality of care and support in mental health and social services and to promote the human rights of people with psychosocial, intellectual or cognitive disabilities throughout the world. QualityRights uses a participatory approach to achieve the following objectives: For more information visit the WHO QualityRights website Build capacity to combat stigma and discrimination, and to promote human rights and recovery. „ WHO QualityRights face to face training modules „ WHO QualityRights e-training on mental health and disability: Eliminating stigma and promoting human rights improve the quality of care and human rights conditions in mental health and social services. „ WHO QualityRights assessment toolkit „ WHO QualityRights module on transforming services & promoting rights Support the development of a civil society movement to conduct advocacy and influence policy-making. „ WHO QualityRights guidance module on advocacy for mental health, disability and human rights „ WHO QualityRights guidance module on civil society organizations to promote human rights in mental health and related areas Reform national policies and legislation in line with the Convention on the Rights of Persons with Disabilities and other international human rights standards. „ WHO guidance currently under development Create community-based and recovery-oriented services that respect and promote human rights. „ WHO guidance and technical packages on community mental health services: Promoting person-centred and rights-based approaches „ WHO QualityRights guidance module one-to-one peer support by and for people with lived experience „ WHO QualityRights guidance module on peer support groups by and for people with lived experience „ WHO QualityRights person-centred recovery planning for mental health and well-being self-help tool 1 2 3 4 5 xx Comprehensive mental health service networks About the WHO Guidance and technical packages on community mental health services The purpose of these documents is to provide information and guidance to all stakeholders who wish to develop or transform their mental health system and services. The guidance provides in-depth information on the elements that contribute towards the development of good practice services that meet international human rights standards and that promote a person-centred, recovery approach. This approach refers to mental health services that operate without coercion, that are responsive to people’s needs, support recovery and promote autonomy and inclusion, and that involve people with lived experience in the development, delivery and monitoring of services. There are many services in countries around the world that operate within a recovery framework and have human rights principles at their core – but they remain at the margins and many stakeholders including policy makers, health professionals, people using services and others, are not aware of them. The services featured in these documents are not being endorsed by WHO but have been selected because they provide concrete examples of what has been achieved in very different contexts across the world. They are not the only ones that are working within a recovery and human rights agenda but have been selected also because they have been evaluated, and illustrate the wide range of services that can be implemented. Showing that innovative types of services exist and that they are effective is key to supporting policy makers and other key actors to develop new services or transform existing services in compliance with human rights standards, making them an integral part of Universal Health Coverage (UHC). This document also aims to highlight the fact that an individual mental health service on its own, even if it produces good outcomes, is not sufficient to meet all the support needs of the many people with mental conditions and psychosocial disabilities. For this, it is essential that different types of community-based mental health services work together to provide for all the different needs people may have including crisis support, ongoing treatment and care, community living and inclusion. In addition, mental health services need to interface with other sectors including social protection, housing, employment and education to ensure that the people they support have the right to full community inclusion. The WHO guidance and technical packages comprise a set of documents including: • Guidance on community mental health services: Promoting person-centred and rights-based approaches – This comprehensive document contains a detailed description of person-centred, recovery and human rights-based approaches in mental health. It provides summary examples of good practice services around the world that promote human rights and recovery, and it describes the steps needed to move towards holistic service provision, taking into account housing, education, employment and social benefits. The document also contains examples of comprehensive, integrated networks of services and support, and provides guidance and action steps to introduce, integrate and scale up good practice mental health services within health and social care systems in countries to promote UHC and protect and promote human rights. Technical package xxi • Seven supporting technical packages on community mental health services: Promoting person- centred and rights-based approaches – The technical packages each focus on a specific category of mental health service and are linked to the overall guidance document. The different types of services addressed include: mental health crisis services, hospital-based mental health services, community mental health centres, peer support mental health services, community outreach mental health services, supported living services for mental health, and networks of mental health services. Each package features detailed examples of corresponding good practice services which are described in depth to provide a comprehensive understanding of the service, how it operates and how it adheres to human rights standards. Each service description also identifies challenges faced by the service, solutions that have been found and key considerations for implementation in different contexts. Finally, at the end of each technical package, all the information and learning from the showcased services is transformed into practical guidance and a series of action steps to move forward from concept to the implementation of a good practice pilot or demonstration service. Specifically, the technical packages: • showcase, in detail, a number of mental health services from different countries that provide services and support in line with international human rights standards and recovery principles; • outline in detail how the good practice services operate in order to respect international human rights standards of legal capacity, non-coercive practices, community inclusion, participation and the recovery approach; • outline the positive outcomes that can be achieved for people using good practice mental health services; • show cost comparisons of the good practice mental health services in contrast with comparable mainstream services; • discuss the challenges encountered with the establishment and operation of the services and the solutions put in place to overcome those challenges; and • present a series of action steps towards the development of a good practice service that is person- centred and respects and promotes human rights and recovery, and that is relevant to the local social and economic context. It is important to acknowledge that no service fits perfectly and uniquely under one category, since they undertake a multitude of functions that touch upon one or more of the other categories. This is reflected in categorizations given at the beginning of each mental health service description. These documents specifically focus on services for adults with mental health conditions and psychosocial disabilities. They do not include services specifically for people with cognitive or physical disabilities, neurological conditions or substance misuse, nor do they cover highly specialized services, for example, those that address eating disorders. Other areas not covered include e-interventions, telephone services (such as hotlines), prevention, promotion and early intervention programmes, tool-specific services (for example, advance planning), training and advocacy. These guidance documents also do not focus on services delivered in non-specialized health settings, although many of the lessons learned from the services in this document also apply to these settings. xxii Comprehensive mental health service networks How to use the documents Guidance on community mental health services: Promoting person-centred and rights-based approaches is the main reference document for all stakeholders. Readers interested in a particular category of mental health service may refer to the corresponding technical package which provides more detail and specific guidance for setting up a new service within the local context. However, each technical package should be read in conjunction with the broader Guidance on community mental health services document, which provides the detail required to also integrate services into the health and social sector systems of a country. These documents are designed for: • relevant ministries (including health and social protection) and policymakers; • managers of general health, mental health and social services; • mental health and other health and community practitioners such as doctors, nurses, psychiatrists psychologists, peer supporters, occupational therapists, social workers, community support workers, personal assistants, or traditional and faith based healers; • people with mental health conditions and psychosocial disabilities; • people who are using or who have previously used mental health and social services; • nongovernmental organizations (NGOs), and others working in the areas of mental health, human rights or other relevant areas such as organizations of persons with disabilities, organizations of users/survivors of psychiatry, advocacy organizations, and associations of traditional and faith- based healers; • families, support persons and other care partners; and • other relevant organizations and stakeholders such as advocates, lawyers and legal aid organizations, academics, university students, community and spiritual leaders. A note on terminology The terms “persons with mental health conditions and psychosocial disabilities” as well “persons using mental health services” or “service users” are used throughout this guidance and accompanying technical packages. We acknowledge that language and terminology reflects the evolving conceptualization of disability and that different terms will be used by different people across different contexts over time. People must be able to decide on the vocabulary, idioms and descriptions of their experience, situation or distress. For example, in relation to the field of mental health, some people use terms such as “people with a psychiatric diagnosis”, “people with mental disorders” or “mental illnesses”, “people with mental health conditions”, “consumers”, “service users” or “psychiatric survivors”. Others find some or all these terms stigmatizing or use different expressions to refer to their emotions, experiences or distress. The term “psychosocial disability” has been adopted to include people who have received a mental health-related diagnosis or who self-identify with this term. The use of the term “disability” is important in this context because it highlights the significant barriers that hinder the full and effective participation in society of people with actual or perceived impairments and the fact that they are protected under the CRPD. Technical package xxiii The term “mental health condition” is used in a similar way as the term physical health condition. A person with a mental health condition may or may not have received a formal diagnosis but nevertheless identifies as experiencing or having experienced mental health issues or challenges. The term has been adopted in this guidance to ensure that health, mental health, social care and other professionals working in mental health services, who may not be familiar with the term ‘psychosocial disability’, nevertheless understand that the values, rights and principles outlined in the documents apply to the people that they encounter and serve. Not all people who self-identify with the above terms face stigma, discrimination or human rights violations. a user of mental health services may not have a mental health condition and some persons with mental health conditions may face no restrictions or barriers to their full participation in society. The terminology adopted in this guidance has been selected for the sake of inclusiveness. It is an individual choice to self-identify with certain expressions or concepts, but human rights still apply to everyone, everywhere. Above all, a diagnosis or disability should never define a person. We are all individuals, with a unique social context, personality, autonomy, dreams, goals and aspirations and relationships with others.

11. introduction 2Comprehensive mental health service networks In several places around the world, individual countries, regions or cities have developed service networks which address the social determinants of health and the associated multiple challenges that people with mental health and psychosocial conditions face every day in all aspects of their lives. Crucially, these networks are making efforts to go a step further and work to rethink and reshape the relationships between services and the people who come to them for help. These networks of services have, in some cases, been explicitly inspired by a human rights agenda and have worked to establish recovery- oriented services. While they are focused on delivering a diversity of mental health services, they also recognize the importance of addressing key social determinants and actively collaborating with other sectors such as housing, education and employment. Many are also seeking to create the conditions for genuine partnerships with people with lived experience to ensure their expertise and requirements are integral to the services being provided. Several examples of mental health networks are provided in this section; some well-established, structured and evaluated networks that have profoundly reshaped and reorganized the mental health system, as well as some networks in transition, which have reached significant milestones. Showcasing these networks is not meant to imply that human rights standards are being met in all the network services at all times. This is not the case in any part of the world. However, these networks provide inspiring examples of what can be achieved with political commitment, determination and a strong human rights perspective underpinning actions in mental health. These examples are living proof that policy makers, planners and service providers can create a unique system of services that people with mental health conditions and psychosocial disabilities want to use and find helpful, and that produce good outcomes, protecting and promoting human rights. The service networks described in this technical package were chosen based on good practices known to the World Health Organization. The selection process was based on five human rights and recovery criteria, namely: respect for legal capacity, ending coercive practices, participation, community inclusion, and the recovery approach. The services described in this technical package are not intended to be interpreted as best practice, but rather to illustrate what can be done and to demonstrate the wider potential of community-based mental health services that promote a person-centred, rights- based, recovery approach. Providing community-based mental health services that adhere to human rights principles represents considerable shifts in practice for all countries and sets very high standards in contexts where insufficient human and financial resources are being invested in mental health. Some low-income countries may assume that the examples from high-income countries are not appropriate or useful, and equally, for high-income countries looking at the examples showcased from low-income countries. New types of services and practices may also generate a range of questions, challenges, and concerns from different stakeholders, be it policy makers, professionals, families and carers or individuals who use mental health services. The intention of this guidance is not to suggest that these services be replicated in their entirety, but rather to take and learn from those principles and practices that are relevant and transferrable to one’s own context in providing community-based mental health services that are person-centred and promote human rights and recovery. 32. Comprehensive mental health service networks – description and analysis 42.1 East Lille community mental health service network France Technical package 5 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS Context France operates with a sectorized mental health system, with approximately 850 sectors offering adult mental health services within population catchment areas of about 70,000 people. The East Lille sector is located in the Hauts-de-France region and serves only adults in an area with 88,000 inhabitants and six suburban towns. The area suffers from relatively high unemployment (15.6%) compared to the national average (11.1%) (1), and has the shortest life expectancy in France. The area is also is known to have an “under-resourced” health system (1). The Établissement Public de Santé Mentale (EPSM) Lille-Métropole, in Armentières, 25 km west of Lille, provides administrative management of the service on a day-to-day basis, and is also responsible for nine additional sectors, and a child and adolescent service that serves all these sectors. Since the 1970s, the mental health service in East Lille has undergone a series of major reforms and has promoted the concept of citizen psychiatry (psychiatrie citoyenne) which holds, as central elements, respect for the human rights of people who use mental health services and their empowerment. The first key phase of these reforms took place from 1970–1995, which saw a wide-scale shift of resources from institutions to the community. In the 1970s, the service mainly consisted of six inpatient units, based in the asylum at Armentières. These hosted over 300 long-term residents, and 98% of the budget was dedicated to their full-time hospitalization. An overseeing body was created in 1977, the Medico-Psycho-Social Association (Association Médico-Psycho-Sociale (AMPS)), to facilitate deinstitutionalization. It brought together the mental health service management, professionals, elected officials from the six towns in East Lille, and other groups that were interested in developing services in the sector. From the beginning, it was realized that reform could not only be about a reduction in the use of the asylum but would also require the inclusion of the wider community through educational work and a policy of integration. The next phase of reforms (1980–2010) involved the development of community- based mental health services alongside the integration of mental health into the health, social, and cultural services of the towns in the East Lille sector. There was also a movement towards the greater involvement of people with lived experience, family members, professional groups and elected officials, in the decisions of the mental health service. The following phase, from 2005 to 2014, witnessed the development of a large intensive mobile care team. From 2011, the emphasis moved towards creating the conditions for health democracy, in which all the stakeholders in the field of mental health (especially people with lived experience) would come together to develop and implement policy in a spirit of dialogue and consultation. Finally, from 2014 onwards, the primary task was to bring a recovery philosophy to the centre of the service. Since 2006, there have been important developments to sustain these achievements, including the replacement of AMPS in 2010 by a Local Mental Health Council (1), in line with changes in the rest of France (2). In East Lille, this local council is called the Intermunicipal Association for Health, Mental health and Citizenship (AISSMC), which is a forum where all the stakeholders from the six municipalities can meet, discuss and plan. It is chaired by the mayors of the municipalities and is co-led by the East Lille mental health service. As well as elected officials, managers and professionals, it involves people with lived experience, families and carers, residents, health and social services, general practitioners, social landlords, people from community centres, and people from the justice department. A general assembly is held every year. 6Comprehensive mental health service networks The AISSMC activities are organized according to four primary themes: • prevention – meetings on mental health issues, promotion of physical activity, cancer screening, and coordination of complex situations; • cultural actions – promotion of cultural and anti-stigma actions that make use of a fund of contemporary art, mixing pieces of art from people with and without mental health conditions; • housing issues – allocation, maintenance and planning of housing for people with mental health conditions in the municipalities; and • the local health contract – a national system which aims to define and coordinate mental health actions in the territories along the main regionally defined issues, which benefits from strong participation of elected officials in the negotiations. Description of the service The network of mental health care provided by the East Lille sector has been built over 40 years of reorganization and reform. The commitment from the head of the sector and the team has demonstrated that a shift from inpatient care to diversified, community-based interventions for people with mental health issues and/or psychosocial, intellectual and cognitive disabilities is possible, with a similar budget and epidemiological profile to other mental health sectors in France. The reforms have been made possible by the involvement of the municipalities, other stakeholders, people with lived experience, and their carers. The Local Mental Health Council (AISSMC) is the basis for actions to promote rights and information on mental health in East Lille. Such councils now operate across France, with 230 currently constituted. The concept of “citizen psychiatry” informs the entire East Lille mental health network, and is based on five pillars (3): 1. human rights are inalienable, and the presence of mental health conditions can never impede or prevent someone from accessing these rights and ensuring they are respected; justice and psychiatry, prison and hospital, seclusion and care must never be conflated; 2. society, and thus mental health services, need to adapt to people’s needs, and not the other way around; 3. there is a need to close medical and social institutions that effectively exclude residents from their communities; and 4. there is a need to fight stigma and discrimination based on mental health conditions. This includes challenging stereotypes about dangerousness and lack of capacity. On the basis of these values, the service in East Lille engages as a partner with other stakeholders, including people who use the service and their families, NGOs, elected officers in the municipalities, and others who are involved in the mental health field. Working in concert with these stakeholders, the various elements of the East Lille mental health system interrelate to form a coherent network. Technical package 7 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS Elements of the mental health service network Local medico-psychological centres (Services Médico-Psychologiques de Proximité (SMPP)) SMPPs represent the first point of contact for people with the mental health system, and provide comprehensive care and support. They are based in two dedicated ambulatory services of the EPSM which are integrated into 12 other health-related facilities. A person is referred to the SMPP by their general practitioner (GP), and can consult a range of professionals there: nurses, psychiatrists, psychologists, psycho-motor therapists,b social workers, peer-support workers, and an adapted sport coach. On arrival at the SMPP, a nurse performs an initial assessment of the person’s psychological and physical needs within 48 hours of the referral. This assessment is then discussed by a multi-disciplinary team that meets twice a week, and the team makes suggestions for care and plans future steps. The suggestions for care are always sent to the GP to ensure continuity of care and effective partnership. There are no waiting lists and all professionals working at the centre also have time allotted for home consultations. Consultations by the SMPP team can take place at a range of venues in the community, making it very accessible, including at a swimming pool and at a social and support centre for youths aged 16-25 (who may directly access services without being referred by a general practitioner). Mobile team (Soins intensifs intégrés dans la cité (SiiC)) The mobile crisis and home-treatment team is the largest in France, in terms of the number of people cared for. It provides crisis response and intensive care at home for up to 15 people at a time. It is a multi-disciplinary team which includes a health executive, day and night nurses, psychologists, special educators, a psychiatrist, psychomotor therapist; and peer health mediator, available 24 hours per day, seven days a week. The average length of time that people are cared for is 12 days; most interventions are for a few days but some last for weeks. In 2018, a total of 253 people were cared for at home, and 640 crisis interventions took place at home, avoiding hospitalization. The ratio of equivalent full-time workers to people being cared for is 0.96 (nearly one professional per person) (4). All workers in the service are sensitized to the recovery approach, the handling of crisis situations without coercion, and the human rights of service users. Jérôme Bosch Clinic General Hospital While the entire network is structured to prevent hospitalizations, when necessary, full time hospitalization can take place in the Jérôme Bosch Clinic which has 10 beds and is located next to Lille University Hospital. Its multidisciplinary team consists of a health executive, day and night nurses, a socio-cultural animator, a psychologist and Qualified Hospital Services Officers who are responsible for maintenance and hygiene. Processes are in place to avoid hospitalization, and especially forced admission. In 2018, there were 341 hospitalizations for a total of 222 people (some people had more than one episode of hospital care). At any time, an average of seven people are resident in the clinic, and the average length of stay is seven days ([Medical information service], [EPSM Lille Métropole], personal communication, [2020]). b Psychomotor therapy is defined as a method of treatment that uses body awareness and physical activities as cornerstones of its approach. It is widely used in a number of European countries, including France. 8Comprehensive mental health service networks When a person enters the clinic, information is provided about their rights and obligations both verbally and in written format, and they can name a trusted person as a supporter. The organization and architecture of the clinic is set up to ensure that people can maintain their right to privacy. All rooms are single occupancy and every person in the service has a key to their room and a safe in which they can keep their personal belongings. People staying in the hospital are free to enter and leave their rooms as they wish. The clinic relies on the close support network of the person using the service, in order to help with negotiation, safety and the avoidance of conflict. There is open visiting (5) and two rooms have a second bed for support people who can stay overnight at the clinic. An important emphasis is placed on the availability of health professionals in the clinic: the ratio of full- time workers to hospital beds is 3.1:1, with a minimum of three nurses during the day and two at night. There is also a nurse assistant, and a worker in the activity room who provides animations and artistic activities. On Sundays, external guests are invited, such as an artist or a sports coach, etc. Special needs workers (éducateurs spécialisés) are available daily to deal with social or administrative issues that a person using the service may encounter. Peer support workers who are employed by the EPSM come in each week to support people in hospital. These peer supporters have undertaken specific training to acquire a recognized national qualification. Throughout their hospital stay, the objectives of care and support are defined with the person using the service. Within 24 hours of arriving at the hospital, there is a consultation with a general practitioner to assess any physical health needs. Most importantly, social workers and special needs workers are involved from the beginning to help address the individual’s needs in terms of housing, protecting other human rights, and practical issues, such as caring for pets. An important aspect of the philosophy of the service is that hospitalization should never isolate a person from the rest of the outpatient system; all the ambulatory teams make visits to people who are in the hospital. The multi-disciplinary team meets daily to discuss care. All health professionals in the sector receive specific training to prevent instances of conflict and violence. The service also employs the services of an external security firm for situations where there is a risk of violence. These security agents can be called by the hospital staff, but otherwise do not interfere in the care offered to individuals. Their role is to help to create a climate of non-violence by reassuring professionals and people using the service that they are safe. In addition to general outpatient crisis plans, specific plans are also agreed upon to avoid any non- consensual interventions. The service does not have a dedicated seclusion area and seclusion is never practiced. While the use of any form of restraint is rare, coercive interventions are not entirely prohibited and physical restraint is used, exceptionally, on a time-limited basis. The clinic monitors the use of restraint and records all such instances and the duration of each. Between 2011 and 2019 physical restraint was used with an average of 1.77 persons per year, but since 2017 only one person per year has been subject to the use of physical restraint ([Medical information service], [EPSM Lille Métropole], personal communication, [2020]). The service has an internal goal of reducing such instances to zero. Chemical restraint is also rarely used and has recently received special attention. In 2019, nine cases of forced neuroleptic injection were reported. Each use of restraints is considered to be a major negative event in care and is subsequently investigated in order to ensure a continuous process of improving practices and reducing its use. Service users and their families are invited to participate in this. Technical package 9 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS The service places an emphasis on continuity of care as people transition out of the hospital. Families and trusted people are notified. An exit questionnaire is optionally completed by the service user, with support if needed (see Evaluation section below). A summary discharge letter is also given to the person who has used the service, with a copy for their GP. Therapeutic host families Staying with host families is another alternative to hospitalization. The goal of this service is to welcome a service user as a member of a family rather than being subject to a traditional patient/caregiver relationship. For this reason, the training of the host families does not focus on providing them with clinical caregiving skills; instead they receive training so that they understand how to support a person with a mental health condition or psychosocial disability within a recovery and human rights-based framework. They are also trained in preventing any form of mistreatment in the private homes, ways to help with agitation and crisis avoidance, and how to host a person as a family member. This host family service was used by 42 people in 2018, with an average length of stay of 32 days (4). The families involved were able to offer seven places at a time. In 2019 the availability of places decreased to two families who were able to offer four places. The host families receiving training and financial support from the EPSM for their service. There is supervision throughout the hosting period, and separate feedback meetings with all involved stakeholders. Peer group meetings are organized between the host families once or twice a year to discuss the challenges that they face. intersectoral family and systemic therapy centre The intersectoral family and network therapy centre (Don Jackson) is a specialized external consultation centre that delivers psychotherapeutic interventions for families and couples. Over 30 years, a total of 667 couples and 506 families have used these services. Although therapists from different backgrounds have worked at the centre, all have received additional training in the systemic approach to family and couples’ therapy over a four-year period. This has created a common, multidisciplinary, holistic perspective from which to consider therapy and support. Habicité Habicité is an Assertive Community Treatment (ACT) (6) team that provides long term intensive input to 80 persons with mental health conditions. This team is comprised of nurses, social workers, peer supporters, psychologists and an executive with a 1:8 professional to service user ratio (7). This service supports people in their personal recovery projects, allowing them to stay in their home and community. In addition, the service offers a range of communal housing; currently there are 13 apartments providing housing for 26 people. Access to this system has recently been democratized by including community representatives in the procedure, including elected representatives, experts with lived experience and social partners. Moreover, the service is now based on a “housing first” philosophy which means unconditional access to housing and unconditional support to make it work (8). Frontière$ Frontière$ is another element of the mental health service network, which is focused on increasing social inclusion and the general wellbeing of people using the service through physical, artistic, cultural, creative and professional activities. The team of Frontière$ comprises a nurse, a GP, an occupational 10 Comprehensive mental health service networks therapist, special needs educators, an artist, an adapted sports coach, a psychologist, psycho-motor educators, as well as five external people who organize the therapeutic activities and support people outside the service setting, through their connections with associations and other municipal bodies. Peer support workers currently at a training stage are also employed in the team and will continue to work with Frontière$ when they have completed their training. One of its services is to organize inclusion activities in ordinary leisure environments, with individualized, sustained support for people experiencing a mental health crisis, through the Service for activities of inclusion and integrated care in the community (Service d’activités d’insertion et de soins intégrés à la cite (SAISIC)). Further, its “Sagacités” system offers support to people who wish to attend activities with people outside the mental health service, also in an ordinary leisure and cultural environment. This support can either be very focused on specific activities or take the form of intensive coaching. Peer support groups can also be offered if people have a common project or interest. Lastly, this service offers support to facilitate access to and retention of employment through partnerships with local actors and stakeholders. An occupational therapist helps to define career and professional plans with service users, and a psychologist helps with motivation and evaluating vocational competencies. Network coordination and connections between services All mental health services in the East Lille network are connected and work together, which allows people to participate in one or more services: for example, people in Habicité can also be a part of Frontière$. By 2018, a total of 3513 people were receiving care from the service network ([Medical information service], [EPSM Lille Métropole], unpublished data, [2018]), and 75% of the professionals employed by the mental health service in East Lille were working in mobile teams and other community-based roles. This intensive community-based support was sufficient to keep the number of inpatient beds to 10, with a current average daily bed occupancy of seven ([Medical information service], [EPSM Lille Métropole], personal communication, [2020]). All East Lille mental health services work and operate as a network to create a coherent care pathway for each individual and are connected via an intranet network. All health professionals in the network have access to the information kept on the intranet about people using the service,c ensuring continuity and making coordination between different elements of the service possible (9). For example, in the SIIC, the intranet enables health professionals to rapidly identify the person’s medical and psychosocial background, and to refer them to the doctor, nurse or psychologist that they know best. The same file is used for outpatient and inpatient care in order to prevent loss of information. c In France, health information is subject to strict regulations regarding data access and storage. Information is stored on secure servers authorized to host health data and is accessible only to the healthcare team and to the person using the service, upon request. Access to medical files is under the strict control of an external institution, the Commission d’accès aux documents administratifs. As a general rule, people using the service can consult their file when they meet with professionals. Technical package 11 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS Core principles and values underlying the community-based mental health network Respect for legal capacity The service is committed to promoting respect for legal capacity by supporting initiatives and procedures that maximize independent and supported decision-making. However, the service does allow for involuntary admission and treatment. Out of the 222 people hospitalized in East Lille from 2013–2019, compulsory hospitalizations averaged 86.4 persons per year (39%), which is an average of 101.6 persons per 100,000 inhabitants per year. This high rate corresponds to the extensive use of these measures in France generally – in 2018 there were 82,000 compulsory admissions in the country – a rate of 122.6 per 100,000 (10). The mean length of stay in East Lille was 57 days, which is fairly close to the average for the Hauts-de-France region. The majority of these compulsory admissions are not organized by the staff from the East Lille sector, but by psychiatrists working in the general hospitals in Lille who see people in crisis who attend the Emergency departments of these hospitals. They arrange the admissions directly with the Jérôme Bosch clinic and effectively bypass the East Lille mobile crisis team (SIIC). The East Lille service does not have the authority to prevent this practice. However, once people are admitted to the clinic, plans are quickly made for discharge and the person’s status is converted to voluntary as soon as this is legally permissible. The average length of stay is only seven days. One of the major obstacles is that French law requires, in some cases, that the person no longer presents with a mental health condition, before the measure can be lifted. One of the new objectives in 2020 is to achieve a rate of zero hospitalizations without consent that last for more than 72 hours. To reinforce respect for legal capacity, the Users’ Commission (La Commission des Usagers (CDU)) – a branch of EPSM Lille-Métropole in charge of relations between users and professionals – organizes three legal advice sessions per month, in which people have access to external and independent lawyers, as well as advice from representatives of users and families. Every involuntary hospitalization is subject to judicial review, as provided by law, on the 12th day. Each person using the service is assisted by a lawyer at no cost to themselves. The East Lille network also uses advance planning as part of overall recovery plans, to discern and respect the will and preferences of individuals using services. These generic crisis plans are inspired by WRAP (11) and differ from the more specific plans used in the Jérôme Bosch clinic, which identify the triggers that might upset service users and list the interventions by professionals that they find helpful. These are used to anticipate and prevent conflict situations, and thus avoid coercive interventions. Advance plans are integrated using the online tool, Cariatides, to ensure that they are offered to the person in a user-friendly way and can be easily modified and followed-up throughout care. The target for the year 2018 was to ensure that every person going through the SIIC services is offered the opportunity to develop an advance plan. In 2018, around 300 people completed an advance plan, with a prioritization for those whose suicidal risk was high. Alternatives to coercive practices All the people working in the service receive training in de-escalation techniques, the recovery approach and in respecting patients’ rights, which helps to avoid and manage conflict situations. While great efforts are made to care for people outside hospital, and a range of concrete alternatives to hospitalization are 12 Comprehensive mental health service networks in place, forced admissions and forced treatment do sometimes occur. The rate of forced interventions is minimized in the Jérôme Bosch clinic through the use of crisis prevention plans. Even though these do not have legal status under French law, the service is fully committed to respecting a person’s prevention plan. In all cases following a crisis, the person is invited to review the plan with staff so that it can be improved and made to work better in the future. If a person refuses to take prescribed medication at the hospital, their wishes are respected. There is always a psychiatrist available to adjust the prescription as needed; they alone have the authority to make decisions regarding medication. If the providers think that a particular treatment would be beneficial, they negotiate (repeatedly, if needed) with the person who does not want to receive treatment, in order to reach informed consent. However, forced treatment still occurs at the clinic, even though every effort is made to avoid it. Failure to respect consent, and in particular the use of physical or chemical restraint (through forced injection of medication) is considered a failure of care, and all such episodes are analyzed by the service afterwards. Any forced use of medication is carefully tracked by the service, and service users and their families participate in the analysis and evaluation of these events. In 2019, there were 11 uses of medication without consent (two of these involved long-acting medication; nine cases involved punctual use) ([Medical information service], [EPSM Lille Métropole], personal communication, [2020]). Seclusion is never used in the hospital or other East Lille services. Community inclusion Community inclusion is the cornerstone and underlying philosophy of the network. Initiatives such as Habicité, Frontière$, the therapeutic host families, and the SMPP are examples of specialized support to promote community inclusion. Several support groups are also offered to service users to promote community inclusion and citizenship. The topics of those groups are based on needs identified by people using the service, such as: how to use public transport, how to access activities, how to protect rights, and how to manage one’s diet and “eat better, feel better” (particularly in relation to the effects of medication). These structured groups have a defined number of sessions and objectives and are led by various professionals. While they are subject to national regulations that require the presence of professionals, there are efforts to make these groups less “professional-dominated” with a greater emphasis on peer support and empowerment. Therapeutic and social inclusion activities are also integrated into public and ordinary community activities, through the Frontière$ service through an initiative called “hors-les-murs”, meaning outside of the facilities of the service. The East Lille sector has many partnerships with sports, cultural and social services to ensure participation of people with mental health conditions and psychosocial disabilities in ordinary community life. The aim is to use a person’s wishes and motivations as a starting point, to support participation administratively so that he or she can take part in community activities, and if necessary, to assist in attending the activity, but withdrawing from this role as soon as feasible. The East Lille service has established active links with many community-based services and organizations over the years, including with elected officials, social institutions, cultural institutions, user and family groups, and various health partners in the towns (GPs, pharmacists and private nurses etc.). It uses these links to help people using the service to re-establish their place in the community (1). Technical package 13 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS Participation In 2008, two self-help groups (Groupes d’Entraide Mutuelle) were established, which marked the starting point of real participation of people with lived experience in the organization of the service. These groups were funded by the Ministry of Health and were independent of the East Lille sector. Their objective was to promote peer support in daily life, leisure and social activities. The groups then became partners of the sector, as local and national users’ and carers’ associations. The creation of the Local Mental Health Council in 2010 (as discussed above) further emphasized participation of people with lived experience, along with their families and carers. In 2012, two peer support workers (Médiateurs de Santé-pairs) were hired as professionals in the mental health teams, which has now expanded to include five peer support workers. Also in 2012, a working group was created dedicated to the participation of people with lived experience – involving professionals, service user associations and peer support workers – which led to several innovations: a forum for people using the service in the form of a community workshop to discuss mental health and the organization of the service, communication tools, a suggestion form and a recovery charter drafted and signed by all stakeholders. In 2015, people using the service elected four representatives who participate directly in the management meetings of the service, to work on suggestions and complaints, and to organize the users’ forum. There are now six representatives who act as spokespersons for people using services in East Lille, who collect opinions and comments on the different network services through quarterly service user forums and suggestion boxes. They are also involved with investigating and reviewing the undesirable events forms that track use of coercive interventions, and participate in the sector’s steering committee meetings, management meetings and working groups. These representatives receive training on human rights and the recovery approach and have monthly meetings with professionals from the sector, to discuss current topics and complaints to be addressed by the service. One of the spokespersons has received the WHO QualityRights training (4). Feedback is also systematically collected at the hospital through exit questionnaires at the time of discharge, and through satisfaction questionnaires (12) that are completed by people using the full range of services. Suggestion boxes are available at all services, where anonymous comments or complaints can be made. This development has been recognized with the “Users Rights” award of the Regional Health Agency and has benefited from two grants, which were used for the training of spokespersons and the development of communication tools. In 2017, a training programme called “experts by experience” was developed, led by people with lived experience or members of service user and carer organizations. It provides training for professionals of the service on topics such as hearing voices, eating disorders, work and burn-out. These sessions happen every month and are aimed at informing the professionals about what is helpful (or not helpful) from the perspective of someone using the service (see next section). At the institutional level of the EPSM, the Commission of Service Users monitors the way in which the rights of those using the service are being respected and represents service users’ interests in the service decision-making bodies. Recovery approach The East Lille network has a steering group specifically on recovery and on promoting recovery-oriented tools in the sectors’ services. Since 2014, all services have been guided explicitly by the recovery 14 Comprehensive mental health service networks approach. In the East Lille sector, all professionals are trained in the recovery approach through presentations and workshops by experts on recovery-based practices, including by persons with lived experience and external guests. The training takes place annually in groups of 20–30 people, to ensure that everyone in the service receives the training. The East Lille mental health sector constantly explores new ways to support the recovery approach. For instance, one of the first tools used was called the Barometer, a recovery-based online platform. It aims to ensure that care not only concerns medication but focuses also on the person’s general quality of life, their social network, their achievements and their strengths. The person, and if desired a support person, can then work together to craft specific objectives that contribute to the person’s recovery, ensuring that progress is tracked consistently. This tool is used to encourage people to make advance plans and recovery plans which are formalized through their online medical file. The service further seeks to promote empowerment in many different ways; for example, training sessions for the professional staff are held by persons with lived experience every month. All these tools serve the same objective: to stay as close as possible to the needs that people identify for themselves, and, when needed, to help them articulate their own wishes and make their own decisions about care. Service evaluation The network of services in the East Lille sector keeps detailed audit figures for its activities, with annual objectives tracked monthly using well-defined and measurable indicators. An important achievement of this network is seen in the steadily decreasing rate of hospital admissions per year from 2002–2018 (from 497 to 341), despite a considerable increase in the number of people receiving care in the network (from 1677 to 3518 people). Furthermore, the length of stay at the in-patient unit decreased from 26 days to seven days over the same period ([Medical information service], [EPSM Lille Métropole], unpublished data, [2018]). In 2018, 34 people out of 222 completed the exit questionnaire at the Jérôme Bosch Clinic. On a scale of 1 to 10, the mean satisfaction rating was 8.06 (SD = 1.94), and 79.4% said that they felt better, or much better, compared to how they felt at the time of admission ([Medical information service], [EPSM Lille Métropole], unpublished data, [2018]). The local SMPP centres also track efficiency indicators which show that 80% of people have their initial assessment within 48 hours of contact. The quality of patient file completions showed between 80- 100% success in 2018, which demonstrates accurate and reliable monitoring ([Medical information service], [EPSM Lille Métropole], unpublished data, [2018]). In September 2018, an independent assessment team composed of eight members (including a psychiatrist, a quality director, a former hospital director, two lawyers, a psychologist, a family member and a service user), conducted the WHO QualityRights evaluationd in all the services of the East Lille sector. It was found that three themes were fully achieved: i) the enjoyment of the highest attainable standard of physical and mental health, ii) freedom from coercion, violence and abuse, and iii) the right to live independently in the community. The remaining two themes: iv) the right to an adequate standard of living and v) the right to legal capacity and personal liberty and security, were partially achieved (4). The existing legal framework was found to be an important barrier to the full achievement of these two themes. d These are the ratings for the five main themes, which are divided into 25 standards and 116 criteria. Full results and recommendations available on the QualityRights platform, see https://qualityrights.org/wp-content/uploads/ QualityRights-59G21-report-2019.docx. Technical package 15 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS The East Lille sector has changed dramatically over a period of four decades. Efficiency outcomes demonstrate that the network is well-run, organized, and cost-effective. The number of new people being cared for in the sector has increased steadily over the last decades, paralleling a decrease in the number of hospitalizations and demonstrating a real capacity of the network to provide community- based alternatives for care. The costs of the service are no higher than elsewhere in France and are actually lower than the cost of mental health services in surrounding sectors. The East Lille sector has been recognized by the French government and is being used as a model for further development of mental health policies in France. For example, the Roadmap for Mental Health and Psychiatry, published in 2018 (Feuille de Route Santé Mentale et Psychiatrie) (13) explicitly voices the government’s objective to integrate people with lived experience in mental health care, to promote the recovery approach to services, and to facilitate the inclusion of people with mental health conditions and/or psychosocial, intellectual and cognitive disabilities in the community. In April 2019 an inter- ministerial delegate was charged with its implementation and concurrently, the national budget for mental health was substantially increased (14). The East Lille sector was also mentioned positively in another recent parliamentary report (15). This national recognition demonstrates the East Lille approach is now becoming national policy. Costs and cost comparisons The service is entirely state-provided, and users of mental health services are completely covered by the national health care system. The average cost per person using the service decreased steadily from 2013–2017, from €3,131 (approximately US$ 3,684) in 2013 to €2,915 (approximately US$ 3,430)e in 2017 (4). These figures include costs associated with the whole care pathway, from the initial consultation to hospitalization. Overall in France, 61% of expenditure on mental health care is spent on hospitalization. However, in East Lille hospitalization represents only 28.5% of expenditure (4). The overall costs in East Lille are the lowest in the entire EPSM area. Challenges and solutions Challenging entrenched attitudes of stigma and discrimination One of the obstacles encountered in establishing the network was that stigma attached to people with mental health conditions (amongst professionals as well as in the wider community) meant that coercive practices and poor standards of care were seen as acceptable. People with mental health conditions were not seen as people who had the same rights as other people. They were generally seen as lacking the capacity to make decisions for themselves. To begin to address these pervasive attitudes, active engagement was necessary with the wider community about mental health and the rights of people who use services to overcome stigma, including bringing politicians and members of the community to visit psychiatric hospitals. The East Lille sector further addressed this issue through development of the philosophy of “citizen psychiatry”, which emphasizes the personal, social and cultural needs of people with mental health conditions and their entitlement to enjoy the same human rights as those of other citizens. Another e Conversion rate as of March 2021. 16 Comprehensive mental health service networks aspect that has helped to change entrenched ideas is the broadening of the network’s focus beyond health and widening of the scope of intervention to include social work, education and housing. The systematic involvement of service users and people with lived experience was also a critical aspect which helped slowly change perceptions and practices. Working within the limits of an outdated national legislative framework Another challenge faced by the East Lille network of services is that the presence of national legislation which allows for coercion continually serves to undermine the efforts of the mental health team to prevent it. Coercion is seen as the ‘easy option’ instead of something to be avoided at all costs. As a result, the network has encountered particular resistance to cultural change within mental health services themselves, in relation to coercive practices such as seclusion, restraint and forced treatment. Fortunately, the sectorization of services in France allowed the local mental health service in East Lille to use its finances to fund alternatives to hospitalization. The East Lille network has found that creating a system where the voice of the person using the service is genuinely heard, acts to counterbalance the drive towards coercive interventions. Having staff trained by people with lived experience also helps them to understand fully the importance of a human rights and recovery agenda. Finally, taking time to explore in some detail any instance when coercion has happened, means that it is less likely to happen again. Maintaining open communication among services Being decentralized, the network also faces the ongoing daily challenge of maintaining a permanent dialogue among the services, in which the notions of recovery and human rights are central to all the different stakeholders. One important action to address this challenge involves the ongoing training of professionals and other stakeholders on recovery and rights-based approaches to mental health. Another key aspect has been the creation of the Local Health Councils (AISSMC). The community-wide consultation structure involves a wide group of stakeholders including people using the service, their families, staff of the mental health service, social services staff, elected representatives, artists, other citizens, GPs, the police, the justice department and education sector, in order to improve communication and create buy-in from all parties. A further innovation supporting cross-sector communication was the establishment of quarterly service user forums which collects opinions and comments from users of all the network services. Key considerations for different contexts Key issues to consider for the establishment or expansion of this service in other contexts include: • uworking with the aim of achieving zero coercion and zero hospitalizations in the service if possible, pushing the service to provide “unconditional care”, characterized by availability and flexibility in working to the person’s own agenda; • systematically involving service users/people with lived experience in any new service development and in research and evaluation efforts; • supporting people with lived experience to have a “professional” status in the service and helping them to develop the skills to represent others in a genuine way; Technical package 17 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS • avoiding a narrow clinical agenda and seeking instead to identify the full range of a person’s personal, social and cultural needs (such as housing, education and employment, while working with other community stakeholders to respond to these issues; • evaluating the service using the WHO Quality Rights assessment Tool Kit provides a very helpful way of evaluating the service, and is the most comprehensive evaluation tool made by and for all the actors involved; • valuing the sense of pride that staff experience when they are able to provide care that is really responsive to the needs and demands of the people using the service; and • considering evaluation outcomes on a “whole system” level, including levels of coercion, suicide figures, rates of people cared for outside of hospital and the costs of the service. Additional information and resources: Website: https://www.epsm-lille-metropole.fr/recherche?field_tags=All&search_api_fulltext=G21 videos: Les SISM, c’est quoi ? Avril 2014, https://youtu.be/D7_1SQSiNb4 Contact: Jean-Luc Roelandt, Psychiatrist, Centre collaborateur de l’OMS pour la Recherche et la Formation en Santé mental, Etablissement Public de Santé Mentale (EPSM) Lille-Métropole, France. Email: jroelandt@epsm-lm.fr Simon Vasseur Bacle, Psychologue clinicien / Chargé de mission et des affaires internationales, Centre Collaborateur de l’Organisation Mondiale de la Santé (Lille, France), Etablissement Public de Santé Mentale (EPSM) Lille-Métropole et Sector 21, France. Email: svasseurbacle@epsm-lille-metropole.fr 18 2.2 Trieste community mental health service network Italy Technical package 19 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS Context Trieste is a city with a population of approximately 236,000 (16) and is the capital of the autonomous Friuli Venezia Giulia region in the north-east of Italy. A profound transformation of mental health services in Trieste began in the 1970s (17) with the closure of the old San Giovanni asylum, where 1200 people were being housed. Historically, the Italian reforms emerged within a social movement for the achievement of human rights across all Italian society. In Trieste, freedom and human rights became a central concern of mental health services, including the relocation of people from the institution to live in the community. The psychiatric institution was replaced by a network of community services which involved major changes in the allocation and spending of budgets (17-21). Today, the promotion of the citizenship of people with mental health conditions and psychosocial disabilities remains an essential feature and central tenet of the mental health service. In order to avoid fragmentation, all services are coordinated by the Department of Mental Health (DMH), which is responsible for the budgeting, planning and delivery of service (22). In 2020, a newly established health care agency, the Azienda Sanitaria Universitaria Giuliano Isontina, became the legal entity responsible for Trieste and the neighbouring territory of Gorizia.f While there is a common approach between both geographical areas the service description below focuses on Trieste as it developed up until the establishment of the wider organization in 2020. Description of the mental health service network Within the Trieste community mental health system, a “whole person, whole system, whole community” approach to mental health care has been developed, which places a major emphasis on working with the wider community to develop a fully integrated system of support with open doors and no restraint. People are supported as much as possible in their own homes and localities so that they are able to maintain links with their communities. There is an emphasis on human rights (including actions to promote social inclusion) and community participation, in order to avoid institutionalization and ensure people live their lives in their communities. This has been achieved through active engagement and collaboration with the health and welfare services, the juridical system, the cultural institutions, the regional and city authorities and other community organizations, in order to enhance the social capital of the city. The development of a broad partnership with peers, staff, trainees, volunteers, family members and social networks has also promoted a “whole life” approach. The Mental Health Department coordinates these partnerships, guided by key operational principles: • accepting responsibility for the mental health of the community • active engagement and responsiveness (there are no waiting lists) • high accessibility of the service • continuity of care • rapid responsiveness to crises in the community • comprehensive care • focus on teamwork and stakeholder participation (23). f Gorizia is a city of 140,000, including the area of Monfalcone. The asylum in Gorizia was the site of the first reforms in Italy in 1961, led by Franco Basaglia who moved to Trieste in the 1970s. 20 Comprehensive mental health service networks Elements of the mental health service network Community Mental Health Centres (CMHCs) Community mental health centres (CMHCs) are the primary point of entry into the mental health services and system. There are four CMHCs in the territory of Triesteg which form the heart of the service. Each serves a catchment area of 50,000 to 70,000 people. Each CMHC has a team of approximately 20-22 nurses and support workers, plus social workers, psychologists, rehabilitation specialists, and psychiatrists. Two members of staff are resident at night. The teams at the centres are multi-disciplinary and work in a flexible and highly mobile way. Staff are involved in delivering care, providing support for the coordination of services and fostering recovery by connecting people to the different initiatives, services and opportunities in the community. Their overarching goal is not only to provide treatment and care in a human rights framework, but also to promote social integration and inclusion (24). Each CMHC contains six beds (the exception is Monfalcone which has eight beds). They are open 24 hours a day and accept all referrals. People who stay overnight are called “guests”, rather than “patients” (24) and are encouraged to continue any involvement they may already have in ongoing activities in the community. They may host visitors as wished on an informal basis. The CMHCs also provide outreach activities for people requiring continuity of care and long-term support. Approximately 50% of the team’s work takes place in the centres, and 50% in the community. Between 08:00 and 20:00 the CMHCs operate a walk-in service. Anyone who enters or telephones a CMHC receives a swift response, usually within one to two hours. The staff members have a rota system, ensuring that a team member is always available. There is no waiting list. A typical day involves a meeting at 08:00 in which the team organizes the structure of the day, with scheduled activities as well as any new priorities that may have emerged. Time is allocated to the guests staying in the service. Daily activities include outpatient visits, administration of medication, informal contacts/talks, group meetings, and the sharing of lunch and dinner together. There is a morning meeting with guests (for information, orientation, reassurance and possible self-disclosure). Staff members who are not involved in the internal activities of the CMHC perform scheduled visits to homes in order to provide support, or to accompany people to the CMHC for day care. Some people are accompanied to medical appointments, and others, for example, to carry out daily life activities, such as collecting their pension, visiting the bank, going to the police station, or attending their workplace etc. In the afternoon, there is a shift change and the new staff members may re-arrange activities if new priorities emerge during the day. The primary aim is to create and maintain a therapeutic, but informal and friendly environment; the concepts of “doing with”, and “being with”, are the guiding principles for interactions between staff and guests. The intake assessment is problem-based, rather than diagnosis-based, and first-person narratives are used to understand people’s life story and circumstances. If a person using the service, or their carer, considers a problem to be urgent, it is dealt with as a priority. Formalities are kept to a minimum. The first contact with a person is frequently made in the community, most often in their own home. In this case, a key worker is appointed promptly, and contact is made with the family and the g There are a further two CMHCs in the territory of Gorizia (one in Gorizia and one in Monfalcone). Technical package 21 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS social network of the person. The team also works to mediate and to resolve any conflicts arising in the network, where possible, but the autonomy of the person is respected at all times. The rapid response to crises in the community results in very few hospital admissions in Trieste. A person in crisis, if unable to receive support at home, is able to spend a brief time at the CMHC as a short-term guest. The offer of ongoing support and care, and an emphasis on discussion and joint decision-making, usually means that involuntary interventions are avoided. Long term follow-up and support is always available. The CMHC centres and teams provide the following services (25): • overnight hospitality and care • day care • an outpatient service • home treatment via home visits • crisis intervention at home, in the community, or at the CMHC • individual and group therapy • medication • psychosocial support and work with social networks • psychosocial rehabilitation • support for group homes • support in accessing education, cultural activities, vocational training and work placements • social activities, self-help and leisure activities. General hospital psychiatric services and unit (GHPU) There is one general hospital mental health unit in Trieste (Servizio Psichiatrico di Diagnosi e Cura), which has six beds and provides a second point of entry to the mental health service. This unit covers the territory of both Trieste and Gorizia, a population of approximately 375,000. It is mainly used for emergencies at night. People usually stay for less than 24 hours and are referred to the CMHC in their own area as quickly as possible in order to transfer them to community-based care. The team based at the hospital includes two psychiatrists, one of whom is the Director of the unit, along with approximately 16 nurses. The team at the GHPU also provides a liaison service to the general hospital; most of their work is based in the emergency department. Community inclusion support services and initiatives The Trieste mental health service network has a comprehensive set of rehabilitation and residential support services working in partnership with a wide range of non-profit organizations, such as social cooperatives, volunteer and social promotion associations, including those of peers and carers, to provide a comprehensive set of interventions aimed at making sure that people are able to live their lives in freedom and with a sense of dignity. The rehabilitation and residential support services interface and collaborate with social cooperatives in order to ensure access to supported housing, including the Trieste recovery house and other types of housing, which is implemented through the personalized health care budget. The aim of these programmes is to ensure full community inclusion and participation for people with mental health conditions and psychosocial disabilities. 22 Comprehensive mental health service networks Personalized health care budget The personalized health care budget is designed mostly for people with complex needs as well as younger people thought to benefit most from a highly personalized programme. It addresses social factors and other challenges that might have a significant impact on people. A plan is developed, which includes a person’s identified goals, and is discussed and agreed upon in collaboration with the person and sometimes his or her family. The latter are only involved with the individual’s permission. Finance for the personalized health care budget programme comes from mental health and sometimes welfare budgets. Several co-ops contribute to the planning and delivery of care. Typically, the areas covered are housing, education, training, employment and social relations (26). The programme caters for approximately 160 people in Trieste every year. These “personal health budgets” (budget individuali di salute) support some of following programmes. Supported accommodation Supported accommodation is provided through several small residential flats, each of which caters for up to five people, or in people’s own homes. These schemes provide accommodation for 42 people at any given time, and approximately 100 people every year. Staff provided by the social cooperatives give flexible support as needed, including on a full-time basis. They operate in collaboration with the CMHCs in order to guarantee continuity of care and treatment and to ensure independent living. Trieste Recovery House opened in 2015 and is a residential project run through the health care budget programme as a collaboration between the Trieste Mental Health Department and a social cooperative. It has space for four to six people to stay, usually for a period of six months. It is open to people aged 18–35 who have had significant contact with the mental health service and who are interested in pursuing a recovery journey. Its essential operational principles are: 1. democracy, self-determination and emancipation (“nothing about me without me”); 2. asset- and strength-based approaches; 3. a whole person, whole life approach; 4. acknowledgment of the expert by lived experience; 5. trialogical meetings;h and 6. a shared learning environment (27). Social enterprises (cooperatives) The mental health service collaborates with a network of approximately 15 social cooperatives (28-32) in Trieste. Some cooperatives cater for the management of socio-health and educational services. They work closely with the staff from the CMHC teams and provide, for example, the previously mentioned supported accommodation. Other cooperatives carry out various activities (agricultural, industrial, commercial and service) and are mainly aimed at sustaining employment opportunities for people. In these social cooperatives at least 30% of the workers must be “disadvantaged people”, who are treated as equals with the other workers (33, 34). h Trialogues are meetings between people using services, their families and supporters and mental health professionals in which the goal is an open discussion of mental health problems, their consequences and ways forward (see: https://www.intervoiceonline.org/tag/trialogical-approach). Technical package 23 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS These cooperatives offer job opportunities and educational/ vocational training, employing approximately 800 people in Trieste. In 2018, there were 292 trainees receiving work-grants (35). Over the years the work has covered a wide range of activities such as cleaning; building maintenance; transport; cafeteria work; catering; hotel and restaurant services; management of a beach resort; gardening; handicrafts; photo, video and radio production; computer services; serigraph printing; administrative services and personal services (23). An example is the Tritone Hotel in Trieste, which is a residence overlooking the sea – entirely managed by a social cooperative, mostly comprising users of services of the Trieste Mental Health Department. Other examples include Strawberry Fields Café (Il Posto delle Fragole), a busy restaurant managed by users of mental health services. The cafes at the Opera House in Trieste, the public radio station, a historical bathhouse, and all museums and public gardens, employ at least one-third of their staff through contract with the social cooperatives of mental health service users (30, 32, 36, 37). As well as the core services described above, Trieste also has several targeted programmes delivered in tandem with the other health district teams of the main health care agency, Azienda Sanitaria Universitaria Giuliano Isontina. These include: • a service for children and adolescents encompassing crisis care, through a day centre with therapeutic groups, psychoeducation, social activities and home visits; • an early intervention service for psychosis in adolescents and young people; • a service for young people with eating disorders; • coordinated care for persons with physical, as well as psychosocial, disabilities; • coordination of care for elderly persons in need of home assistance and in nursing homes (people with cognitive impairments and dementia); • close support for family doctors in providing care to people experiencing mental distress or who have received a diagnosis of a mental health condition; • improving care for persons with mental health and substance use conditions (coordinated through joint personalized care plans); • work in prisons and with the Tribunal for persons who are on trial, or have been convicted; and • work with families (a psychoeducational programme with 10 meetings/modules, self-help groups, and training course for a local carer association). Other activities implemented through the Rehabilitation and Residential Support Services Additional activities are organized across a number of locations through the Rehabilitation and Residential Support Services, with the aim of promoting social participation. Activities are run by volunteer associations, including organizations of peers and carers, and focus on defined areas such as wellbeing, physical health and sport, social participation, self-help and peer support, art expression and anti-stigma initiatives, gender programmes including culture, and work training and placement. Activities are organized in social spaces in the city and are in the style of clubs. Four of the organized activities/clubs, including a gym, are provided by the Department of Mental Health, with activities co- produced by the associations. Four other organized activities/clubs are run directly by the associations 24 Comprehensive mental health service networks themselves. Personalized health care budgets can be used to organize a very individualized programme of activities to suit the specific needs of a person. Core principles and values underlying the service Respect for legal capacity From the very beginning of the reforms in the 1970s, the focus in Trieste has been on promoting autonomy, independence and a respect for the person’s capacity to make their own decisions. This is reflected in the emphasis on the “rights of citizenship” (23). There is an explicit commitment to a right to informed consent as well as other commitments in a Bill of Rights, introduced by the service in 1995. People working in the Department of Mental Health do not wear uniforms and work to minimize barriers and hierarchies between themselves and the people they provide care and support for. All services have an open-door policy, and people can go in and out without physical barriers such as locks, keys or codes. Services in Trieste and Gorizia use the concept of “hospitality”. This means that the person using the service is encouraged to stay in contact with their normal life as much as is possible while they are staying in the CMHC, and can also participate in the on-going daily activities of the centre, if they wish. CMHC staff, people who work in the cooperatives, volunteers, carers and peers are all present in the centre during the day, and anyone staying can socialize and interact as much as they wish. “Guests” who are in crisis in one of the CMHCs are made aware that they have a right to leave the service should they so desire, to go out to cafés or for a walk. Although there are no specific rules about this, guests are asked to let the staff know where they are going and what time they will return. The staff members negotiate with the person as to whether she or he is able to go on their trip unaccompanied or whether they require active support from staff or from a relative, a volunteer or a peer. There is an emphasis on discussion regarding decisions about everything; the day-to-day care plan is adjusted according to personal needs, will and preferences. However, if guests who are experiencing a severe crisis wish to leave and abandon all forms of care, the staff negotiate and seek an agreed plan around safety. This can lead eventually to a legal decision to apply for involuntary treatment as last resort, after several attempts and offers of alternatives. People using the service on a routine basis self-administer their own medication whenever possible. A number of people collect their medication at the centre and take it at home. They, along with carers or supporters, can attend discussion groups and training events related to the treatments used. The effects and side-effects of the various medications are carefully explained. Written information is also provided through leaflets. Thus, people are assisted to make informed decisions about medication and other interventions (38). Personalized care plans are developed with the active participation of the person and their network. Apart from clinical interventions, these are based on the individual circumstances of the person’s life and can cover all relevant needs, from the person’s living situation, including home repairs, maintenance, cleaning, or looking for more appropriate accommodation, to personal finances – such as the need for cash subsidies, use of the centre’s safe, temporary daily money management, or support to maintain tenancies. The personalized care plan also covers aspects related to personal hygiene such as laundry, personal cleanliness and hairdressing, as well as purposeful activities, education, vocational training, work opportunities (such as simple tasks at the CMHC or job placements in a work cooperative or in an Technical package 25 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS open market setting) and leisure, including workshops in drama, art, music and needlework, gym visits, day trips, holidays, parties, cinema and theatre trips (24). These plans also cover the best ways to avoid relapse, and the person’s wishes in times of crisis, including where they would like to receive care. It is usually recommended that the person should keep in contact with the service, and phone immediately when in need (such as during a stressful event). These plans also include a negotiated account of the medication the person is going to take. Formalized advance directives (39) are not routinely used. Furthermore, if a person is considered to have impaired decision-making capacity, the provisions of the Law 6/2004 covering legal agency apply, and a support administrator (or legal proxy: usually a trusted person, a relative or a friend) can be appointed by a tutelary judge. This does not equate to supported decision making as this person may take on a more of a guardianship role and make decisions for the person in a substituted manner. Alternatives to coercive practices The service aims to avoid all forms of institutionalization (such as psychiatric hospitalization, or incarceration in jail, forensic units and nursing homes for the elderly) and all types of coercive, compulsory interventions. However, involuntary treatment (trattamento sanitario obbligatorio) is sometimes used as prescribed by Italian law. The vast majority of treatment, care and support is voluntary and average lengths of stay in either the CMHC or in the GHPU are short (an average of 13.8 days for the former; 1.7 days for the latter (40)). However, in the CMHCs, the “hospitality” extended to guests is informal and flexible, and sometimes lasts for weeks or months if needed until another solution or accommodation is possible. There is an explicit policy of “open door - no restraint” in both the CMHCs and the GHPU (16, 23, 41) and staff are trained in the use of dialogue, de-escalation strategies and the provision of personal support to guests under stress in order to avoid confrontation and the use of coercion. The various places in the CMHC: kitchen, garden, personal rooms are all used in de-escalation; seclusion has not been used since the psychiatric hospital was closed. In 2019, the rate of involuntary treatment was 8.11 per 100,000 population in Trieste (42) compared to 15 per 100,000 in 2017 for Italy as a whole (43). Notably, Italy has the lowest rate of involuntary hospitalization of all countries surveyed in Europe (44). In situations where involuntary treatment is used according to the law, when all attempts to provide care with consent have failed, it must be requested by two psychiatrists and endorsed by the mayor, who is the highest authority in the town, responsible for public health. These compulsory admissions last initially for seven days. As a particularity of Trieste (and its region), these happen mainly in the CMHCs, where the “open door” principle continues to apply. Involuntary treatment may be extended by periods of seven days for several extensions but can also be withdrawn after few days (33) if consent to care is achieved. When a person is receiving compulsory treatment, more staff are deployed in the CMHC, so that there are always two or three people available (mainly staff but also social cooperative support workers, peers, carers or volunteers) to meet the needs of a person in crisis. Close, personalized (one-to-one) care is therefore practiced. Family members may also be involved so that the person retains as much connection as possible to their daily life. The person may even continue to take trips into town if this is negotiated but, in the context of compulsory treatment, there is always someone to accompany the individual. The service aims to respond to the needs of the person, rather than acting in a “guarding” capacity. 26 Comprehensive mental health service networks In a limited number of cases, the police are involved to help and co-manage a situation, which is a legal requirement where immediate risk and a need for the protection of safety and health are considered to be at issue. Forensic hospitals were closed in Italy in 2015 (41); however, Trieste had not sent anyone to these facilities for 40 years. After they were closed, “residential facilities for security measures” (45) replaced them. In the Friuli Venezia Giulia region, a decision was made to locate two secure beds in three locations (Trieste, Udine and Pordenone Provinces), rather than have a single unit. However, from 2015, only one person from Trieste has been hosted in such a facility. Community inclusion The service in Trieste has achieved a significant level of integration of mental health with other community-based services including housing, employment and education. The Department of Mental Health works closely with all health and welfare services and directly funds a wide series of independent partners in the not-for-profit sector, such as social enterprises, cooperatives and volunteer associations. Even when in crisis, people staying at the CMHC are actively encouraged to maintain their usual daily community activities. For people with complex needs, the personalized plans that come with a personal health care budget can be used creatively to help with autonomy and community inclusion. Through a series of programmes developed in the community, people using the service are offered opportunities for engagement with a wide range of activities including sports, leisure, wellness, writing, films, museums and other cultural pursuits. Different educational and training courses are organized by associations and cultural agencies, in language, self-care, social identity and various aspects of community life. Through these various activities people are able to experience reciprocal relationships and new social roles. This is also achieved through job training and placement, and work in the social cooperatives. Participation The reforms in Trieste have always been concerned with the empowerment of people who are recipients of services, and users of the service are involved in planning, delivering and evaluating services (23). Group meetings of peers are actively encouraged and take place regularly in the CMHCs. Peer facilitators of these groups are paid for their work. A designated office within the health care agency receives feedback and complaints from people using services, and people can also request to meet the Director of the Mental Health Service. There is also a Participatory Committee which represents the views of service users and carers along with their associations, and a social cooperatives’ representative. Recovery approach The Trieste service network has sought to be responsive to the “whole life” needs of the person, rather than simply focusing on their diagnosis, and has sought to promote freedom, particularly from institutional residence or detention, as a therapeutic principle. A focus on personal autonomy, citizenship and human rights are basic elements of the “whole person, whole system, whole community” approach used in Trieste (46). Technical package 27 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS The personalized care plans developed with people using the service incorporate explicit recovery goals (26) and allow people to explore their aspirations as a basis for an individual programme or a whole “life project”. They can be assisted with money, work, training, education, living places, activities and relationships when necessary. The Trieste mental health service network recovery approach is based on the following ideals. • Holistic: services focus on values and principles rather than on diagnostic classifications and intervention techniques. Services attempt to respond to the “whole person” and their various needs, not simply their diagnostic label. • Whole life/whole system-oriented: attention is directed towards contextual issues and the services seek to engage with the person’s family and social network when appropriate. Much effort is spent on the promotion of social inclusion and cultural participation. • Rights-based: attention is paid to citizenship, participation and civil rights (both legal and social), such as the right to socially meaningful work (33). Over the past decade there has been a sustained effort to incorporate an overt philosophy of recovery into every aspect of the service. A Recovery Research Group produced a Recovery Charter in 2014 (47), which emerged from focus groups with people in all four CMHCs in Trieste and involved approximately 100 people, the majority of whom were people with lived experience (48). Service evaluation The changes in Trieste have been substantial since the reforms were initiated in the 1970s. From 1971 to 2018 (49) the number of beds was reduced from 1160 to 219 (40), while the number of people treated by the service has risen from 1160 to 4800 over the same period (35).i The suicide rate has also fallen from 25 per 100,000 population in the period 1971–1994, to 13 per 100,000 in 2015 (46). The number of people subjected to involuntary treatment each year dropped from 150 in 1971 to 18 in 2019 – a rate of 8.11 per 100,000 population (40). The number of people in forensic hospitals in Trieste has fallen from 15 in 1977 (49) to zero in 2006 (46) and onwards. Several studies have evaluated the network of mental health services in Trieste and the transition from asylum to community-based care in the city. The first follow-up study after the reform law (conducted from 1983–1987) showed better outcomes for 20 patients with a diagnosis of schizophrenia in Trieste and Arezzo compared to 18 other Italian centres (50). Further, a study of 27 “high priority users”j found that there was a high rate of social recovery at five-year follow up. A significant reduction of symptoms was also found, of about 20%, and a marked improvement of social functioning (score increased by 50%). Nine people secured competitive jobs, 12 achieved independent living, and a measure of unmet needs dropped from 75% to 25%. There was also a 70% reduction of days of admission, and only one person dropped out (51). Other studies over the years have also demonstrated important outcomes for the services in Trieste. A national survey carried out in 13 centres showed that the crisis care provided by the CMHCs open i Excluding small accommodations. j The people studied were selected by the team. Each had at least six of the following characteristics: high family burden, absence of a social network, isolation, frequent drop out from services, repeated failure of previous forms of treatment, episodes of involuntary treatment, imminent risk of serious social drift, imminent risk of committing crimes, use of illegal psychotropic substances. 28 Comprehensive mental health service networks 24 hours a day, seven days per week, resulted in a faster crisis resolution, the prevention of future relapses, and better clinical and social outcomes at two-year follow-up (52-54). This also emphasized the importance of trusting therapeutic relationships, continuity and flexibility of care, and service comprehensiveness. A 50% reduction in emergency presentations at the General Hospital Casualty Department was also reported from 1984 to 2005 (24). Adherence to antipsychotic medication was 75% (55); this was ascribed to the comprehensive care approach with the development of good therapeutic relationships, social network involvement, and the attention to contextual factors associated with the “whole person, whole system, whole community” philosophy (38, 55). Qualitative research has also been used to study the service network in Trieste, based on the analysis of recovery stories from a narrative point of view (56). An international research group pointed to the important interconnections between recovery, social inclusion and lived citizenship (57-61). High rates of service user satisfaction were reported in the early years of reform (62) and a survey carried out for a university dissertation pointed to satisfaction levels of 83% with the work of the CMHCs ([Zanello LE],[Università degli Studi di Trieste], unpublished observations, [2006]). Costs and cost comparisons The budget of the mental health service is heavily weighted towards community interventions (94%) and only a small proportion goes to the GHPU (6%). It is estimated that the annual cost of the service in Trieste in 2018 was approximately €80 per capita (23) (US$ 94)k which amounted to €16.7 million (approximately US$ 19.6 million).j It is calculated that in 2019, the cost of the Mental Health Department amounted to 37% of the cost of the old psychiatric hospital (35). This represents about 4% of the overall health care budget in Trieste. The service is paid for by the national health service which is publicly funded. A regional budget provided to the health care agency is then passed on to the Mental Health Department, based on historical expenditures. This is negotiated according to assigned and agreed objectives. As in all of Italy, private care is available to people who have insurance or who can pay for this directly themselves. Care is also offered free of charge by private accredited providers and is reimbursed by the national health service. However, all private care in Trieste is “office-based” (consultation, psychotherapy, medication) and there are no private hospitals. Challenges and solutions Overcoming the legacy of institutionalization Since the early 1970s, developments in the Trieste mental health service have been driven by a desire to overcome the legacy of institutionalization (19). One of the obstacles to deinstitutionalization was the predominant view of “out of sight, out of mind” leading to the dominance of the psychiatric hospital, and associated power imbalances, human rights violations and social exclusion. From the beginning, the political support of local and regional authorities and their policies was very important in the Trieste context. Other influential factors (63) in the Trieste approach included: the alliance of professionals, administrators, people using the service and their supporters and carers k Conversion rate as of March 2021. Technical package 29 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS as well as multiple actors from outside the institution (volunteers, artists, active citizens, families, intellectuals, non-profit groups); the empowerment of service users in the service and the involvement of families (64). The development of a multi-professional team approach with task-sharing, and a stress on the importance of flexibility in terms of professional roles and inputs were also important factors influencing the professional workforce, along with investing in a comprehensive approach that serves to overcome resistance to change, and investing heavily in training, motivation, and professional development of staff (23). Further, Trieste adopted a multisectoral approach with social care, addressing personal and daily life needs (e.g. housing, income, education, social inclusion etc) and social determinants of mental health. Some of the most important factors, however, involve working actively to prevent admissions to hospitals; adopting a person-centred approach integrating health and social care (36); and adopting a defined organizational model based on a network of services, which has as its main point of reference the services at the 24-hour Mental Health Centres, equipped with very few beds and managed by a single comprehensive team. Since Trieste was designated as a WHO pilot centre for deinstitutionalization in 1973 (18), it has continued to innovate and develop, and has been hugely influential across the world (16, 65-68). It now has established links with countries and services in all continents and there are study visits by approximately 1000 people every year to the city (23). The Parliamentary Commission on the State of the Italian National Health System (69) and the Italian Fellowship of Mental Health Associations has since identified this as a model for the whole of Italy to adopt (41). Changing institutional culture and power relations The mental health system was built on a system of hierarchies. Working to overcome the institutional culture required challenging these hierarchies and the power relations that sustained them. Progress was made with persistent efforts to democratize the world of mental health by broadening discussions and decision-making processes to include all the stakeholders. Initially, daily assemblies were held in the psychiatric hospital in an effort to achieve this. Involving the families of people with mental health conditions and the wider community also helped to counteract the forces of social exclusion that had sustained the central position of the psychiatric hospital. Finally, developing ways for the voices of people using the service to be heard and acted upon created opportunities for people to take back their authority and independence for their own care. Challenging the disease-centred ideology The ideology associated with a disease-centred approach acted to silence the voice of the people using the service and meant that little attention was paid to their personal, social and cultural needs. The establishment of new forms of collective leadership and a whole new set of practices in the mental health system aimed at supporting people to lead a full life in the community was extremely important. Progress was also made through the development of associations and social cooperatives to nurture a new focus on the “whole person”, rather than solely the biomedical model and a narrow disease-centred ideology. 30 Comprehensive mental health service networks Sustaining progress made The Trieste mental health network faces a continual threat of slipping into new forms of institutionalization, or simply service “inertia”. Further, there is an ever-present danger that paternalism, and even different forms of abusive behaviour, might emerge. Being aware of the problems and actively engaging with them helps avoid these risks. Supporting staff through periods of change Without the easy fallback of reliance on clinical models, the Trieste staff were pushed to use their own personal resources to relate to people using the service. This sometimes led to burnout and conflict because this was a new approach which was less structured and had more uncertainties. One of the solutions found was to create a culture of “sharing the burden”, so that no staff member is left alone to carry all the worry and concern about a particular individual or family. Another organizational solution involved efforts to create a genuine democracy within the organization so that both people using the service and staff members feel that their voices are being heard and that their concerns are listened to. Key considerations for different contexts Key issues to consider for the establishment or expansion of this service in other contexts include: • nurturing critical thinking and reflection within the service as a vital ingredient of creating and sustaining the positive impact of your service; • shifting from a clinical understanding of mental health conditions to a ‘whole person-whole life’ philosophy; • investing heavily in staff training and development; • creating opportunities for staff members, people using the service, their families and people from the wider community to meet and discuss the vision of the service; and • recognizing that clinical outcomes (as measured by rating scales) are not as important as outcomes relating to the citizenship of the people using the services, such as the levels of coercion used by the services; and • evaluating networks of services using an approach and measures that capture the overall working and outcomes of the network rather than just the individual services and interventions provided. Technical package 31 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS Additional information and resources: Website: www.triestementalhealth.org videos: BBC News, Trieste’s mental health revolution: “It’s the best place to get sick”; https://www.youtube.com/watch?v=5v0jki3GaBw&feature=youtu.be Episode 8 - Lived experience in Trieste, a mental health system without psychiatric hospitals, with Marilena and Arturo: https://www.spreaker.com/user/apospodcast/episode-8-lived-experience-in-trieste-a- Roberto Mezzina, 2013; https://youtu.be/UnMSHQDrByI Contacts: Elisabetta Pascolo Fabrici, Director, Mental Health Department of Trieste and Gorizia, WHO CC for Research and Training – Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), Italy. Email: elisabetta.pascolofabrici@asugi.sanita.fvg.it Roberto Mezzina, Psychiatrist, Former Director, Mental Health Department of Trieste and Gorizia, WHO CC for Research and Training – Azienda Sanitaria Universitaria Giuliano, Isontina (ASUGI), Italy. Email: romezzin@gmail.com; who.cc@asuits.sanita.fvg.it 32 2.3 Brazil community mental health service network a focus on Campinas Technical package 33 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS Context Brazil is a federal republic, the world’s fifth-largest country by area with 27 federative units and 5570 municipalities. It is the sixth most populous country in the world, with over 211 million people (70). It is an upper-middle-income country, but with high levels of social inequality (71). Universal healthcare is a constitutional right in Brazil provided under the country’s Unified Health System (Sistema Único de Saúde (SUS)). Brazil’s mental health network is provided under the SUS. The mental health network in Brazil today is a reflection of the significant psychiatric reform that has taken place in Brazil since the late 1970s. Originating as a civil society movement, psychiatric reform took place through shifting from institutionalized care to care in the community and the development of a supporting legal framework, service regulations and rights-based mental health policy. Institutional structures and practices have been replaced by a community-based network of services through incremental resource reorientation (72, 73). Of the federal financial resources allocated to mental health in 2002, psychiatric hospitals accounted for almost 80% of expenditure, with community-based mental health services accounting for the remaining 20%. By 2013, in contrast, nearly 80% of mental health budgeting was invested in community-based services while 20% was hospital expenses (74). In 2017, though, psychiatric hospitals were again formally included in the mental health network (following a change in mental health policy in 2016) and federal government investment in the implementation of community-based services also decreased (75, 76). However, due to a level of autonomy at municipality and state level in the implementation of public policy and strong foundations in psychiatric reform from institutions, legal, financial and civil society, this shift did not automatically lead to a cessation in implementation of community-based services, nor the closure of psychiatric hospitals across municipalities (77). All community-based mental health services in Brazil follow the main guiding principles of the mental health network in Brazil: • promotion of equity; • guarantee of open access to services; • rights-driven, quality services offering comprehensive care based on a person-centred recovery plan and multi professional input; • person-centred and needs-focused care and actions; • respect for human rights; • promotion of people’s autonomy, social inclusion and participation, rights of citizenship and freedom; • community-based approach with participation of people with lived experience; • combating stigma and prejudice; and • joint actions with other sectors, such as housing, work, education and culture, and the development of capacity building strategies (78). The community-based mental health network is implemented throughout all regions in Brazil; how each element of the network is implemented and what people may experience though, varies. For the purpose of describing the network, a good practice example of a local (municipality level) network was selected to provide practical insight into its workings. The municipality of Campinas was selected for 34 Comprehensive mental health service networks the following reasons: it is a municipality with an entirely community-based mental health network, having closed the city’s psychiatric hospital in 2017; it does not refer individuals to psychiatric hospitals outside of the municipality, for example, to regional hospitals; it has a comprehensive integrated network of services that work well together at the local level; and evaluation data is available. Campinas – Profile Campinas has a population of approximately 1.2 million people. In 2010, 30% of the population had monthly earnings less than half the national minimum wage. A total of 39% of the population had formal employment, with 72% aged between 15 to 64 years old (79). When the transformation of the Campinas mental health network began in 1990, there were 1200 psychiatric beds across five hospitals in Campinas. The first step in this process was the deinstitutionalization of the psychiatric hospital, Sanatório Dr. Cândido Ferreira. From the 2000s onwards, substitute services such as those described in this document began to be implemented and in parallel, a progressive and agreed closing of the psychiatric hospital beds and the deinstitutionalization of the people who lived there. In 2017 the Sanatório Dr. Cândido Ferreira psychiatric hospital was finally closed. Description of the mental health service network in Brazil, with examples from Campinas The services described below work together to provide continuous community mental health care and support that meets the needs of both the individual and the community. Mental health forums in Campinas provide an opportunity for community-based service professionals, the individuals who use the service and family members to come together to discuss and address common issues related to services and regional needs. The mental health network links with the general health network in addition to other relevant sectors and services (for example, employment, culture, sports) through the community-based mental health centres. Elements of the mental health service network Community-based mental health centres Community-based mental health centres, known as Centro de Atenção Psicosocial (CAPS), are the cornerstone of the community-based mental health network in Brazil. CAPS provide continuous, tailored and comprehensive community-based mental health care to individuals with severe or persistent mental health conditions and/or psychosocial disabilities, including during challenging and crisis situations. CAPS have a rights-centred and people-centred approach. Their primary goals are providing psychosocial care, promotion of autonomy, addressing power imbalances and increased social participation. As a principle, CAPS do not refer users to psychiatric hospitals. CAPS are active both within the confines of the centre itself and in the community. The number and type of CAPS in a region depends on the population and the unique needs of that region. CAPS services are classified according to catchment area and target population. CAPS I serve the adult population in catchment areas of over 15,000 people and CAPS II in areas of over 70,000. CAPS III servicesl cater for adults as well as children and adolescents in areas of over 150,000, and l A more in-depth description of a CAPS III is provided separately in this guidance using the example of CAPS III Brasilândia in the technical package, Community mental health centres: Promoting person-centred and rights-based approaches. Technical package 35 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS are open 24 hours a day, seven days per week, providing overnight accommodation if needed. CAPSi serve children and adolescents, and CAPS ad provide support for problems and needs associated with substance use. Alternative configurations are also possible: for example, while CAPS I and CAPS II services mainly serve the adult population, they may also provide care and support to children and adolescents to ensure access to community-based support where a CAPSi is not available. Different types of CAPS can also be combined to meet the needs of the community. For example, In December 2017 new legislation established the creation of a new CAPS type: CAPS ad IV, focused on people with problems and needs associated with substance use in areas with over 500,000 people. The staffing of each CAPS varies according to the type of CAPS, population needs, hours of operation and specific demands. Minimum staffing levels for each type of CAPS are prescribed by law as shown below; however, municipalities may fund staffing beyond these minimum levels. The staffing requirements refer to various staff categories. University level educated professionals include psychologists, social workers, occupational therapists, pedagogues, physical educators, speech therapists or other professionals as required for service users’ needs. Mid-level professionals include nursing technicians and/or assistants, administrative technicians, educators and “artisans”. The minimum staffing levels for CAPS services are as follows. CAPS I – a physician with training in mental health, a nurse, three university level educated professionals and four mid-level professionals. CAPS II – a psychiatrist, a nurse with training in mental health, four university level educated professionals and six mid-level professionals. CAPS III – two psychiatrists, a nurse with training in mental health, five university level educated professionals, eight mid-level professionals. For the night shift: three nursing technicians under the supervision of the nurse and a mid-level professional. CAPS ad – a psychiatrist, a nurse with training in mental health, a clinical physician responsible for screening, evaluating and monitoring clinical complications, four university level educated professionals and six mid-level professionals. CAPSi – a psychiatrist, neurologist or paediatrician with training in mental health, a nurse, four university level educated professionals and five mid-level professionals. Among all of the CAPS modalities, CAPS III is considered a key strategic service to have in a mental health network. In operating 24 hours a day, seven days per week, and with the availability of a dorm facility, a network with a CAPS III can provide continuous care in the community to its users at all times but also to other CAPS in the network where a user would benefit from continuous (day and night) support. For smaller municipalities without a CAPS III, service users may be referred to a CAPS III in another city or region. CAPS III dorms are not considered nor used as traditional mental health beds. They can be accessed for respite, to take time away from difficult situations, during challenging and crisis situations, or any other situation when an individual feels that they may benefit from additional, constant support (78). People can stay for up to 14 consecutive days during which the CAPS proactively support the user in addressing the factors that led them to require overnight support. The dorms aim to provide a similar environment to that of being at home. There are no rules or requirements in terms of using this service. 36 Comprehensive mental health service networks Operational principles All CAPS services follow three guiding principles. 1. Open door policies – To access a CAPS a person can simply walk in without an appointment to have a first meeting about using the centre. A person may also be referred by another service, or can be visited at home. The CAPS physical structure aims to provide a welcoming and comfortable homely environment that helps people to feel at ease and encourages active participation and interaction (80). There is no involuntary admission or forced use of CAPS. No individual is refused access to the centre, including if they present in a crisis or challenging situation. A mental health diagnosis is not required to attend the centre. 2. Wide reaching community engagement – For CAPS, being community-based is not limited to being a service that is available in the community, rather this principle requires full engagement with and understanding of the community, as well as the individuals who live there. CAPS team members talk to people in the community to understand the social dynamics and to map the common problems that most impact people’s lives and mental health to gain a better understanding of possible mental health and psychosocial needs. At CAPS, team members identify and activate community resources and create partnerships with people and services to carry out mental health care initiatives. CAPS also engage with the community on mental health and psychosocial disability topics such as promotion of rights of individuals with psychosocial disabilities, and initiatives to reduce stigma and prejudice. 3. Deinstitutionalization – As CAPS were designed to replace psychiatric hospitals and other institutionalization structures (81), all CAPS have capacity and responsibility to attend to complex, challenging and crisis situations, offering care and support with community-based practices. CAPS interpret this role as requiring more than acting as a physical alternative to traditional institutional services, but also deinstitutionalizing services, practices and attitudes. At an individual level, this can mean therapeutic support based on recognition of an individual’s human rights, respect for different ways of life, practicing validation and empowerment of the user and respecting that the user has knowledge about themselves and their recovery process. At a service level, no doors in the centre are locked and the individuals who use the service can enter or leave any room in the centre at any time. Neither involuntary admission nor seclusion are used in a CAPS. The use of restraint goes against the core principles of the CAPS model. Operational practices While each CAPS can shape its practices to best meet the needs of service users and the wider community, there are important commonalities in operational practices across all CAPS services (80). Development of a person-centred recovery plan • A wide-ranging person-centred recovery plan for all service users (Projeto Terapêutico Singular (PTS)), is co-developed by the individual and a team member. It includes personal history, an individual’s wants and needs, social relationships, current life context, challenges, strengths and goals. Individuals are encouraged to reflect about the future and take risks. There is also a focus on promoting an individual’s rights and enjoying these rights. The plan also defines care strategies with shared responsibilities. Developing a PTS is seen as a strategy to empower people to take charge of their own recovery process. The PTS is reviewed and updated on an ongoing basis. All activities in a CAPS reflect the PTS of its users (82). Technical package 37 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS Empowerment actions • CAPS seek to recognize and address power imbalances within the service (for example, team members recognize differences in power and seek to redistribute power in relationships). • Staff create positive opportunities for dialogue, negotiation and exercising rights. For example, service users receive practical support for engaging with and participating in the community (such as making a purchase in the local market), support for managing finances and mediating conflicts. • CAPS centres hold periodic assemblies with participation of the individuals who use the service, family members and staff. The assemblies provide opportunities to participate in discussions regarding daily life and activities of the CAPS, as well as debates on broader topics that affect CAPS users, such as poverty and stigma. In the assemblies, everyone participates on an equal basis and all are responsible for the discussions and decisions taken. • Service users are encouraged to engage in management councils, mental health conferences and mental health service forums. Needs-focused meetings between team members and CAPS users • At a first welcoming meeting (Acolhimento), the aim is to create a welcoming and positive dynamic, and meet an individual’s needs in that specific moment. The welcoming team member explains the service and together they begin the process of identifying whether the centre is the right service for that individual. Team members listen to understand the needs and wants of the individual, their personal history, their social and support network and general mental health. Information from the first meeting is recorded, and the service user has access to this information at any time. Standardized mental health screening tools or assessment tools are not used. • All subsequent individual meetings (including therapeutic activities) maintain the same approach; team members actively listen to and recognize the individual’s needs in that moment in time rather than focus on mental health diagnosis, personal history or past discussions. Group activities • CAPS services provide group activities both at the centre and in the community. Group activities provide opportunities to socialize and build relationships, and promote co-existence and a sense of belonging. Each CAPS defines which activities it will carry out depending on users’ PTS and the resources available in the CAPS and in the community. Types of activities include self-care, art, theater, dance, social activities, cooking and gardening, amongst others. • Some group activities are not limited to registered users of CAPS but may also have wider engagement and participation. These activities can provide broader opportunities to socialize, increase community participation and reduce stigma. Home visits • Individuals can be visited at home both for a first meeting about potentially using a CAPS or for further needs. This ensures that individuals who have difficulties reaching or accessing the centre can still access its support. Family support • CAPS services develop individual and collective care strategies for family members. The objective is to identify and meet the demands of family members in order to support their role and co-responsibility for care. 38 Comprehensive mental health service networks Providing a space to be and to participate • CAPS offer the possibility for users to spend the day and/or night (if a CAPS III) in the service. Users can participate in activities that are happening and give their opinion on the service’s practices and, together with others, remodel them. They have a chance to be with other people and progressively create new social relationships, a sense of belonging and a space to be and participate. Crisis support • Individuals in acute crisis are welcomed and supported, and there is no involuntary admission or forced use of the centre. An individual in crisis is never referred to another service where coercive practices could be used. • In a CAPS, crises are understood as moments in a person’s life and recovery during which the individual needs to be supported based on their stated wishes, needs and preferences. Support is based on the principles of Open Dialogue (for more information see Mental Health Crisis services: Promoting person-centred and rights-based approaches). • Team members are available to listen to individuals, understand and mediate possible conflicts. Support can be provided at the service itself, at the individual’s home or in community spaces. Psychosocial rehabilitation • Psychosocial rehabilitation is one of the most important aspects and activities of CAPS. These activities reflect the unique needs and life history of each individual and their PTS. Practices can include team members accompanying an individual as support in their daily activities, mediating relationships or conflicts with family members or their support network, or providing individual or group activities that contribute to an individual’s recovery. • A key focus of psychosocial rehabilitation is ensuring active citizenship. This may include, for example, accompanying an individual and providing support to navigate bureaucracies so that a person can have documentation and be formally recognized as a citizen; or to create opportunities so that a person can study or work, and in doing so, increasing that person’s social participation. • Psychosocial rehabilitation also involves creating and developing initiatives with community resources. Rehabilitation strategies are developed in the areas of housing, social life and work, creating opportunities to enable an individual’s social participation and enhance autonomy. • These actions also aim to build new social places of belonging for the individuals who access CAPS services, in that people can be increasingly recognized by society and have an active citizen role. Network coordination and cohesion • CAPS offer support to other mental health and general health services, including independent living facilities, primary health centres, emergency services and hospital services, and to other networks and institutions. The aim of this support is to promote collaboration in the co-management and co- responsibility of the various services and service networks to fulfil their role in each service user’s PTS. • As a strategic service in the mental health network, CAPS also develop and implement strategies to create links and partnerships with other services in the health, education, justice and social assistance network, as well as with community resources, with the aim of promoting and guaranteeing rights. Technical package 39 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS A typical day and night at a CAPS iii – Campinas In a CAPS lll in Campinas, an average of 60 people (service users and team members) are at the service on any given day. The day at CAPS III is lively with diverse activities that promote well-being, self-care, social exchanges and the strengthening of relationships between the individuals who access the service, team members and the community. Generally the CAPS III has designated team members to ensure that the day at the CAPS flows, offering support in organizing meals for people coming to the service, listening and meeting the unexpected demands of the day, proposing activities and creating opportunities for social exchange. The individuals who use the CAPS come and go during the day. It is common for individuals to go to the CAPS during the day to watch a movie, talk, meet people, bake a cake, play games, read a newspaper together or water the plants for example. In addition, CAPS III activities take place in the community. CAPS team members go to other community mental health services, such as the Núcleo de Atenção à Saúde da Família teams and independent living facilities, to provide support to Family Health Teams and to visit and provide support to independent living facility residents. Team Members also go out with CAPS III service users to accompany them in their activities, putting into practice the activities of psychosocial rehabilitation and actions in the community. For example, an individual and a team member might take public transport together to go somewhere (which involves planning the destination, separating the right amount of money to pay for the bus ticket, and selecting the right bus to take) or they may choose to take a walk around the neighbourhood (which involves leaving home, getting to know the neighbourhood, being around and relating to other people). Team members also support individuals to participate in other services, such as community-based “Coexistence Centres” and other city services such as cultural centres, and support activities to generate work and income. At night, individuals are supported by professionals and activities are organized to meet the needs of people in the service at that time. A welcoming environment is created that enables people to experience a crisis in a safe, caring environment. The average duration of overnight stays in a CAPS III in Campinas is 6.7 days (in 2020). While CAPS centres provide a key and strategic service in the community-based mental health network in Brazil, other services within the network play just as essential complimentary roles. Community Based Health Centres Community Based Health Centres (CBHC) (Unidade Básica de Saúde) are considered the first contact point for people to enter the Brazilian public health system (83). CBHCs provide basic community care across general practice, paediatrics, gynaecology, nursing and dentistry. Family Health Teams situated within the CBHC, provide an important link between the CBHC and the community. One of the key responsibilities of the Family Health Teams is to ensure every family in their catchment area is registered with their respective CBHC, to monitor each family’s general health and living conditions and to provide health care. The Family Health Teams key practitioners are Community Health Workers (Agentes Comunitários de Saúde) who are basic level professionals with an understanding and knowledge of the community they work in, the people that live there, and the community’s unique dynamics and challenges. 40 Comprehensive mental health service networks Community Based Health Centres – Campinas There are 66 CBHCs in Campinas (approximately one for every 20,000 inhabitants). All CBHCs in Campinas are linked with and receive support from a CAPS service. The typical staffing of a CBHC in Campinas varies, however minimum staffing includes: a coordinator, physicians (including specialists in paediatrics, gynaecology and obstetrics), nurses, a dentist, nursing assistants, dental assistants, and support staff. About a third of CBHCs have mental health professionals, including psychiatrists, psychologists and occupational therapists. Small CBHCs in Campinas have between 16-20 individuals in professional roles, in addition to the support staff described above. Medium sized CBHCs are made up of approximately 47 professionals in addition to support staff, with large CBHCs having 84 professionals, plus support staff. All CBHCs in Campinas have Family Health Teams and there are a further 146 Family Health Teams in Campinas. The minimum staffing of a Family Health Team includes: a physician, a nurse, two nursing technicians and community health agents. In addition, most Family Health Teams have other support professionals, including paediatricians, gynaecologists, nutritionists, psychologists, occupational therapists, physiotherapists, social workers, dentists and dental assistants. Núcleo de Atenção à Saúde da Família (NASF) teams NASF are multidisciplinary expert teams providing direct general support to Family Health Teams at the CBHCs. These teams are not mental health specific, but include mental health expertise. NASF teams typically comprise a social worker, psychologist, occupational therapist, nutritionist, physical education professional, pharmacist, physiotherapist and speech and language therapist, and usually a physician. NASFs provide support by discussing clinical cases, doing shared consultations with the Family Health Teams and CBHC teams, collaborating in the development of PTS plans, and delivering prevention and health promotion activities. NASFs are also involved in capacity building for professionals in CBHCs in their specialist areas, and provide care and support to individuals with less severe or less complex mental health needs. When a NASF can successfully support CBHCs to meet these needs, it allows CAPS in the region to focus on providing care and support to individuals with more complex mental health needs. This can help to prevent excessive demand on a CAPS service. NASFs follow the same human rights principles as CAPS and link and engage with CAPS as needed. They do not practice or promote the use of seclusion, restraint or any other coercive practices. NASFs are particularly important in municipalities with less than 15,000 inhabitants. These municipalities, which represent about 60% of Brazilian municipalities and account for approximately 12% of the total Brazilian population, are not large enough to qualified for a CAPS. Therefore within these municipalities, the actions of community-based health centres at primary health care level are the main care and support strategy for the mental health needs of the population they serve (73). NASFs – Campinas Campinas has a total of five NASFs. Their staffing levels reflect the unique needs and demands of the services they support and the communities they serve. All NASFs in Campinas typically include as a minimum: a psychiatrist, psychologist and occupational therapist, with additional professionals as needed. Technical package 41 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS Street Outreach Teams Street Outreach Teams (Equipes de Consultório na Rua) are part of the CBHC and are focused on the homeless population. They provide support, health care, protection against the risks to which this population is exposed (such as greater risk of urban violence, lack of financial income, absence of social support network, risks associated with drug use), and take actions to protect and promote the rights of this community. Teams provide mental health care to the homeless population in general but also to people with mental health conditions, psychosocial disabilities and problems associated with substance use. Street Outreach Teams map out the areas or regions frequented by individuals who may be able to benefit from their service, go directly to these areas to offer help and support, and provide referrals to health and social services. Street Outreach Teams are in constant dialogue and develop partnerships with CBHCs, Family Health Teams and CAPS in order to best meet the needs of the population and individuals they serve (78). The services share relevant information about the person and their recovery process, and identify actions or support required to meet the person’s needs. Street Outreach Teams can also help to facilitate access to CAPS, including for individuals who use drugs. Teams consist of between four and seven members. Teams may include a nurse, psychologist, social worker, occupational therapist, doctor, social agent with lived experience, nursing assistant and dental health technician. Larger teams also include a physician. Street Outreach Teams do not refer or otherwise direct people to psychiatric hospitals or other services where coercion, restraint or seclusion may be used. Street Outreach Teams – Campinas There are two Street Outreach Teams in Campinas, who provided support to approximately 476 individuals per month in 2020. The typical staffing of a Street Outreach Team in Campinas includes: • 1.75 medical professionals (equivalent to 70 hours, provided by 1 psychiatrist and 3 physicians) • 2 nurses • 1 occupational therapist • 1 psychologist • 1 social worker • 3 harm reduction professionals • 3 nursing technicians • 1 administrative assistant • 2 drivers • 1 coordinator. The Street Outreach Teams meet at the beginning of each working day to plan the day’s activities. The teams provide an outreach service in areas of the city that have been mapped as places where people in vulnerable situations live, generally public squares. Each day, the Street Outreach Team travel to these designated areas, set up a tent from which they work and begin consultations (for example, nursing and social assistance assessments, referral to other services and social activities). In providing health care to the homeless population in Campinas, cultural activities such as music and capoeira (a dance-like martial art of Brazil) exist side-by-side with medical, nursing and mental health practices. Once assessed by the Street Outreach Team, a person can be referred to the primary care network 42 Comprehensive mental health service networks and/or to a CAPS where their mental health needs and/or any issues regarding substance use can be identified. The services then work closely together in an integrated manner to support and meet the needs of the individual. The Street Outreach Teams in Campinas also work very closely with individuals who are homeless and pregnant. This includes identifying individuals who may need support, monitoring prenatal care and providing referrals to shelters and maternity hospitals. In 2020, Campinas Street Outreach Teams supported 100 women who were pregnant and homeless, allowing the baby to stay with the mother or extended family and avoiding the child being taken into care. The Street Outreach Team’s relationship with the wider network, especially in terms of social assistance and public security, is crucial in the care of this population. Of the people supported each month by the street outreach service, an average of 20 individuals are accompanied to attend a CAPS for adults and 65 individuals are accompanied to attend the CAPS ad. Both CAPS and the Street Outreach Teams are responsible for the care of this population. independent living facilities Independent living facilities (Serviços Residenciais Terapêuticos (SRT)) are houses located in the community designed for people with a history of long-term hospitalization (two years or more uninterrupted) who have been discharged from psychiatric hospitals or custody hospitals. For individuals who do not have a family or support network available, or there is no possibility to return to the family home, an SRT provides the individual with an independent accommodation option in the community. This service is part of the deinstitutionalization strategy of the Brazilian psychiatric reform process. An SRT can accommodate up to ten residents, with houses exclusively for women, exclusively for men, and mixed houses (81). Each residence has five caregivers per work shift and one nursing technician. Residents of SRTs are also CAPS users. Using each individual’s PTS, psychosocial rehabilitation is provided through a close partnership between the individual, the SRT and the CAPS, with the objective of promoting autonomy, social inclusion and guaranteeing rights. A person can live indefinitely in an SRT. They are seen as a person’s home, rather than a health or social service and fall outside regulatory or inspection activities. As a principle, seclusion, coercion and restraint are not used in an SRT. independent living facilities – Campinas Campinas has 20 SRTs with a total available capacity of 160 spaces. Currently SRTs in Campinas are housing 139 people. The typical staffing of an SRT in Campinas includes a housing assistant, a monitor and a nursing technician, depending on the needs of the individuals in the SRT. Each house has its own unique configuration, also according to the needs of the people resident there. In the day-to-day life of an SRT, residents may engage in various activities in the community – for leisure, religious observance, activities at the CAPS – or be at home pursuing their interests or having visitors. In each SRT there is a weekly discussion during which the residents decide on the menu for the week. The residents then go out to buy the necessary groceries, with the support of caregivers as needed. The residents also manage household chores; however, in the case of houses with people with more serious clinical conditions and with a greater need of support, there is a cleaning team. Technical package 43 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS The SRT houses are located in different neighbourhoods across Campinas. All SRTs are linked with a CAPS III and there is continuous dialogue and engagement between SRTs and CAPS services. A CAPS team member visits the SRT daily to check-in on the daily life at the residence, for example, to check if the shopping needs for the house are up to date, if anyone needs to make any personal purchases, and if all residents are well. The linking of SRTs with CAPS is particularly important as the same professionals who provide care at the CAPS are also involved in the psychosocial rehabilitation process in the community. This in turn, facilitates the overall development and oversight of the individual’s care plan (PTS) at both a service and community level. However each SRT resident participates in the community’s mental health services network according to their wishes and needs. Going Back Home Programme The Going Back Home Programme (Programa De Volta Para Casa) is a deinstitutionalization strategy that consists of a transfer of financial resources to people who have been discharged from long-term psychiatric hospitalization (two or more years uninterrupted) (84). The aim of the programme is to promote psychosocial rehabilitation by strengthening a person’s contractual power by ensuring that the person has an income to be able to make choices, for example, about what to buy and where to go. The monthly amount paid at federal level was 412 Brazilian Real (R$) (approximately US$ 72)m in 2020. Going Back Home Programme – Campinas In Campinas, a total of 139 individuals are currently recipients under the Going Back Home Programme, with a cost of R$ 57,268 (approximately US$ 10,070)m per month. Mental health beds in general hospitals Mental health beds in general hospitals (Leitos de saúde mental em Hospitais Gerais) provide health care for people with mental health conditions, psychosocial disabilities, and problems and needs associated with substance use. Access to mental health beds in general hospitals is coordinated through a centralized bed management system. Admission is based on clinical criteria and hospitalizations must be of short duration (that is, until the clinical stability of the individual allows discharge). To access a bed, a mental health network service, such as a CAPS, must request the use of the bed; this ensures that only those people who have a specific need to use the bed will in fact use it, preventing the inappropriate use of hospital beds and avoiding unnecessary hospitalizations. CAPS may refer people to mental health beds at a general hospital, for example when an individual who uses that CAPS has co-morbidities, or difficulties or needs associated with their general health that requires secondary level care. Mental health beds in general hospitals can also act as a barrier to admissions to psychiatric hospitals in a region. The mental health beds may be ring-fenced beds reserved by the hospital in the event an individual with mental health needs is admitted or they may be part of a mental health unit or ward. The number of mental health beds in a general hospital cannot exceed 15% of the total number of beds, up to a maximum of 25 beds. There is a minimum of four mental health beds in a general hospital. m Conversion rate as of March 2021. 44 Comprehensive mental health service networks As part of the mental health network in Brazil, these beds follow the same principles as the previously listed services. However, at the time of writing no evaluation data was available on the use of coercive practices in these services. Anecdotal information suggests that coercive practices (namely the use of mechanical and chemical restraints) may be used and that this practice varies across hospitals. A further challenge is the effective integration of this service with other services in the network in order to guarantee the continuity of an individual’s care across services. Mental health beds in general hospitals – Campinas There are 36 mental health beds in the two general hospitals in Campinas. One hospital, Complexo Hospitalar Mayor Edvaldo Orsi, has 20 mental health beds and the other, Hospital das Clínicas da UNICAMP has a total of 14 such beds. The mental health beds are located in a designated ward in both hospitals. To illustrate the staffing levels in one of these wards, the staffing at the mental health ward of the general hospital Complexo Hospitalar Mayor Edvaldo Orsi includes: • 1 psychiatrist (service coordinator with medical responsibilities) • 1 medical supervisor • 1 nurse supervisor • 1 psychiatrist on call • 1 nurse • 5 nurse technicians • 1 occupational therapist • 1 psychologist • 1 social worker. In Campinas, hospitalization is generally used for support during a crisis situation, based on the severity of the crisis and the needs of an individual. An individual may also be referred to one of these beds to remove them from their current environment, or because of the existence of a clinical comorbidity that requires psychiatric care and other medical specialties. These beds may also be used for the purpose of diagnosis (more common in the care of CAPS ad service users) and protection purposes, especially in the vulnerable underage population. Mental health beds in a general hospital may also be considered when the CAPS and general hospital considers that an individual may benefit from it. For example, the hospital may provide a more appropriate environment for some individuals than the busy active environment of a CAPS, and also provide an alternative if there are no dorm vacancies within a CAPS III in the network. If an individual is admitted to a mental health bed in a general hospital in Campinas, the hospital team and the team from the reference service of that person (for example, a CAPS) work to continue the PTS of that individual. They will discuss the user’s recovery plan and any adjustments that may be needed during their time in hospital. Visits by professionals to the individual, for example, from CAPS, are common and encouraged during the hospitalization period. Technical package 45 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS Engagement between the services and team members is ongoing throughout the time an individual is using one of these beds. The general hospital team also goes to CAPS to attend meetings and to discuss shared strategies to better serve the individuals who access these services. The care provided by a general hospital follows the same principles of the mental health network and CAPS. In a crisis situation, both verbal and medication approaches are used, but medication is used only with the consent of the individual. The network reported, however, that restraints may still be used in extreme circumstances and this is important to change. Mental health beds in general hospitals are important in the Campinas network for their role not only in providing additional support to individuals experiencing a crisis situation, but also for their ability to link and work with all the municipal mental health services. Emergency and urgent services Urgent and emergency care services associated with the mental health network are part of the emergency services network of the general health system, including mobile emergency services, emergency care units (standalone emergency care-specific services) and hospital emergency rooms. As a general guideline, the urgent and emergency care services work together with CAPS when an individual with mental health needs presents at one of these services. On arrival, the emergency service contacts the relevant CAPS for that individual. Once contact is made, the CAPS has shared responsibility for the individual’s care, including for example, discussing the individual’s needs, following up emergency service actions, resuming the person’s PTS in the community upon discharge from the emergency service, etc. Other mental health network services Reception Units (Unidade de Acolhimento) are community-based residential services, designed to provide support to CAPS centres in the health care of people with problems and needs associated with substance use who are in situations of social vulnerability and/or when a more intense presence and monitoring for a transitory period of time is required. This service is not described in more detail as substance use services were beyond the scope of this document. Cross-network initiatives A strength of the network in Brazil is not only that these services co-exist to meet the evolving needs of the community, but also in its cross-network initiatives that are transformative in terms of the individual and community. Such initiatives have been instrumental in widening the perception of and engagement with mental health and psychosocial disability at a community level. Coexistence Centres Coexistence Centres (Centro de Convivência (CECO)) are community-based centres open to all members of the community, and the participation of people with psychosocial disabilities, cognitive disabilities, older adults, and children and adolescents with social vulnerabilities is highly encouraged. The primary goal of CECOs is the mediation and promotion of opportunities for coexistance, promoting social inclusion and belonging. While CECOs are considered part of the national mental 46 Comprehensive mental health service networks health policy, they are currently only implemented in some regions of Brazil. CECOs are funded at state and municipality level. Coexistence Centres – Campinas There are five Coexistence Centres (CECOs) across Campinas each with a service capacity of between 120 and 300 people per month. The typical staffing at a CECO in Campinas includes: two professionals (psychologist, occupational therapist, group leader, physical educator or nurse), a monitor, cleaning assistant and coordinator. The CECOs of Campinas were established as part of local public policy before CECOs were recognized at a national policy level, and are funded at a local level. CECOs are usually located in public parks or green areas and link health, sport, culture, education and the environment from a psychosocial rehabilitation, prevention and health promotion perspective. CECO activities reflect two main themes – coexistence (group activities, public meetings, promoting understanding and tolerance of differences between people) and partnerships (with public institutions and civil society) that can contribute to the inclusion and autonomy of individuals accessing the CECO. For example, a literacy programme for young people and adults was developed by the CECO in partnership with the educational sector, in which both CAPS users and residents of SRTs may participate. Each CECO has its own schedule of activities published monthly. Activities include literacy, guitar lessons, English, capoeira, zumba, painting and craft activities, garden activities, a cinema workshop and cooking, among others. All activities are free, open to the community and often rely on the active participation of volunteers. CECOs also link directly to mental health services. For example, if a CAPS identifies that a CECO can enhance the PTS of an individual (in the sense that participating in some CECO activity could be beneficial to the person) a referral can be made. Likewise a CECO can also identify if someone who attends its activities could potentially benefit from a CAPS service and facilitate a referral. Work and income generation services and initiatives Work and income generation initiatives aim to guarantee the right to work and to provide training and qualifications for work. These initiatives promote social inclusion and autonomy, increasing power and improving people’s living conditions. They are also a psychosocial rehabilitation strategy for strengthening the protagonism of individuals who access the mental health network. Some of the initiatives carried out in different regions include cooking, craft products, clothing production, agriculture, recycling, stamping, rendering of services, sales, among others. These initiatives are based on the solidarity economy perspective (85). Work and income generation services and initiatives – Campinas Campinas has two services focused on the Solidarity Economy and the generation of work and income – Workshops House (Casa das Oficinas) and the Centre for Workshops and Work (Núcleo das Oficinas e Trabalho). Both of these services develop activities focused on guaranteeing the right to work, promoting autonomy, fostering social inclusion through work, and participation in social associations and cooperatives. They develop collective and participative training activities and Technical package 47 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS income and work generation activities, in a variety of areas. A further entity focuses on commercializing products, Workshops Warehouse (Armazém das Oficinas). Casa das Oficinas is staffed by a coordinator, psychologist, occupational therapist, monitors, administrative assistant and cleaning assistant. It has seven work and income generation initiatives in the areas of cooking, stationary and sewing (Gira Mundo), handicrafts, printing, bread making and mosaics. Approximately 50 people per month access this service. Nucleo de Oficinas e Trabalho is staffed by a coordinator and administrative assistants. Each of the work and income generation initiatives has a separate coordinator who may be an occupational therapist, psychologist, social worker or architect, and monitors. The organization has 12 work and income generation initiatives in the areas of: recycled paper, joinery, metalwork, mosaics, events, agricultural, culinary and restaurant, printing, flat stained glass, religious stained glass, sewing and hydraulic/ceramic tile. Approximately 300 people per month access this service. To access one of these services, a person is referred by one of the municipality’s mental health services, for example, a CAPS. After being informed of all the options for work and income generation projects and workshops, a person can then choose the initiative or activity in which they would like to participate. All participants are remunerated as a result of the production and sale of the products. The total sale value is divided among the participants according to the performance evaluation of each person. This monthly assessment is made by a group that includes the service coordinator, a monitor of the project or workshop and the individual, considering criteria such as attendance, punctuality, responsibility, initiative and creativity. The network in Campinas reported the number of people who manage to participate in the formal job market is however, still very small. An alternative employment avenue has been developed with employment directly by Serviço de Saude Dr. Cândido Ferreira. As of September 2020, 34 people had gained employment through this initiative. Cultural initiatives – Campinas The mental health network in Campinas also has a number of collective and cross-network projects that include the participation of individuals who use mental health services, professionals and family members from different CAPS, SRTs, CECOs and beyond. Examples of initiatives include: Rádio Maluco Beleza, a radio programme that brings together individuals who use mental health services, family members, social projects, employees and people from the community. It is on air 24 hours a day with a variety of programmes that address different themes; Jornal Candura, a bimonthly publication covering news and events related to mental health services, addressing issues of social inclusion and citizenship; and Coletivo de esportes, a sports initiative responsible for InterCAPS, an event that brings together the CAPS of the city of Campinas and region in a football championship and celebration of the 18 May, the national day on which the civil society social movement celebrates and demands advances on psychiatric reform. Coletivo de esportes is also responsible for the Inclusion Cup, a weekly football championship among the CAPS in Campinas. This initiative promotes weekly meetings between employees, the individuals who use the service and family members through sports activities in mental health services and in community spaces. 48 Comprehensive mental health service networks Core principles and values underlying the service Respect for legal capacity Respect for the legal capacity of individuals who access mental health services is embedded in the principles of the community-based mental health network in Brazil. At a service level, this is reflected in person-led recovery plans, the absence of involuntary admission or treatment, proactive addressing of power imbalances and support of individuals to exercise and enjoy their legal capacity both within the service and in their communities. The Going Back Home Programme (Volta Para Casa) and SRTs support individuals with a history of institutionalization with a supported, person-led return to exercising their legal capacity in society. Alternatives to coercive practices The use of coercive practices is against the principles of the community-based mental health network in Brazil. Services instead emphasize the practice of negotiation and mediation in conflicting and challenging situations. In addressing power imbalances and recognizing an individual’s own knowledge of their experiences, needs, wants, preferences, and person-led recovery plans, services develop a permanent dialogue and relationships of trust with service users, shifting service dynamics away from coercive practices. There were no reports of the use of coercive practices in NASF, CBHC, SRT or Street Outreach Teams in 2020. The occurrence of coercive practices in CAPS rare and considered an unacceptable practice by the service and its team members. The use of coercive practices (physical and chemical restraints) in general hospitals, however, was identified as being variable from hospital to hospital. This is an area that requires constant attention and efforts to change. Nevertheless, the network in Brazil illustrates the emphasis on and success of building relationships to prevent the use of coercive practices. Community inclusion At an individual level, a person is supported by the network to participate in their community according to their needs and preferences, guided by their person-centred recovery plan (PTS). Proportionate support is available, reflecting the needs of the individual, for examples through SRTs. The mental health network is active in the community, reflecting the collective nature of inclusion, and that it is through collective actions with people in the community that possibilities for social inclusion are created and in the process, the community and its relationships are transformed. Practices such as CAPS activities, CECOs and cultural initiatives that are open to the wider public promote community inclusion, diversity and reduced stigma. Partnerships between services and the practice of continuous care carried out between services increases people’s access to and inclusion in the community across diverse areas including health, mental health, employment, sport and culture. Participation Strategies of collective dialogue, such as the CAPS assemblies, are actively used in the network. Users participate in the design and implementation of the service network, including network and service practices. This occurs daily through social exchanges within the services, in formal structures such as mental health forums, and also through the civil organization in the social movement for psychiatric reform. Technical package 49 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS Recovery approach The community-based mental health network principles are consistent with the recovery approach, including promoting autonomy, social participation, community inclusion and equal rights. The use of individual person centred recovery plans (PTS) across services is consistent with the recovery approach, encouraging each individual to identify their own hopes, goals and aspirations and lead in their own recovery journey. The focus of each service and the structure of the network, in particular cross network initiatives, lend to a whole-person and holistic approach including essential recovery elements such as access to community participation, employment, education, culture and sports. Service evaluation Due to the size and complexity of the network in Brazil, the following is not a comprehensive description of all studies pertaining to the community-based mental health network in Brazil. This section includes evaluation data of the mental health network of different Brazilian municipalities and regions (divided into general network studies and CAPS-oriented studies). Studies are also presented from the case study municipality of Campinas. The evaluation data reviewed for the purpose of this document supports that the network can offer high quality services and support to the individual and community. Community-based mental health network, Brazil Several studies have evaluated the community-based mental health network in Brazil. A 2015 systematic review of studies on the mental health services in Brazil reported satisfaction with the services that were developed as a substitute to institutionalization (e.g. CAPS) in relation to welcoming and humanizing attitudes, breaking with social isolation, establishing connections, improvement in clinical conditions, quality of life and support with mental health (86). It also reported improvement in self-confidence, emotional health, quality of sleep and the capacity to handle difficult situations. In comparing psychiatric hospitals and community-based mental health services and strategies that replaced psychiatric hospitals, community-based mental health services were found to be more effective and efficient. A 2019 study demonstrated a correlation between increasing CAPS and primary health centre coverage with decreased psychiatric hospitalization rates (87). In a study of CAPS II linking with primary health care teams, quality of care increased in crisis situations in the community, preventing escalation and use of coercive practices such as police actions, use of physical force, involuntary conduct for emergencies and hospitalization (88). The role of the NASF has also been found to be effective in supporting mild and moderate mental health needs, preventing excess demand on specialist services such as CAPS, in municipalities who have clear policies and practices to support this practice (89, 90). The implementation of NASF teams in a rural area was also found to increase individual engagement with activities proposed by the health services and health needs were more comprehensively attended to (91). Residential services such as the SRT have been found to support individuals who had experienced long term hospitalization to increase an individual’s own sense of power and autonomy, to establish relationships and increase social participation (92, 93). Similar findings support the role of financial programmes such as Going Back Home to support individuals’ return and life in the community after extensive periods of hospitalization (91, 94). However, studies have also identified that challenges exist in the networks, for example, the integration of services, the effectiveness of mental health actions provided by the network in supporting community-based health centres (CBHCs) and capacity building of SRT caregivers to manage residents’ complex demands and needs (90, 95). These studies highlight the scope for variance in the network in how well it can work together to meet the needs of the communities it serves and the importance of integration in a network infrastructure. 50 Comprehensive mental health service networks CAPS Studies have identified high levels of satisfaction by both individuals who use CAPS and family members. When measuring level of satisfaction (on a scale of 1–5), a 2018 study reported a measure of 4.6. Questions relating to professional competence, needs-focused first meeting and care provided, and being treated with respect and dignity recorded the highest levels of satisfaction (96). CAPS were also found to favour the expansion of individuals’ autonomy, co-responsibility in recovery, and protagonism (97, 98). Family members also reported satisfaction with the service, the quality of care and the support that they receive (99, 100). In a prospective cohort study from 2010 with 1888 users of CAPS, the study found that CAPS practices were effective in supporting users in challenging and crisis situations (101). After attending CAPS, 24% of users reported absence of crisis, 60% had crises less frequently and 70% reported less intensity. The longer the time attending the CAPS, the greater the time elapsed since the last psychiatric hospitalization. The implementation of CAPS has also been found to reduce the risk of suicide by 14% (102). In a 2018 cross-sectional study, 917 CAPS users from four municipalities were interviewed. Results show that “in all cities, less than 10% of users had a psychiatric hospital admission after treatment at the CAPS was started” (103). Community-based mental health network, Campinas Studies from Campinas have demonstrated the effectiveness of the network at both system and individual level. Long-term users of CAPS III in the city of Campinas showed a reduction in crisis occurrence, in medication use and number of psychiatric hospitalizations. Non-intensive CAPS users experienced reduced medication. Both individuals who used the service and family members reported high levels of confidence in the service at a time of crisis and in terms of psychosocial rehabilitation (104). Specific CAPS practices have also been positively received, in particular the availability and trust in the overnight accommodation facility of CAPS III and the allocation of a “reference practitioner” for all CAPS users (105, 106). In a cross-sectional study, 95% of CAPS users interviewed reported not having had any psychiatric hospitalization after starting to attend the CAPS; 73% reported seeking CAPS in a crisis situation and 0% reported seeking a psychiatric hospital. This study supports the premise of the community-based network in Campinas as a replacement to psychiatric hospitals (103). The positive integration between the mental health network and general health network was also identified as important, allowing the networks to share knowledge and experience, and allowing greater continuity of care (107). Costs and cost comparisons The mental health network is part of a wider health network of services and is delivered under the Unified Health System (SUS). This universal health system is financed at federal, state and municipal level, sustained through a public tax system. There is no direct cost for the population to access and use any service in the network. Technical package 51 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS Costs of the Campinas network The annual health budget in Campinas in 2019 was approximately R$ 1.2 billion (roughly US$ 213 million).n The community-based mental health network was allocated 6.6% of this total budget, equivalent to R$ 80 million (approximately US$ 14 million). (This figure does not include the costs of mental health beds in the general hospitals, nor the wider CBHC non-mental health costs.) This equates to a cost of approximately R$ 67 (US$ 12) per capita in Campinas per year (based on an approximate population of 1.2 million). Challenges and solutions increasing poor health coverage An early challenge in establishing the community-based mental health network in Campinas was the absence of a public health system to address coverage of general health, including mental health. The first steps toward overcoming this issue were taken in the 1980s when Brazil recognized and established health (and mental health) as a constitutional right with the implementation of its universal public health system (SUS) in 1988. Challenging the predominance of the biomedical model and psychiatric hospitals A major obstacle to establishing the community-based network in Campinas was the predominance of the biomedical model and psychiatric hospitals, leading to human rights violations, social exclusion and denial of power to people with mental health problems. The establishment of a human rights-based national mental health policy which focused on deinstitutionalization and freedom first principles and aimed at promoting continuous care at the community in all levels of health system began the process of deinstitutionalization. Other approaches were sought at various levels and included: showcasing and promoting deinstitutionalization experiences including successes in closing psychiatric hospitals and developing community-based services; establishing a programme to continually evaluate progress towards reducing the size of psychiatric hospitals and expansion of community-based services; and further, a powerful lever of reform involved the redirecting of financing from psychiatric hospitals towards the development of community-based services using an incremental, phased approach. Finally, open dialogue and articulation of experiences from other countries helped to change mindsets and show possible paths forward. Dissolving political resistance to deinstitutionalization Another serious challenge faced by the network was the presence of local political resistance to deinstitutionalization and closure of psychiatric beds, at the municipality and community level. Other sectors and systems also held attitudes and practices that favoured institutionalization, including the legal system. n Conversion as of March 2021. 52 Comprehensive mental health service networks A major aspect that helped overcome this barrier was the enacting of laws to guarantee the rights of people with mental health problems and establish service regulation norms to implement community- based mental health services. Further, holding mental health conferences at national and municipal levels to encourage debates and democratize decision making amongst service users, family members and staff from the mental health network to discuss mental health policy and deinstitutionalization practices also helped address this political resistance. The network has been negotiated and debated by stakeholders at all levels of the mental health system, which created a level of buy-in and commitment. Finally, civil society movements remain active in pushing the progressiveness of the network forward. Addressing poor workforce knowledge of human rights Another ongoing challenge is the lack of knowledge and understanding of human rights in newly recruited professionals working in community-based mental health services. Engaging in continuous dialogue with all stakeholders including in different sectors, to address any concerns, and provide practical support to solve challenges at the local level has helped improve understanding of human rights in the mental health context. An additional effective solution has been the organizing of CAPS placements for people training in academic programmes and residency programmes that emphasize multidisciplinary approaches. Key considerations for different contexts Key issues to consider for the establishment or expansion of this service in other contexts include: • engaging continuously at all levels in the system, in particular with those who access mental health services, their families and civil society movements to identify the network services that are needed and wanted; • embracing a whole person-centred approach to meet the entire range of needs of the individual (for example, mental, physical, employment, education, community participation); • considering tiered services to meet the range of mental health needs in an appropriate setting (i.e. primary health centres through the support of NASFs able to meet low complexity needs, CAPS meeting high complexity needs); and • establishing an overall coordinating body (CAPS and CBHC in the Brazilian context) that guide the mental health network in each area. Technical package 53 2 | C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K S – D E S C R IP T IO N A N D A N A LYS IS Additional Information and resources: Website: https://www.gov.br/saude/pt-br http://www.saude.campinas.sp.gov.br/ videos: Morar em Liberdade: Retratos da Reforma Psiquiátrica Brasileira - FIOCRUZ (Portuguese)/ Living in Freedom: Portraits of the Brazilian Psychiatric Reform - FIOCRUZ (English) https://www.youtube.com/channel/UCD2xLN_GIeJRWqOs8yWLDPQ/videos Memórias da reforma psiquiátrica no Brasil - FIOCRUZ (Portuguese)/Memories of psychiatric reform in Brazil - FIOCRUZ (English) http://laps.ensp.fiocruz.br/ Rádio ‘Maluco Beleza’ – Campinas (Portuguese)/Radio ‘Maluco Beleza’ – Campinas (English) https://www.youtube.com/watch?v=ujRDWeL_cnM Contact: Coordination of the Area of Mental Health, Alcohol and other Drugs, Brazil. Email: saudemental@saude.gov.br Coordination of the Technical Area of Mental Health, Municipal Health Secretariat, Campinas, Brazil. Email: dptosaude@campinas.sp.gov.br Serviço de Saúde Dr. Candido Ferreira, Campinas, Brazil. Email: contato@candido.org.br

3. Moving forward: from concept to good practice comprehensive mental health service network 56 Comprehensive mental health service networks The purpose of this section is to provide readers with some key practical steps and recommendations that will facilitate the process of conceptualizing, planning and piloting the setting up or transformation of a network of services. It is not meant as a comprehensive and complete plan for undertaking this since many context-specific factors, including socio-cultural, economic and political factors play important roles in this process. Further detail on integrating the service into health and social sectors is provided in the guidance and action steps section in Guidance on community mental health services: Promoting person-centred and rights-based approaches. Action steps for setting up/transforming a network of services: • Set up a group of different stakeholders whose expertise is crucial for setting up or transforming the network of services in your social, political and economic context. These stakeholders can include but are not limited to: » policymakers and managers from health and social sectors, people with lived experience and their organizations, general health and mental health practitioners and associated organizations, legal experts, politicians, NGOs, OPDs, academic and research representatives and community gatekeepers such as local chiefs, traditional healers, leaders of faith-based organizations, carers and family members. • Provide the opportunity for all stakeholders to thoroughly review and discuss the good practice services and networks outlined in all the technical packages to get an in-depth understanding of the respective services and networks. This is the opportunity to identify the values, principles and features you would like to see incorporated into your network given the social, political and economic context. • Establish contact with the management/providers of the service(s) and networks that you are interested in to get information and advice on setting up/transforming a network in your context and to understand the nuances of their network. Ask specific questions about how the services and network operate keeping in mind the local context in which they would be developed. This can be done via a site visit to the good practice service/service network and/or video conference. • Provide training and education on mental health, human rights and recovery to the groups who will be most relevant for setting up/transforming the network and individual services using WHO QualityRights face-to-face training materials (https://www.who.int/publications/i/item/who- qualityrights-guidance-and-training-tools) and e-training platform. Changing the attitudes and mindsets of key stakeholders is crucial to reduce potential resistance to change and to develop attitudes and practices in line with the human rights-based approach to mental health. • Discuss and agree on the roles and responsibilities of the health and social sectors required to comprehensively address the support needs of people with mental health conditions and psychosocial disabilities that were identified in your stakeholder discussions, including but not limited to housing, employment, access to education and to adequate health services for overall health not just mental health. Technical package 57 3 | M O V IN G FO R W A R D : FR O M C O N C E P T TO G O O D P R A C T IC E C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K Questions specific for setting up/transforming a network of services: • What gaps have you identified in your network of services that need to be addressed (for example, in relation to the availability of crisis response services, community mental health centres, hospital-based services, community outreach services, peer support services and living support services, and in relation to how they operate in respecting rights and promoting recovery)? • What existing community-based mental health services are you aiming to transform in your network of services (see services showcased in the other six technical packages)? • What new community-based mental health services need to be created to fill any gaps in service provision (see for example, the services showcased in the other six technical packages)? • Are there opportunities to build these service reforms into policies and strategies under development in the areas of mental health, general health, disability and other related areas? • What treatments/interventions are you planning to provide through the network and within each category of service included in the network? For example: » interventions explicitly related to community inclusion (see community inclusion section below) » assessments of support needs and diagnosis if agreed by a person » trauma informed therapy » person-centred recovery planning » psychotherapy, e.g. Cognitive Behavioural Therapy » problem solving and behavioural activation/activity scheduling » individual and group-based supportive counselling/therapy » psychotropic and other medication (including prescribing medication, as well as support for withdrawing safely from medication) » dialogue/meetings with families, friends and supporters (with the agreement of the person using the service) » transitional support for people returning to their home and community » crisis hotline phone-in » peer support » other. • How will your service assess, provide for or refer people for any physical health conditions they may have? • What additional human resources will be required (doctors including psychiatrists, general practitioners and others, psychologists, nurses, social workers, peer support workers, occupational therapists, outreach workers, community/lay workers, administrative staff, etc.) and what new skills and training will be required for them to provide quality and evidence-based service in line with human rights? 58 Comprehensive mental health service networks • What will be the interrelationship between all the services and supports within the network and with other services and resources in the community, including upward and downward referral systems? • What will be the overall coordinating mechanism for the network of services? • What mechanism or forums will be required to support the operation of the network, in particular integration of services and consistency of principles and values across services in the network? • What strategies and training will be put in place to realize legal capacity, non-coercive practices, participation, community inclusion and recovery orientation?o „Legal capacity • How will you ensure that mechanisms for supported decision making are in place in each service in the network to make sure that decisions are made based on the will and preference of the person? • How will you ensure a consistent human rights-oriented approach to informed consent by service users in relation to treatment decisions across all services in your network? • How will all network services ensure that people are: » able to make informed decisions and choices about different options for their treatment and care; and » provided with all critical information relating to medication and other treatment including on their efficacy and on any potential side effects? • How will you ensure network services have processes in place to systematically support people to develop advance plans? • How will you ensure network services have processes in place to respect each individual’s advance plan? • What kind of mechanisms will network services put in place to ensure that people can make a complaint if they need to? • How will network services facilitate access to legal advice and legal representation by its users in need of this type of service, e.g. pro bono legal representation? „ Non-coercive practices • How will you ensure the systematic training of all staff on non-coercive responses and de- escalation of tense and conflictual situations throughout the service network? • Will the service network support people to write individualized plans to explore and respond to sensitivities and signs of distress? • How will you create a “saying yes” and “can do” culture in which every effort is made to say “yes” rather than “no” in response to a request from people who are using the service, throughout the service network? o For more information see section 1.3 in Guidance on community mental health services: Promoting person- centred and rights-based approaches. Technical package 59 3 | M O V IN G FO R W A R D : FR O M C O N C E P T TO G O O D P R A C T IC E C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K • How will the service network incorporate comfort rooms and response teams that operate in alignment with human rights principles? • How will the service network incorporate human rights and recovery-oriented community- based responses to individuals experiencing crisis or challenging situations? „ Participation • How will people with lived experience be an integral part of the team within services and the service network as staff, volunteers or consultants? • How will people with lived experience be represented in the high-level decision-making in the different services and also at the network level? • How will feedback be systematically collected from service users and integrated into the services of the network? • How will the services in the network link people using the service to peer networks in the community? „Community inclusion • How will the service network support people to find work and income generation, for example through a transitional employment programme, supported employment programme or through independent employment as appropriate? • How will the service network facilitate access to housing services? • How will the service network facilitate supported education and assistance in accessing community-based education opportunities and resources to continue education? • How will the service network facilitate access to social protection benefits? • How will the service network facilitate access to social, cultural and recreational programmes, initiatives and events? • How will the service network support deinstitutionalization and the return of individuals back to the community, including people who have been long term residents of institutions? „Recovery • How will the service network ensure that persons will be considered in the context of their entire life and experiences and that care and support will not solely focus on treatment, diagnosis and symptom reduction? • How will the service network ensure that the five dimensions of recovery: (1) connectedness, (2) hope and optimism, (3) identity, (4) meaning and purpose and (5) self-empowerment, are integral components of service provision? • How will people throughout the service network be supported to develop recovery plans in order to think through and document their hopes, goals, strategies for dealing with challenging situations, managing distress, strategies for keeping well, etc.? • How will people throughout the service network be supported to review and update their recovery plans on a regular basis? 60 Comprehensive mental health service networks • Will the service network provide training and support activities regarding the human rights- based approach in mental health to other stakeholders and in the community? » Will the service network provide training and support to organizations in the community, including civil society groups? » Will it provide training and support to staff of other health and social services, including non-specialized health services? • Awareness-raising and advocacy » Will the service network undertake awareness-raising on mental health and human rights, including with families, schools, employers, local organizations and other community settings? » Will the service network undertake advocacy actions on mental health and human rights for the rights of people with mental health conditions and psychosocial disabilities and create positive opportunities for individuals to engage in the community with the ultimate aim of creating a community whereby individuals can live autonomously? This includes actions to reduce stigma around mental health and creating positive opportunities for community engagement. • What actions will the service network undertake to understand the social dynamics of the local community and to map the frequent problems that most impact people’s lives and mental health (for example, police violence, threats related to drug trafficking, economic hardship)? Technical package 61 3 | M O V IN G FO R W A R D : FR O M C O N C E P T TO G O O D P R A C T IC E C O M P R E H E N S IV E M E N TA L H E A LT H S E R V IC E N E T W O R K • Prepare a proposal/concept note that covers process issues, detailing the steps for setting up the service network, the vision and operation of the service network based on the full range of services that will be provided, covering the following: » human resource, training and supervision requirements; » how this service relates to other local mental health and social services; » strategies to ensure that human rights principles of legal capacity, non-coercive practices, community inclusion and participation will be implemented, along with a recovery approach; » details about the monitoring and evaluation of the service; and » information on costs of the service and how this compares with the previous services in place. • Secure the required financial resources to set up or transform the service network, exploring all options including government health and social sectors, health insurance agencies, NGOS, private donors etc. • Use financing mechanisms to support the transformation or creation of the good practice service network that adheres to a human rights-based approach and is sustainable. • Set up and provide the service network in accordance with administrative, financial and legal requirements. • Monitor and evaluate the different services within the service network on a continual basis and publish research using measures of service user satisfaction, quality of life, community inclusion criteria (employment, education, income generation, housing, social protection) recovery, symptom reduction, assessment of quality and human rights conditions (for example using the QualityRights assessment toolkit), and rates of coercive practices (involuntary treatment, mechanical, chemical and physical restraints). • Establish dialogue and ongoing communication with key stakeholders and members of the public by holding public forums and hearings with these groups where people can openly express their views, ideas and concerns about the overall service network and the individual services within it, and to address these concerns. • Advocate and promote the service network with all relevant stakeholder groups (politicians, policy makers, health insurance agencies, media, people with lived experience, families, NGOs, OPDs and the community at large). 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70 Policy, Law and Human Rights Department of Mental Health and Substance Use World Health Organization Avenue Appia 20 1211 Geneva 27 Switzerland

Technical package 기술 패키지 통합 정신 건강 네트워크 사람 중심 및 권리 기반 접근방식 촉진 목차 서문 감사의 말 개요서 세계보건기구(WHO) 퀄리티라이츠(QualityRights) 이니셔티브는 무엇인가? 지역 사회 정신 건강 서비스에 대한 세계보건기구의 지침과 기술패키지 1. 개요 2. 통합 정신건강 서비스 네트워크 - 설명과 분석 2.1 동쪽 릴(East Lille) 지역 사회 정신 건강 서비스 네트워크 (프랑스) 2.2 트리에스테(Trieste) 지역 사회 정신 건강 서비스 네트워크 (이탈리아) 2.3 브리질 지역 사회 정신 건강 서비스 네트워크 캄피나스(Campinas) 지역을 중심으로 3. 앞으로 나아가기: 개념으로부터 우수한 통합 정신 건강 서비스 네크워크 사례로 참고문헌 3 4 10 11 15 17 18 32 45 66 73 서문 전세계적으로, 정신질환이나 사회심리적 장애를 가진 사람들을 위해 양질의 멘탈 건강 서비스와 도움 을 주기 위해 노력하고 있다. 하지만 많은 국가에서 여전히 사람들의 필요와 그들의 권리와 권위에 충족되지 못하는 수준의 서비스가 제공되고 있다. 오늘날까지도, 정신 건강 시설에 방치되어 강압적 이고 때때로 학대와 같은 비인간적인 환경에 놓여 있는 등 넓은 범위의 폭력과 차별에 노출되어 있 다. 2006년에 제정된 장애 인권 권리 협약(CRPD)는 정신 건강 분야에서 인권을 보호하고 증진하기 위해 대대적인 개혁이 필요함을 인정한다. 이러한 내용은 정신건강과 행복 증진 목표로 하는 지속가능한목 표들(SDGs)와 유엔(the United Nations)의 보편적 의료보장에 대한 정치적 선언에도 잘 드러나 있다. 지난 20년간 정신 건강 서비스의 발달 필요성에 대한 관심도가 올라갔음에도 불구하고 많은 국가에 서 소득 수준과 관계 없이 시대에 뒤처진 법, 제도, 부족한 자원한다는 한계에 맞닥뜨렸다. COVID-19 팬데믹은 전세계적으로 정신건강체계와 서비스가 부족하고 시대에 뒤처져있다는 점을 더 욱 부각시켰다. 이는 시설의 유해성, 사회적 네트워크의 부족, 불충분하고 분열된 정신 건강 서비스와 함께 정신 질환을 앓고 있는 사람이 고립되고 소외되어 있다는 점을 드러냈다. 어느 국가든지 정신 건강 서비스를 제공함에 있어 강압적인 관행(practice)는 거부해야하고, 환자 자 신들의 치료와 케어에 있어 직접 선택할 수 있도록 지지해야하며, 사람에게 있어 중요한 부분들을 – 관계, 일, 가족, 가정, 그리고 교육 – 함께 다룸으로써 단순히 증상을 완화시키는 데에 집중하기 보다 지역공동체의 참여와 융합에 주목해야 한다. WHO의 ‘2020-2030 종합정신건강행동계획(Comprehensive Mental Health Plan)’은 국가가 정신건강 측면에서 사람중심, 권리기반, 회복접극방식을 우선순위에 두고 운영할 수 있는 틀을 제공한다. 해당 지침은 전 세계에 다양한 우수 정신 건강 서비스 관행 사례들을 소개함으로써 평등, 비차별, 법적 능 력, 고지된 동의, 지역사회융합과 같은 주요 권리들을 증진하고 인권 관점으로 국가들이 지역사회 기 반 서비스를 개발하고 지원한다. 시설 수용과 강제 입원을 종결시키는 로드맵을 제공하고 개개인의 고유한 존엄성을 존주하는 정신 건강 서비스를 위한 세세한 행동 단계도 제시한다. 정책입안가, 의료서비스 제공자, 시민사회, 정신질환이나 심리사회적 장애가 있는 사람들 모두 국제 인권기준에 맞는 정신 건강 서비스를 만들기 위한 역할을 가지고 있다. 해당 지침서는 국제인권기준에 부합하는 지역사회기반 정신건강서비스에 예산을 투입해야할 필요성 과 긴급성을 전세계의 정책입안가에게 알리고 촉구하는 데 있다. 또한, 정신건강서비스에서 최고 수 준의 인권 존중의 비전을 제시하고 수백만명의 정신질환이나 심리사회적 장애가 있는 사람들, 그리고 그들의 가족들과 세계가 더 나은 삶을 가질 수 있는 희망을 전달한다. 개요서 지난 10여년에 걸쳐 정부, 비정부기구(NGOs), 유엔(UN), 세계은행을 포함한 다자간기구는 정신 건강 에 대한 관심을 높였다. 사람중심, 인권기반 치료와 서비스 제공의 중요성에 대한 인식이 증가함에 따 라 전세계적으로 양질의 치료와 지원을 제공하기 위해 노력하고 있다. 하지만 여전히 서비스는 자원이 제한적이고 시대에 뒤떨어진 제도와 법적 규제의 틀에 갇혀 운영된 다. 반면 사람들의 정신건강에 주요하게 영향을 끼치는 사회 전반의 결정 요인들은 도외시 된 채, 대 부분이 진단, 약물치료, 증상 감소에만 의존한다. 이는 인권 중심 기반 접근방식을 실현 시키는 데 방 해요인이 된다. 결과적으로 충분한 케어나 지원이 부족해지면서 정신질환자나 심리사회적 장애가 있 는 많은 사람들이 그들의 인권을 침해당하고 있다. 해당 지침서는 장애인권리협약(the Convention on the Rights of Persons with Disabilities; CRPD)를 포함한 국제 인권 기준에 맞춰 정신 건강 체계와 서비스를 조정하고자 하는 국가들을 지원하고자 한 다. 그리고 사람중심, 인권중심의 접근법을 증진시키기 위해서는 사람중심, 회복중심 그리고 권리기 반의 지역사회기반 정신건강 서비스 확대하는 데 집중해야함을 요구한다. 전 세계의 다양한 맥락에서 우수한 정신건강서비스 관행 사례들을 제공하고 주거시설, 교육, 고용, 사회보장영역의 필요성을 연 결지으며 정신질환이 있는 사람들이 지역사회에서 완전하고 의미있는 삶을 살아갈 수 있도록 해야함 을 설명하고 있다. 해당 지침서는 포괄적인, 통합된, 지역적 국가적 지역사회기반 정신건강서비스와 지원의 네트워크의 예시들을 소개한다. 끝으로, 사람들의 인권을 존중하고 회복에 집중하는 지역사회 정신건강서비스를 국가와 지역이 발달시킬 수 있도록 세부적인 권고사항과 행동 지침들을 소개한다. 해당 지침서에는 7개의 다른 영역의 정신건강서비스에 대해 자세히 설명하는 기술패키지가 함께 동 봉되어 있다. 1. 정신건강위기서비스(Mental health crisis services) 2. 병원기반 정신건강서비스(Hospital-based mental health services) 3. 지역사회 정신건강센터(Community mental health centres) 4. 동료지원 정신건강서비스(Peer support mental health services) 5. 지역사회 아웃리치 정신건강 서비스 (Community outreach mental health services) 6. 정신 건강을 위한 생활 지원 서비스(Supported living for mental health) 7. 통합 정신 건강 서비스 네트워크(Comprehensive mental health service networks) 이 지침서의 핵심 메시지 • 정신질환과 심리사회적 장애를 앓는 많은 이들이 열악한 치료환경과 인권침해를 직면하고 있 다. 따라서 정신건강체계와 서비스 제공에 있어 엄청난 변화가 필요하다. • 세계 곳곳에는 사람 중심, 회복 중심, 인권 기준을 고수하는 우수한 지역사회기반 정신건강서 비스 사례가 존재한다. • 이런 우수한 지역사회기반 정신 건강 사례들은 기존의 주요 서비스와 비교했을 때 훨씬 금액 이 적게 든다. • 정신질환 및 심리사회적 장애를 앓는 이들을 위해 교육, 고용, 주거와 사회적 혜택을 지원할 수 있도록 사회 분야에 있어 상당한 변화가 필요하다. • 장애인권권리협약(CPRD)이 요구하는 변화를 성취하기 위해서는 통합된, 지역사회 기반 정신 건강서비스가 확대되어야 한다. • 해당 지침서에는 이러한 목표를 달성하기 위한 권고 사항과 행동 단계에 대한 명확한 로드맵 을 제공한다. 도입(들어가며) 전세계적으로 정신건강치료영역에서 차별을 해결하고 인권을 증진해야한다는 필요성이 보고되고 있다. 여 기에는 강제입원이나 강제치료와 같은 강압적 관행 뿐만 아니라, 육체적, 물리적 혹은 화학적 강박 및 격리 1를 없애고 의료업계 종사자와 해당 서비스를 사용하는 사람들 간에 존재하는 힘의 불균형 또한 해결해야 한다. 저소득 국가 뿐만 아니라 중,고소득 국가에서도 폭넓은 해결방안이 필요하다. 장애인권권리협약(CPRD)는 이러한 문제를 인지하고 인권 증진과 개혁을 주되게 요구하고 있으며 지속가 능한목표들(SDGs)에서도 개혁의 필요성을 강조한다. 정신질환 및 심리사회적 질환을 앓는 사람들에게 부 정적 영향을 주는 여러 분야에 걸친 정책, 법안, 체계, 서비스와 관행에 대해 재고해보고 정신 건강 분야에 근본적인 패러다임 변화의 필요성을 강조한다. 2006년에 장애인권권리협약(CPRD)를 도입한 이래로 지역사회 통합, 존엄성, 자율성, 권한강화 (empowerment)과 회복을 증진시키기 위해 다수의 국가들이 그들의 법과 정책을 개혁하기 위해 노력하고 있다. 그러나 현재까지 국제인권체계에서 요구하는 광범위한 변화에 부합하는 정책이나 입법 체계를 이륙 한 국가는 거의 없다. 많은 경우에, 기존의 정책과 법률이 정해둔 시설기반치료, 격리뿐만 아니라 강압적인 – 그리고 유해한 – 치료 관행을 이어가고 있다. 평등, 비차별, 전체적이고 효율적인 사회 참여와 통합, 개인의 존엄성 및 자율성 존중에 대한 근본적인 권 리를 담고 있는 장애인권권리협약에는 인권 원칙에 부합하는 지역사회기반 정신건강 서비스를 제공하기 위해서는 모든 국가에 상당한 변화를 요한다. 정신건강에서 불충분한 사람과 재원이 투입된 상황에서 이러 1 강박과 격리를 끝내는 전략. WHO 퀄리티라이츠 전문 교육. 과정 안내. 제네바: 세계 보건 기구; 2019 (https://apps.who.int/iris/bitstream/handle/10665/329605/9789241516754-eng.pdf) 한 변화는 상당한 어려움일 수 있다. 해당 지침서는 국가가 그들의 정신건강체계와 서비스를 향상시키기 위해 도입하고 고려될 수 있는 다양한 옵션들을 제공한다. 지역사회기반 보건 체계에 입각한 우수한 우수한 사례들을 소개하고 있으며, 혁신적이 고 권리 기반의 정신건강케어서비스를 개선하기 위한 과정도 드러낸다. 여러 제약 조건으로 인해 해당 접 근방식을 실현하는 데 있어 많은 어려움들이 잔제할 것이다. 그럼에도 해당 지침서에는 이러한 제약 조건 들을 이겨내고 잘 운영되고 있는 정신건강서비스의 사례들을 구체적으로 소개한다. 지역 사회 기반 정신 건강 서비스 우수사례들 많은 국가에서 지역사회기반 정신건강서비스는 넓은 분야에 걸쳐 다양한 서비스를 제공한다. 여기에는 위 기지원, 지역사회원조활동(community outreach), 동료지원, 병원기반 서비스, 주거지원서비스와 지역사회 정신건강 센터가 있다. 해당 지침서에 소개되는 예시는 인도의 에트미야타(Atmiyata)에 지역사회 정신건강 원조 서비스부터 미얀마의 지역사회 정신건강서비스인 아웅 클리닉(Aung Clinic) 그리고 짐바브웨에의 프 렌드 벤치(Friendship Bench)가 있다. 이들은 모두 지역사회의 보건 인력과 1차 보건 체계를 활용한다. 다 른 예시로는 노르웨이의 BET 단체로 회복을 중점에 두는 병원기반 서비스이며, 뉴질랜드의 투푸아케(Tupu Ake)같은 위기지원서비스도 소개한다. 여기에 더해, 영국의 키링 주거지원네트워크(KeyRing Living Support Networks)와 같은 설립된 주거지원서비스와 케냐의 정신질환 생존자 모임(the Users and Survivors of Psychiatry groups)과 전세계에 퍼져있는 히어링보이스단체(Hearing Voices Groups)같은 동료 지원 서비스 또한 소개한다. 각각의 서비스는 특징적이지만 가장 중요한 지점은 소개되는 모든 서비스가 정신건강체계와 서비스에 있 어 사람중심, 인권기반, 회복접근에 중점을 둔다는 사실이다. 해당 사례가 완벽하다고는 볼 수 없지만, 다음 의 장애인인권권리협약(CRPD) 기준에 부합하는 옳은 방향으로 구체적인 조취를 취하려는 이들에게 영감 과 희망을 줄 것이다. 각각의 정신건강서비스를 기술하면서 법적 능력과, 비강압적 관행, 지역사회 통합, 참여와 회복 접근에 대 한 존중에 기반하여 핵심 원칙을 소개하고 있다. 중요한 점은, 각각의 서비스는 그 품질과 성과, 비용 효율 성을 지속적으로 평가하기 위한 서비스 평가 방식을 제시한다. 거기다 서비스 비용과 함께 지역별, 국가별 유사 서비스를 비교하고 그 비용 또한 비교하여 소개한다. 다음과 같은 우수한 정신건강서비스 예시들은 새로운 정신건강서비스를 구축하거나 기존의 서비스를 재 구성하려는 이들에게 유용할 것이다. 기술패키지에 있는 세부적인 서비스에 대한 설명은 서비스가 성장해 가면서 마주하게 되는 어려움에 대한 실질적인 통찰과 그에 따른 해결책을 포함하고 있다. 이러한 전략과 접근법은 다른 맥락에서 서비스가 개발될 때, 되풀이되거나, 전환되거나 확장될 수 있다. 해당 지침서는 실 질조치와 권고안을 소개함으로써 우수한 정신건강서비스를 구축하거나 재구성할 수 있도록 한다. 인권을 보호하고 강압적 관행을 피하며 법적 능력을 증진시키면서도 넓은 범위의 법적 틀 내에서 성공적으로 시 행될 수 있도록 한다. 사회 부분에서 대폭적인 변화 필요 보다 넓은 맥락에서, 정신건강에 영향을 미치는 주요 사회적 결정요인들인, 폭력, 차별, 가난, 배제, 소 외, 직업 불안정성 혹은 실업, 그리고 주거, 사회안정망, 건강 서비스의 접근성 부족 등은 정신건강에 대한 담론과 이를 실천하는 데 있어 간과되거나 배제된다. 실제로 정신질환이나 심리사회적 장애를 앓고 있는 이들은 그 장애로 인해 근본적인 인권인 교육, 고용, 주거 그리고 사회적 혜택의 접근이 제 한되어 있으며, 그 결과 상당 수가 빈곤하게 살고 있다. 이러한 이유로, 이러한 주요 삶의 요소들을 다루는 정신건강서비스를 발달시키면서 정신질환이나 심 리사회적 장애를 앓고 있는 사람들도 일반 대중이 이용하는 서비스를 사용할 수 있도록 해야 한다. 얼마나 정신건강서비스가 어떻게 잘 제공되고 있는가와 무관하게 특히 가난에 시달리거나, 주거나 교 육, 돈을 벌 수단이 없는 이들에게 있어서는 서비스 그 자체로는 모든 이들의 필요를 지원하기엔 불 충분하다. 따라서, 정신건강서비스와 사회적 영역 서비스는 전체적인 지원을 제공하기 위해 실질적이 고 의미 있는 방식으로 협력하는 것이 필요하다. 많은 국가에서 이미 정신건강서비스를 다양화하고 더 넓은 지역사회와 통합시키는 큰 진전을 보이고 있다. 이를 위해서는 복지, 보건, 사법, 지방자치단체를 포함한 다양한 서비스와 지역사회 행위자가 문 화, 스포츠 그리고 다른 이니셔티브와 적극적으로 참여하고 협력할 수 있도록 해야한다. 이러한 협력 을 이루기 위해서는 보건 영역 뿐만 아니라 사회 영역에서의 상당한 전략, 정책, 시스템의 변화가 필 요하다. 정신건강서비스 네트워크의 확장 해당 지침서는전반적인 정신건강서비스와 기능을 다루는 총체적인 접근법을 위해서는 사회 영역과 연계해서 정신건강서비스 네트워크를 확장시키는 것이 중요하다는 것을 보여준다. 세계 곳곳에서, 국가와 지역 혹은 도시는 정신건강서비스 네트워크를 개발하여 정신건강과 심리사회 적 질환을 앓고 있는 사람들이 마주하는 어려움들과 상위 사회 결정요인을 다룬다. 여기서 소개하는 몇 개의 예시들은 정신건강시스템을 완전히 재구성하고 재편성함하여 잘확립된 우 수한 네트워크로 평가받고 있다. 그 외에도 상당한 변화를 일궈냈으나 아직 과도기에 있는 예시 또 한 소개한다. 잘 확립된 네트워크는 곧 인권과 회복기반 접근성을 채택하고자 정신건강케어시스템을 재구성하려 는 정치적 노력이 수십년간 지속됐음을 뜻한다. 그들의 성공의 토대에는 새로운 정책과 법을 포용했 을 뿐만 아니라, 지역사회기반 서비스를 위해 자원을 할당했다는 데에 있다. 예를 들어, 브라질의 지 역사회기반 정신건강서비스는 어떻게 국가가 인권과 회복 원칙을 중심에 두고 대규모로 서비스를 시 행할 수 있었는지를 보여준다. 프랑스의 동쪽 릴(East Lille)의 경우 입원 치료에서 다양화된, 지역사회 기반의 참여로의 전환이 기존의 정신건강서비스만큼의 투자로 성취가 가능함을 보여준다. 끝으로, 이 탈리아의 지역사회 정신건강서비스인 트리에스테(the Trieste)는 인권기반 치료와 지원을 바탕으로 하고 있으며, 탈시설화(deinstitutionalise)를 강력하게 주장하였다. 이러한 네트워크는 사회, 보건, 고 용, 사법 등 다양한 영역에서의 지역 행위자와 통합되고 연결되어 있는 지역사회기반 정신건강서비스 의 개발을 반영한다. 최근에는, 보스니아, 헤르체고비나, 레바논, 페루 등 다양한 국가에서 신생 네트워크를 빠르게 확장하 고 있다. 또, 지역사회기반, 권리기반, 회복 중심의 서비스와 지원을 제공하고자 공동의 노력을 기울이 고 있다. 이러한 신생 네트워크의 핵심은 정신건강서비스를 정신병원에서 꺼내와 지역 사회로 옮겨오 는 것이다. 따라서 정신건강질환이나 심리사회적 장애를 앓고 있는 개인이 지역사회에 소속되고 온전 히 참여할 수 있도록 보장한다. 물론 많은 시간과 지속적인 노력이 필요하지만, 주요 변화들은 이미 눈에 보이기 시작했다. 이러한 네트워크는 정치적 의지, 결단 그리고 정신건강에서 행동의 근간이 되 는 강력한 인권 관점으로 우리가 무엇을 성취할 수 있는지에 대한 고무적인 예시를 제공한다. 주요 권고사항 전세계 소득에 상관없이 어느 국가든 인권을 보호하고 증진하는 우수한, 사람과 회복 중심의 정신 건 강 서비스의 필요성을 점차 깨닫고 있다. 정부와 보건, 사회 치료 전문가들, 비정부 기구(NGOs), 장애 인단체(OPDs), 다른 시민 사회 활동가와 이해관계자들은 모든 사람들의 건강과 웰빙을 증진시키기 위해 상당한 발전을 이룰 수 있다. 그들은 인권을 보호하고 증진시키면서 동시에 정신건가에 대한 우 수한 서비스와 지원을 도입하고 확대시킴으로써 이를 성취할 수 있다. 해당 지침서는 국가와 조직에게 주요 권고사항을 제공한다. 여기에는 정신건강 정책과 전략, 법 개정, 서비스 제공, 재정, 인력 개발, 심리사회적·심리학적 개입, 향정신약, 정보 체계, 시민 사회와 지역 사회 참여 그리고 연구에 필요한 세부적인 조치와 변화의 필요성을 담고 있다. 국가는 법적 프레임워크를 장애인권권리협약(CPRD)의 필수조건에 맞추기 위해 상당한 노력을 기울 어야 한다. 변화는 정책, 전략, 시스템에서도 나타나야 한다. 보건과 사회 부문과의 강한 협력과 공동 정책을 통해 정신건강의 주요결정요인을 더 잘 다룰 수 있을 것이다. 많은 국가들은 이미 재정, 정책, 법률을 변화시킴으로써 정신건강체계를 개혁하였다. 이러한 개혁을 이루는 과정에 인권과 회복 접근 을 최우선에 두면 정부와 지역사회는 상당한 사회, 경제, 정치적 측면에서 혜택을 가져다 준다. 정신 건강에서 사람중심, 회복중심, 인권기반의 접근이 성공적으로 통함되기 위해서는, 국가는 기존 의 사고방식을 바꾸고 넓혀야 하며, 낙인 찍는 태도를 고치고 강압적인 관행을 철폐해야 한다. 정신건 강체계와 서비스는 기존의 생의학 모델에서 벗어나 개의 삶의 모든 측면을 아우르는 총체적인 접근 을 하도록 초점을 전환하는 것이 필요하다. 하지만 대부분의 경우 현재 향정신약을 치료의 중심에 두 고 있다. 그러나 심리사회적·심리학적 개입 그리고 동료 지원은 사람중심, 회복과 인권기반 접근에 있 어 제공되어야 한다. 이를 위해서는 보건과 사회서비스를 제공하는 전문가들의 지식, 역량, 기술에 대 한 상당한 변화가 수반된다. 더 넓게는 다양성이 허용되고 모든 사람의 인권이 존중받고 증진될 수 있는 포용적인 사회와 지역사 회를 만들기 위해서는 노력이 필요하다. 부정적인 태도와 차별적인 관행을 변화시키는 것은 건강과 사회 치료 시설에서 뿐만이라 사회 전반에 있어서도 필수적이다. 재활 경험자(people with lived experience)의 인권에 관심을 갖는 캠페인이 이런 관점에서 중요하며, 시민 단체는 이를 옹호하는 핵 심적인 역할을 수행할 수 있다. 더 나아가, 최근 몇십년 동안 정신건강 연구는 생의학적 패러다임이 주류였기 때문에 인권기반 접근 방식을 검토하는 연구가 부족한 실정이다. 전 세계적으로 인권기반 접근 방식을 검토하고, 서비스 비 용을 비교 분석하고, 생의학 기반 접근 방식의 회복 성과와 비교하는 연구에 더 많은 투자가 이루어 져야 한다. 이처럼 연구 우선순위의 변화는 정신건강과 사회보호체계와 서비스에 인권기반의 접근을 더욱 공고히 만들어 줄 것이다. 끝으로, 정신건강 질환이나 심리사회적 장애를 앓고 있는 이들이 활발하게 참여하지 않는다면 인권증 진과 회복기반이라는 목표를 달성하기 어려울 수 있다. 재활 경험자들은 그들의 권리 존중뿐만 아니 라 그들이 실제 필요에 부합하는 서비스와 기회 개발에 필수적인 파트너이자 전문가이다. 인권을 존중하고 회복 기반 접근 방식을 채택한 지역사회 기반 정신건강서비스의 지속적인 개발을 약속하는 국가들은 정신건강질환자나 심리사회적 장애를 앓고 있는 이들의 삶을 증진시킬 뿐만 아니 라, 그들의 가족, 지역사회, 사회 전반을 향상시킬 것이다. WHO QualityRights 이니셔티브는 무엇일까? WHO QualityRights는 정신건강과 사회 서비스 분야에 치료와 지원의 질을 향상시키고 전세계적으로 사회심리적, 지적, 인지적 장애를 앓는 사람들의 인권을 증진시킨다는 목표를 가지고 있다. QualityRights는 다음과 같은 목표를 성취하기 위해 참여 접근법을 사용한다. 1) 낙인과 차별과 싸우고 인권과 회복을 증진하기 위한 역량 쌓기 • WHO QualityRights 대면 학습 모듈 • 정신건강과 장애에 대한 WHO QualityRights 온라인 교육: 낙인 제거 및 인권 증진 2) 정신건강과 사회 서비스에서의 돌봄의 질과 인권 조건 개선 • WHO QualityRights 평가 도구(toolkit) • 서비스 전환과 인권 증진에 대한 WHO QualityRights 모듈 3) 인권을 존중하고 증진시키는 지역사회기반 회복지향 서비스 구축 • 지역사회 정신건강 서비스에 대한 WHO 지침서와 기술 패키지: 사람중심, 권리기반 접근 방식 • WHO QualityRights 재활 경험자를 위한, 재활 경험자의 의한 1대 1 동료 지원 모듈 • WHO QualityRights 재활 경험자를 위한, 재활 경험자의 의한 단체 동료 지원 모듈 • WHO QualityRights 정신건강과 안녕을 위한 사람 중심 회복 플랜과 자립 도구 4) 정책 결정에 영향을 미치고 옹호하는 시민 사회 움직임의 발전을 지원 • WHO QualityRights 정신건강장애와 인권 옹호를 위한 지침 모듈 • WHO QualityRights 정신건강과 관련 분야에서 인권 증진을 위한 시민 사회 조직 지침 모 듈 5) 장애인권리협약(the Convention on the Rights of Persons with Disabilities; CRPD)과 그외 다 른 국제 인권 기준을 준수하는 국가 정책과 법률 개혁 • 현재 WHO 지침 개발 중 더 많은 정보가 필요하다면 WHO QualityRights 웹사이트 접속 요망 지역사회 정신건강 서비스에 대한 WHO 지침서와 기술 패키지에 대하여 해당 문서는 정신건강 시스템과 서비스를 개발하고 바꾸고자 하는 모든 이해관계자들을 위해 정보와 지침을 제공하기 위함이다. 지침서는 국제 인권 기준을 준수하고 사람 중심, 회복 접근방식을 증진시 키는 우수한 치료 서비스를 위한 깊이 있는 정보를 제공한다. 해당 접근은 강압적인 방식 없이 사람 들의 필요에 응하고, 회복을 지원하며 자율성과 통합을 증진시킨다. 또한, 서비스 개발, 전달, 모니터 링에 재활 경험자가 참여할 수 있도록 한다. 전세계 국가에서 많은 서비스가 이미 회복과 인권 원칙을 중심으로 운영되고 있지만 정책 입안가, 보 건 전문가, 해당 서비스 사용자와 다른 이들을 포함한 다수의 이해관계자들은 이를 의식하지 못하고 있다. 해당 문서에서 소개되는 서비스는 WHO의 지원을 받은 것은 아니지만 전세계 다양한 환경에서 성공 적인 성과를 거둔 구체적인 사례를 제공하기 위해 선정되었다. 해당 사례들은 회복과 인권 안건 내에 서 운영될 뿐만 아니라, 평가되고 시행될 수 있는 넓은 범위의 서비스를 보여주고 있기에 선정되었다. 이처럼 혁신적인 서비스를 실제로 제공했을 때 효과적이라는 것을 보여줌으로써 정책입안가와 주요 행위자가 새로운 서비스를 개발하거나 인권 기준에 부합하도록 기존의 서비스를 변화시켜 보편적 의 료 보장 (Universal Health Coverage; UHC)에 포함시킬 수 있다. 해당 지침서는 각각의 정신건강서비스가 그 자체로 좋은 결과를 냈을 지라도 정신질환이나 심리사회 적 장애를 앓는 많은 이들의 필요 지원을 충족시키기에 불충분하다는 사실을 강조하고자 한다. 이를 위해 위기 지원, 지속적인 치료와 돌봄, 지역사회 생활과 통합 등 사람들이 가질 수 있는 다양한 필요 에 응하기 위해 여러 유형의 지역사회 기반 정신건강 서비스가 함께 제공되어야 한다. 더 나아가, 정신건강서비스는 사회보장, 주거, 고용 그리고 교육 등 다른 부문과 공유함으로써 지원하 는 사람들이 지역사회에 완전히 통합되어 살아갈 권리를 누리도록 해야한다. WHO 지침서와 기술 패키지는 다음과 같은 내용을 담고 있다: • 지역사회 정신건강 서비스 지침서: 사람중심, 인권기반 접근방식 증진 – 해당 지침서는 사람 중심, 회복과 인권기반 접근방식에 대해 상세히 기술하고 있다. 인권과 회복을 증진시키는 전 세계의 우수한 사례들의 요약 사례를 제공하고 주거, 교육, 고용과 사회보장 등을 고려한 통 합적 서비스를 제공하기 위해 필요한 단계를 설명한다. 또한, 서비스와 지원을 포괄하고 통합 하는 네트워크의 예시도 담고 있다. 거기다 보편적 의료보장(UHC)과 인권을 증진시키기 위해 국가의 보건과 사회적 돌봄 체계 내에서 우수한 정신 건강 서비스를 소개하여 통합하고 확대 해 나갈 수 있는 지침을 제공한다. • 지역사회 정신 건강 서비스에 대한 일곱 가지 지원 기술 패키지: 사람중심과 인권기반 접근법 증진 – 각각의 기술 패키지는 특정한 정신건강 서비스 카테고리에 집중하고 전체적인 지침서 와 연결되어 있다. 다양한 서비스의 종류에는 다음과 같은 내용이 포함된다: 정신건강 위기 서비스, 병원기반 정신건강 서비스, 지역사회 정신건강센터, 정신건강서비스에서의 동료 지 원, 지역사회 원조 서비스, 주거 서비스 지원, 정신건강서비스 네트워크. 각각의 패키지에는 우수한 서비스 사례에 해당하는 구체적인 예시를 담고 있으며 여기에는 통합적인 서비스에 대한 깊이 있는 이해와 어떻게 운용되고 어떻게 인권 기준에 부합하는지를 설명한다. 다른 상 황에서 적용할 때 주요 고려사항과 서비스를 운영할 때 맞닦뜨릴 수 있는 어려움과 그 해결 방안에 대해서도 상세히 설명했다. 끝으로, 각 기술 패키지 마지막 부분에 모든 정보와 소개 된 서비스에서 배운 점들을 실질적인 지침과 실행 단계 형식으로 정리해 추상적인 개념에서 우수한 실천 서비스로 구현해 나갈 수 있도록 했다. 구체적으로, 각각의 기술 패지지는 다음과 같은 내용을 담고 있다: • 국제 인권 기준과 회복 원칙에 부합하는 서비스와 지원을 제공하는 여러 국가로부터 다 양한 정신건강 서비스를 구체적으로 소개한다. • 우수 서비스 사례들에서 법적 능력, 비강압적 실천, 지역사회통합, 참여, 회복접근방식 등 이 국제인권기준에 맞춰 어떻게 운영되는지를 구체적으로 서술한다. • 우수한 정신건강 서비스를 활용했을 때 성취할 수 있는 긍정적인 결과물들을 서술한다. • 기존 유사 서비스와 우수 정신건강 서비스 사례에서 소요되는 예산을 비교해서 보여준 다. • 서비스 확립과 운영 과정에서 마주할 수 있는 어려움과 이를 해결하기 위한 해결책을 논 의한다. • 지역의 사회적, 경제적 맥락 내에서 사람중심, 인권과 회복을 지향하는 우수서비스를 개 발하기 위한 여러 시행 단계를 제시한다. 대부분의 서비스가 하나 또는 이상의 유형에 걸쳐 기능을 수행하다보니 하나의 유형으로 완벽하게 구분되지 않는 점은 알아두길 바란다. 이는 각 서비스 설명하는 초반부의 유형 구분에 반영되어 있다. 해당 지침서는 정신 질환이나 심리사회적 장애를 앓는 성인을 위한 서비스에 특히 주목한다. 따라서, 인지장애나 신체장애, 신경학적 질환 및 약물 남용과 섭식장애 치료와 같은 고도로 전문화된 서비스 는 포함하지 않고 있다. 이밖에도 온라인 개입, 전화 서비스(예. 핫 라인), 예방, 증진과 조기 개입 프로 그램, 특정 도구 활용 서비스(예. 조기 계획), 교육과 옹호에 대해서도 다루지 않는다. 또한, 비전문적 인 보건 환경에서 제공되는 서비스에 대해 따로 서술하고 있진 않지만, 여기서 다루는 내용이나 정보 는 비전문적인 환경에서도 적용될 수 있다. 해당 지침서를 어떻게 활용할 수 있을까. 지역사회 정신 건강 서비스를 위한 지침서: 인간중심, 권리기반 접근방식을 증진을 위해 관련된 이해 관계자들이 참고할 수 있는 주요 문서이다. 정신건강 서비스 중 특정 유형에 관심이 있는 독자는 해 당하는 기술 패키지를 참고할 수 있다. 해당 패키지에는 지역에서 새로운 서비스를 적용하기 위한 더 자세하고 구체적인 지침을 제공하고 있다. 다만, 각각의 기술 패키지는 지역사회 정신 건강 서비스를 위한 지침서와 함께 읽혀야 하며, 보건과 사회부문을 통합하는 데 필요한 세부 사항까지 다룰 수 있 어야 한다. 해당 문서는 다음과 같은 독자를 위해 제작되었다: • 관련 부처(보건과 사회 보장)와 정책 입안자 • 일반 건강, 정신건강과 사회 서비스 관리자 • 정신건강과 기타 건강 분야 지역사회 실무진 (예. 의사, 간호사, 정신과 의사, 심리학자, 동료 지원가, 작업 치료사, 사회 복지사, 지역 사회 지원가, 개인 보조, 전통신앙에 기반한 치료사) • 정신건강 질환이나 심리사회적 장애를 가진 사람 • 정신건강과 사회 서비스를 ㅇㅇ이용했었거나 이용하는 사람 • NGO 및 정신건강, 인권 혹은 다른 연관 분야 종사자 (예. 장애인 조직, 정신의학 당사자 조직, 옹호 조직, 전통신앙에 기반한 치료사 협회) • 가족, 지원가, 기타 돌봄 파트너 • 기타 관련 조직과 이해 관계자 (예. 옹호자, 변호사, 법률 구조 기관, 학계, 대학생, 지역사회와 영적 지도자) 용어 주의사항 해당 지침서와 기술 패키지 전반에서 “정신질환이나 심리사회적 장애가 있는 사람(persons with mental health conditions and psychosocial disabilities)”, “정신건강 서비스를 이용하는 사람(persons using mental health services)”, “서비스 사용자(service users)” 라는 용어를 사용한다. 우리는 장애라는 개념이 진화하면서 언어와 용어에 반영되고 시간이 지나면서 다른 맥락에서 다른 사람들에 의해 다른 용어가 사용될 거라는 것을 알고 있다. 사람은 그들의 경험, 상황, 혹은 고통에 따 라 이를 설명할 수 있는 어휘, 관용구, 설명을 결정할 수 있어야 한다. 예를들어 정신건강 분야에서는 사람들은 다음과 같은 용어를 사용한다: “정신과 진단을 받은 사람(people with a psychiatric diagnosis)”, “정신장애가 있는 사람(people with mental disorders)” 혹은 “정신 질환자(mental illnesses)”, “정신질환이 있는 사람(people with mental health conditions)”, “소비자(consumers)”, “서 비스 이용자(service users)”, “정신질환 생존자(psychiatric survivors)”. 다른 이들은 이러한 용어의 일 부나 전부에 낙인이 내포되어 있다고 생각하고 그들의 감정, 경험 혹은 고통을 나타내기 위해 다른 용어를 사용한다. “심리사회적 장애(psychosocial disability)”라는 용어는 정신건강 관련 진단을 받았거나 스스로를 해 당 용어로 지칭하는 사람을 모두 포함하여 사용되어왔다. “장애(disability)”라는 용어는 이 맥락에서 중요하다. 왜냐하면 실제로 혹은 인지된 장애를 가진 사람들의 전체적이고 효율적인 사회 참여를 저 해시키는 큰 장벽이 있다는 점과 CRPD에 의해 보호받을 수 있다는 사실을 강조하기 때문이다. “정신건강 질환(mental health condition)”이라는 용어는 신체건강 질환이라는 용어와 비슷하게 사용 된다. 정신건강 질환이 있는 사람은 공식적인 진단을 받았을 수도 받지 않았을 수도 있지만 그럼에도 정신 건강 문제나 어려움을 겪고 있거나 겪었던 이를 지칭한다. 해당 용어가 지침서에 사용된 이유는 “심리사회적 장애”라는 용어가 익숙하지 않은 건강, 정신건강, 사회 돌봄 및 정신건강 서비스 종사자 가지침서에 서술된 가치, 권리와 원칙을 이해하고 그들이 마주하고 돕는 이들에게 적용하도록 하기 위함이다. 상위 용어들로 스스로를 지칭하는 모든 사람들이 낙인, 차별 혹은 인권 침해를 마주하진 않는다. 정신 건강 서비스 이용자는 정신건강 질환이 없을 수도 있고 정신 질환을 앓는 어떤 사람은 사회에 전반적 으로 참여하는 데 있어 어떠한 제한이나 장벽을 마주하지 않을 지도 모른다. 해당 지침서에서 사용되는 용어들은 포괄성을 위해 선정되었다. 특정 표현이나 개념으로 스스로를 지 칭하는 건 개인의 선택이지만 인권은 여전히 모두에게, 그리고 모든 곳에서 적용된다. 특히, 진단 결 과나 장애가 누군가를 절대 정의해서는 안된다. 우리는 모두 특정한 사회 환경에서, 성격, 자율성, 꿈, 목표와 영감 그리고 다른 이들과의 관계를 가지고 살아가는 개인이기 때문이다. 1. 도입 전세계 여러 곳에서 개별 국가, 지역 또는 도시는 사회적 결정 요인과 정신건강과 심리사회적 질환을 가진 사람들이 사람의 삶의 모든 측면에서 매일같이 직면하는 여러 가지 문제를 해결하는 서비스 네 트워크 개발해왔다. 결정적으로, 해당 네트워크는 더 멀리 나아가고 서비스와 도움을 요청하기 위해 찾아오는 사람들 간의 관계를 재고하고 바꾸기 위해 노력하고 있다. 어떤 경우에는, 이러한 서비스 네 트워크는 인권 안건에 상당한 영감을 받았고 회복 중심 서비스를 설립하기 위해 노력해왔다. 정신건 강 서비스의 다영화를 위해 노력해 온 한편, 그들은 핵심 사회적 결정 요인을 해결하고 주거, 교육과 고용과 같은 부문과 적극적으로 협력하는 것의 중요성을 깨달았다. 또한 그들의 전문 지식과 요구 사 항이 제공되는 서비스에 필수적임을 보장하기 위해 정신건강 문제를 경험한 사람들과 진정한 협력관 계를 구축할 수 있는 환경을 조성하고자 노력하고 있다. 해당 부분에는 정신건강 네트워크에 대한 여 러 예시를 제공하고 있다; 일부는 정신건강 시스템을 크게 재구성하고 재구조화한 잘 구축되고, 구조 화된, 그리고 평가된 네트워크 예시에 대해 말하면서도 일부는 중요한 이정표에 도달한, 전환 중에 있 는 네트워크 예시에 대해 서술한다. 이 네트워크를 보여준다고 해서 언제나 모든 네트워크 서비스가 인권 기준에 부합함을 의미하는 건 아니다. 이는 전세계 어디에서도 해당되지 않는다. 하지만 해당 네트워크는 정치적 공약, 결정 그리고 정신건강에서의 행동을 뒷받침하는 강력한 인권적 시작에서 성취될 수 있는 부분들에 대한 고무적인 예시들을 제공한다. 해당 예시들은 정책 입안자, 설계자, 서비스 제공자들이 정신건강 질환과 심리사 회적 장애를 가진 사람이 이용하고 싶고 도움이 된다고 여겨지며, 좋은 결과를 만들어내고 인권을 보 호하고 증진시킬 수 있는 특별한 서비스 시스템을 만들어낼 수 있음을 보여주는 살아있는 증거이다. 해당 기술 패키지에 기술된 서비스 네트워크는 세계보건기구(WHO)에 알려진 좋은 사례를 바탕으로 선택되었다. 선정 과정은 다섯 개의 인권과 회복 기준을 바탕으로 이루어졌으며 이는 법적 능력 존중, 강압적 관행(coercive practice)의 종식, 참여, 지역사회 포용, 그리고 회복 접근방식이다. 해당 기술 패 키지에서 서술하는 서비스는 최고의 사례라고 해석되기 보다는 무엇을 할 수 있고 사람 중심, 인권 기반, 회복 접근을 증진시키는 지역사회 기반 정신 건강 서비스의 넓은 잠재력을 보여주기 위함이다. 인권 원칙을 고수하는 지역사회 기반 정신건강 서비스를 제공하는 것은 모든 국가의 관행에서 상당 한 변화를 보여주고 불충분한 인적 자원과 재정적 자원의 투자가 정신건강 분아에 이루어지는 상황 에서 아주 높은 기준을 부여한다. 일부 저소득 국가는 고소득 국가에서의 사례가 적절치 않거나 유용 하지 않다고 여길 수 있고 이는 고소득 국가에서 저소득 국가의 사례를 볼 때도 동일하게 나타난다. 새로운 유형의 서비스나 관행 또한 정책 입안자, 전문가,가족, 간병인, 그리고 정신 건강 서비스를 사 용하는 개인으로부터 다양한 질문, 어려움과 우려를 낳을 수도 있다. 이 지침서의 목적은 해당 서비스 를 전체로 복제할 것을 제안하기 보다는 사람 중심의, 인권과 회복을 증진시키는 지역사회 기반 정신 건강 서비스를 제공함에 있어 관련성이 있고 자신의 맥락에 맞게 바꿔 적용할 수 있는 원칙과 관행을 취하고 배우기 위함이다. 2. 통합 정신건강 서비스 네트워크 - 설명과 분석 2.1 동쪽 릴(East Lille) 지역 사회 정신 건강 서비스 네트워크 프랑스 맥락 잡기 프랑스는 구역화된 정신건강 시스템을 운영하고 있으며 이는 약 70,000명의 사람들이 거주하는 지역 내에 서 성인 정신 건강 서비스를 제공하는 대략 850개의 구역으로 되어 있다. 동쪽 릴 구역은 프랑스 위쪽 구역 (the Hauts-de-France region)에 위치해 있으며 88,000명의 거주민과 6개의 교외 마을이 있는 지역에서 성 인들에게만 서비스를 제공하고 있다. 해당 지역은 국가 평균(11.1%)과 비교했을 때 상대적으로 높은 실업률 (15.6%)로 어려워하고 있으며, 프랑스 내에서 가장 짧은 기대 수명을 가지고 있다. 이 지역은 또한 “자원이 부족한” 건강 시스템을 가지고 있는 것으로도 알려져 있다 (1). 릴의 서쪽에서 25km 떨어져 있는 아르망티 에르(Armentières)에 위치한 릴 국립 정신건강 기관(The Établissement Public de Santé Mentale (EPSM) Lille-Métropole)에서는 일상적으로 서비스를 관리하고 9개의 구역을 추가로 담당하며, 이 모든 구역에 아 동과 청소년에게 서비스를 제공한다. 1970년대부터, 동쪽 릴의 정신건강 서비스는 일련의 대대적인 개혁을 진행시키고 정신건강 서비스를 사용 하는 사람들의 인권과 권한 부여를 중심으로 시민 정신의학(psychiatrie citoyenne)이란 개념을 촉진시켰다. 해당 개혁의 첫 번째 주요 단계는 1970-1995년에 이루어졌는데, 기관에서 지역 사회로 자원이 넓은 범위로 변화하였다. 1970년대에는 아르망티에르에 있는 정신병동(asylum)을 기반으로, 서비스는 여섯 개의 입원 환 자 단위로 구성되어 있었다. 300명이 넘는 장기간 입원 환자들을 관리하였고 98%의 예산은 그들의 입원을 위해 쓰였다. 1977년 의학-정신-사회 협회(Association Médico-Psycho-Sociale (AMPS))란 감독기관이 만들 어졌고 비제도화를 가능하게 했다. 해당 감독기관은 정신건강 서비스 관리, 전문가, 동쪽 릴의 여섯 개 마을 에서 온 선출된 공직자들, 그리고 해당 구역에 서비스를 발전시키는 데 관심이 있는 기타 단체들을 한 데 모 았다. 처음부터 개혁은 정신병동의 이용을 줄이는 것 뿐만 아니라, 교육적 사업과 통합 정책을 통해 더 넓은 지역 사회의 포용이 필요함을 알고 있었다. 개혁의 다음 단계는(1980-2010) 동쪽 릴 구역에 있는 건강, 사회, 그 리고 문화적 서비스에 정신건강을 통합과 함께 지역사회 기반 정신건강 서비스를 발전을 포함했다. 또한, 정신건강 서비스 결정에 있어서 정신건강문제를 경험한 사람들(people with lived experience), 가족구성원, 전문가 집단 그리고 선출된 공직자를 대거 개입시키기 위한 움직임도 있었다. 그 다음 단계는 2005년부터 2014년에 이루어졌으며, 대규모 집중 이동 치료 팀이 개발되는 걸 목격했다. 2011년부터는 정신건강 분야에 있는 모든 이해 당사자(특히 정신건강문제를 경험한 사람들)가 한 데 모여 대화와 상담의 정신으로 하는 정책을 개발하고 시행하는 보건 민주주의의 조건을 형성하는 움직임으로 나 아갔다. 마침내, 2014년부터는 회복 철학을 정신건강 센터로 가지고 오는 것이 일차 과제가 되었다. 2006년부터, 이러한 성취들을 지속시키기 위해 주요한 개발이 있었다. 프랑스 내에서의 변화에 발맞추어 (2) 2010에는 AMPS를 지역 정신건강 의회(Local Mental Health Council)로 대체하였다(1). 동쪽 릴에서는 지방 의회를 지방자치단체간 보건협회(Intermunicipal Association of Health), 정신건강과 시민권(Mental Health and Citizenship (AISSMC)), 라고 불리며 해당 포럼은 여섯 개의 지방 자치 단체로부터 온 모든 이해 당사자 들이 만나고, 의견을 나누고, 계획을 수립할 수 있다. 지방 자치 단체의 시장들이 의장을 맡으며, 동쪽 릴의 정신건강 서비스에 의해 공동 주도된다. 선출된 공직자, 관리자 및 전문가뿐만 아니라 정신건강문제를 경험 한 사람들, 가족 및 보호자, 주민, 보건 및 사회 서비스 종사자, 일반의, 사회 지주, 지역사회 센터에서 온 사 람들과 법무부 관계자들이 포함된다. 총회는 매해 열린다. AISSMC의 활동은 네 가지의 주요 주제에 따라 구성됩니다: • 예방 – 정신건강 문제들에 대한 회의, 신체 활동 홍보, 암 검진, 그리고 복잡한 상황의 조정; • 문화 행동 – 정신건강 질환이 있거나 없는 사람들의 예술 작품을 혼합하여 현대 예술의 기금을 활 용하여 문화적, 그리고 반낙인적(anti-stigma) 행동을 홍보; • 주거 문제 – 지방 자치 단체의 정신건강 질환자를 위한 주거 할당, 유지 및 계획; • 지역보건계약 – 주요하게 지역적으로 정의된 문제를 따라 영내 정신건강 행동을 정의하고 조정를 목표로 하는 국가 시스템으로, 교섭에 있어 선출된 공직자의 활발한 참여로부터 이익을 얻음 서비스에 대한 설명 동쪽 릴 구역에 의해 제공되는 정신건강 치료의 네트워크는 40년 이상의 재정비와 개혁을 통해 구축되었다. 구역의 책임자와 팀의 노력은 입원 치료에서 프랑스의 다른 정신건강 분야와 유사한 예산과 역학적 관심 (epidemiological profile)으로도 정신건강 문제 와/혹은 심리사회적, 지능적, 인지적 장애를 가진 사람들을 위해 다양화된, 지역사회 기반의 참여로의 전환이 가능함을 보여준다. 개혁은 지방 자치 단체, 기타 이해 당 사자, 정신건강문제를 경험한 사람들, 그리고 그들의 보호자의 참여 덕분에 가능하였다. 지역 정신건강 의 회(AISSMC)는 동쪽 릴에서의 정신건강에 대한 권리와 정보를 증진시키는 행동을 기반으로 한다. 해당 의회 는 프랑스 전역에 230개 정도 설립되어 운영되고 있다. “시민 정신의학”의 개념은 동쪽 릴의 정신건강 네트워크 전반을 담고 있으며 다섯 개의 기둥을 기반으로 한 다 (3): 1. 인권은 양도할 수 없는 권리이고 정신건강 질환의 발현은 누군가가 이러한 권리에 접근하고 존중 받도록 보장하는 것을 방해하거나 막을 수 없다; 사법과 정신의학, 감옥과 병원, 은둔과 치료는 절 대 혼용되어서는 안된다. 2. 사회, 그리고 따라서 정신건강 서비스는, 사람들의 필요에 맞게 맞춰야하고 그 반대가 되어서는 안 된다. 3. 주민을 그들의 지역 사회에서 사실상 배제시키는 의료, 사회 기관은 문을 닫아야할 필요가 있다. 4. 정신건강 질환에 대한 낙인과 차별에 저항해야할 필요가 있다. 여기에는 위험성과 역량 부족에 대 한 고정관념에 도전하는 것을 포함한다. 해당 가치들을 기반으로, 동쪽 릴의 서비스는 서비스를 이용하는 사람과 그들의 가족, NGO, 지방 자치 단체 에서 선출된 공직자, 그리고 정신건강 분야와 관련된 이들을 포함한 기타 이해 당사자들과 협력관계를 맺고 있다. 이러한 이해 당사자들과 협력하여 동쪽 릴의 정신건강 시스템의 다양한 요소들은 일관된 네트워크를 형성하기 위해 상호 연관되어 있다. 정신 건강 서비스 네트워크 요소 지역 의학-심리 센터 (Services Médico-Psychologiques de Proximité (SMPP)) SMPP는 정신건강 시스템을 가진 사람들의 첫 번째 접점을 나타내고 통합적인 돌봄과 지원을 제공한다. SMPP는 12개의 다른 보건 관련 기관과 통합되어 있는 EPSM의 두 개의 전용 통원 치료 서비스(ambulatory services)에 기반하고 있다. 일반의(GP)에 의해 환자는 SMPP로 보내지고 그곳의 다양한 전문가들, 간호사, 정신과 의사, 심리학자, 심리운동치료사2, 사회복지사, 동료지원사, 적응형 스포츠 코치 등과 상담할 수 있다. SMPP에 도착하자마자 간호사는 환자 후송 48시간 이내로 환자의 심리적, 신체적 필요를 초기 평가를 진행 한다. 해당 평가 자료는 이후 다학제팀(multi-disciplinary team)을 통해 주 2회 회의를 통해 논의되며 이후 치료와 계획에 대해 여러 제안을 내놓는다. 해당 치료를 위한 제안은 치료의 지속성과 효과적인 파트너십을 확실시하기 위해 일반의에게 보내진다. 대기 명단은 없으며 센터에 근무하는 모든 전문가들은 외진(home consultations)을 위한 시간이 할당되어 있다. SMPP 팀에 의해 이루어지는 진찰은 지역사회 내 다양한 장소 에서 이루어질 수 있으며 매우 접근성이 용이하다. 여기에는 수영장과 16-25세 사이의 청년을 위한 사회적 지원 센터를 포함하고 있으며, 이들은 일반의에 의해 보내어지지 않고도 바로 서비스에 접근할 수 있다. 이동 팀 (Soins intensifs intégrés dans la cité (SIIC)) 위기와 가정 치료 이동 팀은 프랑스에서 치료하는 환자의 숫자에서 가장 큰 규모이다. 한번에 15명의 사람 에게까지 위기 대응와 집중 치료를 제공한다. 다학제팀으로 이루어지며, 여기에는 보건 책임자, 주야간 간 호사, 심리학자, 특별 교육자, 정신과 의사, 심리 운동 치료사 및 동료 건강 중재인이 포함되며, 주7일 24시 간 이용이 가능하다. 사람이 치료를 받는 평균적인 시간은 12일이고 대부분의 개입은 며칠 동안이지만 일 부는 몇 주 동안 지속된다. 2018년에는 입원 없이, 253명의 사람들이 집에서 치료를 받았으며 640명의 위 기 개입 또한 집에서 이루어졌다. 치료받는 사람에 대한 상시 근로자의 비율은 0.96으로, 거의 1인당 한 명 의 전문가가 대응되는 수준이다 (4). 해당 서비스의 모든 직원들은 회복 접근과 강압(coercion)없이 위기 상 황 처리, 서비스 사용자의 인권에 대해 민감하게 반응한다. 제롬 보쉬 클리닉 종합병원 (Jérôme Bosch Clinic General Hospital) 전체 네트워크가 입원을 방지하도록 설계되어 있긴 하지만 필요하다면 릴 대학 병원 옆에 위치한 10개의 베드를 보유한 제롬 보쉬 클리닉에서 입원이 가능하다. 해당 다학제 팀은 건강 임원, 주야간 간호사, 사회문 화 애니메이터, 심리학자 및 유지와 위생을 담당하는 자격 있는 병원 서비스 담당자(Qualified Hospital Services Officers)로 구성된다. 입원, 특히 강제 입원을 피하기 위한 절차가 마련되어 있다. 2018년에는 총 222명의 환자에 대한 341번의 입원이 있었다 (1회 이상 입원 진료를 받은 사람들이 있었음). 언제든지 평균 7명의 사람이 클리닉에 입원해 있고, 입원 기간은 평균 7일정도이다 ([Medical information service], [EPSM Lille Métropole], personal communication, [2020]). 2 심리운동 치료는 신체 익식과 신체 활동을 접근의 초석으로 삼는 접근방식이다. 프랑스를 포함한 여러 유럽 국가에서 널리 사용된다. 어떤 사람이 클리닉에 들어오면, 그들의 권리와 의무에 대한 정보가 구두와 서면 형식으로 제공되며, 그들 이 신뢰하는 사람을 지원자(supporter)로 지정할 수 있다. 진료실의 조직과 구조는 사람들이 자신의 사생활 에 대한 권리를 유지할 수 있도록 보장하기 위해 마련되었다. 모든 병실은 1인실이고 개인은 그들의 방에 대한 열쇠와 개인 소지품을 보관할 수 있는 금고를 가지고 있다. 병원에 입원한 사람들은 그들이 원할 때마 다 자유롭게 병실을 출입할 수 있다. 클리닉은 서비스 이용자의 긴밀한 지원 네트워크에 의존하여 협상, 안전, 갈등 회피를 돕는다. 개방된 면회 실이 있고 병실 2개에에는 클리닉에서 하룻밤을 지낼 수 있는 지원자들을 위한 세컨드베드가 있다. 해당 클리닉에 근무하가는 보건 전문가의 접근성에 강조점을 둔다: 병상 대비 상시 근무자는 3.1대 1로, 낮 에는 최소 3명, 밤에는 최소 2명의 간호사가 근무한다. 활동실에는 애니메이션과 예술 활동을 제공하는 간 호 조무사와 근무자가 있다. 일요일에는 예술가나 스포츠 코치와 같은 외부 강사를 초대한다. 서비스를 사 용하는 사람이 직면할 수 있는 사회적 혹은 행정적 문제를 처리하기 위해 특별 필요 근무자 (éducateurs spécialisés)가 매일 근무한다. EPSM에 의해 고용된 동료 지원 근로자들은 병원에 있는 사람들을 지원하기 위해 매주 방문한다. 이러한 동료 지원자들은 공인된 국가 자격을 취득하기 위해 특정 연수를 받는다. 그들의 입원 기간 동안, 돌봄과 지원 목표는 서비스 사용자와 함께 정해진다. 병원에 도착하는 24시간 이내 에, 신체적 건강 요구를 평가하기 위한 일반의와의 상담이 있다. 가장 중요한 점은, 사회복지사와 특별 필요 근무자들이 처음부터 참여하여, 주거, 다른 인권 보호, 그리고 애완동물 돌보기와 같은 현실적인 문제 해결 을 돕는다. 서비스 철학의 중요한 측면은 입원은 절대로 한 사람을 나머지 외래 시스템으로부터 격리시켜서 는 안된다는 점이다; 모든 외래 팀(ambulatory team)은 병원에 있는 사람들을 방문한다. 다학제팀은 치료에 대해 논의하기 위해 매일 회의를 갖는다. 해당 분야의 모든 보건 전문가들은 갈등과 폭력 사례를 예방하기 위한 구체적인 연수를 받는다. 또한 해당 서비스는 폭력의 위험이 있는 상황에 대해 외부 보안 회사의 서비스를 이용한다. 이러한 보안 요원들은 병 원 직원에 의해 호출될 수 있지만, 그렇지 않은 경우에는 개인에게 제공되는 치료 서비스에는 간섭하지 않 는다. 이들의 역할은 전문가들과 서비스 이용자들의 안전을 보장함으로써 비폭력의 분위기를 조성하는 데 도움을 주기 위함이다. 전반적인 외래 위기 계획에 더해 어떠한 비동의적 개입을 피하기 위한 구체적인 계획에도 의견을 같이한다. 서비스에는 전용 격리 영역이 없으며, 격리는 어떠한 경우에도 실행되지 않는다. 어떤 형태든 강박의 사용 은 드물지만, 강압적 개입이 완전히 금지된 것은 아니며 예외적으로, 시간이 제한된 상태에서 신체적 강박 이 사용된다. 클리닉은 강박의 사용을 모니터링하고 이러한 모든 사례와 각 사례간의 지속 시간을 기록한 다. 2011년부터 2019년 사이에 신체적 강박은 연간 평균 1.77명정도 사용되었지만, 2017년부터는 연간 1명 만 신체적 강박의 사용 대상이 되었다 ([Medical information service], [EPSM Lille Métropole], personal communication, [2020]). 해당 서비스는 이러한 사례를 0으로 줄이려는 내부적 목표를 가지고 있 다. 화학적 강박 또한 거의 사용되지 않고 있으며 최근에 특별한 관심을 받고 있다. 2019년에는 9건의 강제적 신경성 약물 주입 사례가 보고되었다. 각 강박의 사용은 치료에 있어 주요한 부정적인 사례로 간주하고 지 속적으로 관행을 개선하고 사용을 줄이는 과정을 보장하기 위해 이후로도 연구가 진행 중에 있다. 여기에 서비스 이용자와 그 가족이 참여하도록 요청받는다. 서비스는 사람들이 병원에서 퇴원하고 나서도 지속적인 관리를 강조한다. 가족과 신뢰할 수 있는 사람들에 게 전해진다. 서비스 사용자는 퇴원 설문지를 선택적으로 작성하고 필요하다면 지원을 받게 된다 (아래 평 가 섹션 참고). 서비스 이용자들은 퇴원 요약본을, 그들의 일반의의 사본과 더불어 함께 제공받게 된다. 치료 호스트 가족 (Therapeutic host families) 호스트 가족과 함께 지내는 것이 입원의 또다른 대안이 될 수 있다. 이 서비스의 목표는 서비스 이용자를 전 통적인 환자/간병인 관계의 대상에서 가족의 일원으로 받아들이는 것이다. 이러한 이유로, 호스트 가족의 교육은 그들에게 임상적 간병 기술을 제공하는 것에 초좀을 두지 않고 대신에 회복 및 인권 기반 틀 안에서 정신건강 질환이나 심리사회적 장애를 가진 사람을 지원하는 방법을 이해하도록 교육받는다. 그들은 또한 개인 가정에서 발생할 수 있는 어떠한 형태의 학대도 예방하고, 불안과 위기 회피를 도울 수 있는 방법과 환 자를 가족 구성원으로 대우하는 방법을 교육 받는다. 해당 호스트 가족 서비스는 2018년 42명이 이용하였으며, 평균 체류 기간은 32일이었다 (4). 관련 가족은 한 번에 7개의 장소를 제공할 수 있었다. 2019년에는 2개의 가족이 4개의 장소를 제공하며, 장소 이용 가능성 이 감소하였다. 호스트 가족은 서비스에 대해 EPSM으로부터 교육과 재정적 지원을 받는다. 호스팅 기간 전 반에 걸쳐 감독, 관리를 받게 되며 모든 관련 이해 관계자들과 별도의 피드백 미팅이 있다. 호스트 가족 간 에는 1년에 1~2회 동료 그룹 미팅을 조직하여 그들이 직면한 어려움들에 대해 논의한다. 구역간 가족 및 시스템 치료 센터 (Intersectoral family and systemic therapy centre) 구역간 가족 및 네트워크 치료 센터(돈 잭슨; Don Jackson)는 가족과 커플을 위한 심리치료적 개입을 제공 하는 외부 상담 센터이다. 30년 동안 총 667쌍의 커플과 506명의 가족이 해당 서비스를 이용했다. 비록 다 른 배경을 가진 치료사들이 이 센터에서 근무했지만, 모두 4년동안 가족 및 커플 치료에 대한 체계적인 접 근 방식에 대한 추가 교육을 받았다. 이를 통해 치료와 지원을 고려할 수 있는 공통적이고 다학제적이며 총 체적인 시각이 형성되었다. 아비씨테 (Habicité) 아비씨테(Habicité)는 정신건강 질환을 앓고 있는 80명의 사람들에게 장기적으로 집중적인 인풋을 제공하 는 ACT(적극적 지역사회 치료; Assertive Community Treatment) 팀이다. 이 팀은 간호사, 사회복지사, 또래 지지자, 심리학자와 전문가와 서비스 사용자의 비율이 1:8로 구성되어 있다 (7). 이 서비스는 사람들이 그들 의 집과 지역사회에 머물 수 있도록 하면서 그들 개인의 회복 프로젝트를 지원한다. 게다가, 이 서비스는 다 양한 공동 주거를 제공하는데, 현재 13개의 아파트가 26명의 사람들에게 제공되고 있다. 이 시스템에 대한 접근은 선출된 대표자, 정신건강 문제를 체험한 전문가, 사회적 파트너를 포함한 지역사회 대표자를 포함시 킴으로써 최근 민주화되었다. 더 나아가, 해당 서비스는 “주택 우선” 철학에 기반하고 있는데, 이것은 주택 에 대한 무조건적인 접근과 해당 접근이 가능하도록 하는 무조건적인 지원을 의미한다 (8). 프론티어$ (Frontière$) 프론티어$(Frontière$)는 정신 건강 서비스 네트워크의 또다른 요소로, 신체적, 예술적, 문화적, 창의적 및 전 문적 활동을 통해 사회적 포용과 서비스 사용자의 전반적인 복지를 높이는 데 중점을 두고 있다. 프론티어 $ 팀은 간호사, 지역 보건의(GP), 작업 치료사, 특수 필요 교육자, 예술가, 적응형 스포츠 코치, 심리학자, 심 리 운동 교육자 및 협회와 기타 지방 자치 단체와의 연결을 통해 치료 활동을 조직하고 서비스 환경 밖에서 의 사람들을 지원하는 5명의 외부 사람으로 구성된다. 현재 교육 단계에 있는 동료 지원 인력도 팀에 고용 되어 있으며 교육을 완료한 뒤에도 프론티어$에 계속해서 협력할 것이다. 그 서비스 중 하나는 지역사회 내 포용 및 통합 돌봄 활동을 위한 서비스(Service d'activités d'insertion et de soins intégrés à laites; SAISIC)를 통해 정신건강 위기를 경험하는 사람들을 위한 개별화되고 지속적인 지원과 함께 일반적인 여가 환경에서 포용 활동을 조직하는 것이다. 또한 "사가씨테(Sagacités)" 시스템은 정신건강 서비스 외부의 사람들과 함께하는 활동과 일반적인 여가 및 문화 환경에서의 활동에 참여하기를 원하는 사람들에게 지원을 제공한다. 이 지원은 특정 활동에 매우 집중 하거나 집중적인 코칭의 형태로 이루어진다. 동료 지원 그룹 또한 사람들의 공통적인 프로젝트나 관심을 가 지고 있는 경우 제공될 수 있다. 마지막으로, 이 서비스는 지역 행위자 및 이해관계자와의 파트너십을 통해 고용에 대한 접근과 유지가 용이 하도록 지원을 제공한다. 작업 치료사는 서비스 이용자와 함께 경력 및 직업 계획을 함께 정하고 심리학자 는 동기부여 및 직업역량 평가에 도움을 준다. 네트워크 조직 및 서비스 간 연결 동쪽 릴 네트워크의 모든 정신건강 서비스는 연결되어 함께 작동하며, 이 덕분에 사람들은 하나 이상의 서 비스에 참여할 수 있다. 예를 들어, 아비씨테(Habicité)에 참여한 사람들도 프론티어$(Frontière$)에 참여할 수 있다. 2018년까지, 총 3513명이 서비스 네트워크에서 치료를 받고 있었으며 ([Medical information service], [EPSM Lille Métropole], unpublished data, [2018]), 동쪽 릴의 정신 건강 서비스에 고용된 전문가 의 75%는 이동 팀 및 기타 지역 사회 기반 역할에서 일하고 있었다 ([Medical information service], [EPSM Lille Métropole], personal communication, [2020]). 모든 동쪽 릴 정신건강 서비스는 네트워크로 작동 및 운영되고 있어 각 개인의 일관성 있는 치료 계획을 수 립하고 인트라넷 네트워크를 통해 연결된다. 네트워크의 모든 보건 전문가들은 인트라넷에 보관된 서비스 사용자에 대한 정보에 접근하여3 (치료의) 연속성을 보장하고 서비스의 서로 다른 요소를 조정한다 (9). 예 를 들어, SIIC에서 인트라넷은 보건 전문가가 그 사람의 의료 및 심리사회적 배경을 신속하게 확인하고 그 들을 가장 잘 아는 의사, 간호사 또는 심리학자에게 자문을 구할 수 있도록 한다. 정보의 손실을 방지하기 위해 동일한 파일을 외래 및 입원 진료에 사용한다. 3 프랑스의 경우 건강 정보는 데이터 접근 및 저장에 관해 엄격한 규제를 받는다. 정보는 건강 데이트를 사용할 수 있는 권한을 부여받은 보안 서버에 저장되며, 요청 시 의료팀과 서비스 이용자만이 접근할 수 있다. 의료 파일에 대한 접근은 외부 기관 (Commission d'accès aux documents administifs)의 엄격한 통제 하에 있다. 일반적 원칙에 따라, 서비스 이용자들은 전문가와 만날 때 자신의 파일을 가지고 상담할 수 있다. 지역사회 기반 정신건강 네트워크의 핵심 원칙 및 가치 법적 능력 존중 이 서비스는 독립적이고 지원되는 의사결정을 극대화하는 이니셔티브와 절차를 지원함으로써 법적 능에 대 한 존중을 증진시키는 데 전념한다. 다만, 해당 서비스는 비자발적 입원과 치료를 허용한다. 2013-2019년 동안 동쪽 릴에 입원한 222명의 사람들 중 의무 입원은 연평균 86.4명 (39%)으로, 10만 명 당 연평균 101.6명의 수치이다. 이 높은 비율은 프랑스에서 일반적으로 해당 조치를 광범위하게 사용되기 때 문인데, 2018년에는 82,000명의 의무 입원이 있었고 수치는 이는 10만 명 당 122.6명의 비율이었다 (10). 동 쪽 릴에서의 평균 입원 기간은 57일로, 오트 드 프랑스(Hauts-de-France) 지역 평균에 상당히 가깝다. 이러 한 의무 입원의 대부분은 동쪽 릴 구역 직원들에 의해 조직되지 않고, 릴의 종합 대학에서 일하는 정신과 의 사들이 병원의 응급실에 오는 위기에 처한 사람들을 본다. 그들은 제롬 보쉬 병원에 직접 입원을 처리하고, 사실상 동쪽 릴 이동 팀 (SIIC)를 건너뛴다. 동쪽 릴 서비스를 이러한 관행을 막을 권한이 없다. 하지만, 일단 사람이 클리닉에 입원하면, 퇴원 계획이 빠르게 세워지고 이것이 법적으로 허용된느대로 그 사람의 상태가 자발적으로 전환된다. 평균 입원 기간은 7일 동안만이다. 주요 장애물들 중 하나는 프랑스 법이, 경우에 다 라, 조치가 해제되기 전에 해당 사람이 정신건강 질환을 보이지 않도록 요구한다는 것이다. 2020년의 새로 운 목표 중 하나는 72시간 이상 지속되는 동의없는 입원 비율이 0이 되도록 하는 것이다. 법적 능력에 대한 존중을 강화하기 위해, 서비스 사용자와 전문가 사이의 관계를 담당하는 EPSM Lille- Métropole의 한 부서인 사용자 위원회(La Commission des Usagers (CDU))는 사람들이 사용자들과 가족의 대표들로부터 조언뿐만 아니라 외부의 독립적인 변호사에게 한 달에 세 번의 법률 상담 세션을 받을 수 있 다. 모든 비자발적 입원은 법에 의해 제공되는 대로 12일째 되는 날에 사법 검토의 대상이 된다. 각각의 서 비스 사용자는 무료로 변호사의 도움을 받는다. 동쪽 릴 네트워크는 또한 서비스를 이용하는 개인의 의지와 선호를 파악하고 존중하기 위해 전체적인 회복 계획의 일부로써 사전 계획을 사용한다. 이러한 일반적인 위기 계획은 WRAP (11)에 의해 영감을 받았으며, 서비스의 사용자를 속상하게 할 수 있는 요인을 파악하고 도움이 될 수 있는 전문가의 개입의 리스트를 제 공하는 제롬 보쉬 클리닉이 사용하는 보다 구체적인 계획과는 다르다. 이는 갈등 상황을 예측하고 예방하여 강압적인 개입을 피하기 위해 사용된다. 사전 계획은 온라인 도구인 카리아티드(Cariatides)를 사용하여 통 합되어 사용자 친화적인 방식으로 개인에게 제공되고 치료 전반에 걸쳐 쉽게 수정 및 후속 조치가 가능하 도록 보장한다. 2018년의 목표는 SIIC 서비스를 거치는 모든 사람에게 사전 계획을 개발할 수 있는 기회를 제공하는 것이다. 2018년에는 대략 300명의 사람들, 특히 자살 위험이 높은 사람들을 우선시하며 사전 계 획을 완료하였다. 강압적 관행/치료에 대한 대안 서비스에 종사하는 모든 사람들은 갈등 상황을 피하고 관리하는 데 도움이 되는 단계적 축소 기법(de- escalation technique), 회복 접근법 및 환자의 권리 존중에 대한 교육을 받는다. 병원 밖 사람들을 치료하기 위해 많은 노력을 기울이고 입원에 대한 다양한 구체적인 대안들이 마련되어 있는 동안, 강제 입언 및 강체 치료가 간혹 발생한다. 제롬 보쉬 클리닉에서는 위기 예방 계획 사용을 통해 강제 개입의 비율을 최소화한 다. 비록 프랑스 법에 따른 법적 지위를 갖진 않지만 서비스는 개인의 예방 계획을 존중하는 데 전적으로 전 념한다. 위기 이후 모든 경우에, 개인은 직원들과 함께 계획을 검토하도록 자리가 마련되고 미래에 더 개선 될 수 있도록 한다. 만약 개인이 병원에서 처방받은 약 복용을 거부한다면, 그들의 의사를 존중한다. 필요에 따라 처방전을 조 정할 수 있는 정신과 의사는 항상 있으며, 그들만이 약에 대한 결정 권한을 가지고 있다. 만약 의사가 특정 치료가 도움이 될 것이라고 생각하면, 치료를 원하지 않은 사람과 (계속해서 필요한경우) 상의를 하여 사전 동의를 얻는다. 하지만 클리닉에서는 강제 치료를 피하기 위해 모든 노력을 기울이더라도 여전히 발생하게 된다. 동의를 존중하지 않는 행위, 특히 (약물 강제 주입을 통한) 물리적 또는 화학적 억제의 사용은 치료의 ㅅㄹ 패로 간주되고 이러한 모든 경우는 이후 서비스에 의해 분석된다. 어떠한 강제적 약물 사용은 서비스에 의 해 신중하게 추적되고 서비스 사용자와 그 가족은 이에 대한 분석과 평가에 참여한다. 2019년에는 11건의 동의없는 약물 사용(이 중 2건은 지속적 작용성 약물, 9건은 시간 준수 사용 건이 포함된다)이 있었다 ([Medical information service], [EPSM Lille Métropole], personal communication, [2020]). 격리는 병원이나 다른 동쪽 릴 서비스에서는 절대 사용되지 않는다. 지역 사회 포용 지역사회 포용은 네트워크의 근간이자 기본 철학이다. 지역사회 포용을 촉진시키기 위해 특화된 지원의 예 시로 아비씨테(Habicité), 프론티어$(Frontière$), 치료 호스트 가족, SMPP가 있다. 지역사회 포용과 시민의식을 증진하기 위해 서비스 이용자들에게 여러 지원 단체들도 제공된다. 이 단체들 의 주제들은 서비스 이용자에 의해 확인된 필요에 기반한다: 대중교통을 이용하는 방법, 활동에 접근하는 방법, 권리를 보호하는 방법, 그리고 어떻게 시간을 관리하고 (특히 약물의 효과와 관련하여) “더 잘 먹고, 더 기분이 좋아질 수 있는지”에 주목한다. 해당 단체들은 정해진 수만큼의 세션과 목표를 가지고 있고 다양한 전문가에 의해 주도된다. 전문가의 존재를 요구하는 구가 규제의 대상이되지만, 동료 지원과 권한 부여에 더 큰 중점을 두고 해당 단체를 “전문가 중심”에서 벗어나기 위해 노력하고 있다. 치료 및 사회적 포용 활동은 또한 서비스 시설의 외부를 의미하는 “hors-les-murs (벽 너머)” 라는 이니셔티 브를 통해 프론티어$(Frontière$) 서비스 통해서 공공 및 일반 지역사회 활동으로 통합된다. 동쪽 릴 구역은 정신 건강 질환 및 심리사회적 장애를 가진 사람들의 일반적인 지역사회 생활 참여를 보장하기 위해 스포 츠, 문화 및 사회 서비스와 많은 파트너십을 맺고 있다. 목표는 개인의 희망과 동기를 출발점으로 삼아 지역 사회 활동에 참여할 수 있도록 행정적으로 참여를 치원하고 필요한 경우, 활동 참여를 지원하지만 가능하다 면 빠르게 해당 역할을 그만둘 수 있도록 한다. 동쪽 릴 서비스는 선출된 공무원, 사회 기관, 문화 기관, 사용자 및 가족 단체와 지역의 다양한 보건 파트너 (일반의, 약사 및 간호사 등)를 포함하여 수년 동안 많은 지역사회 기반 서비스 및 조직과 적극적인 연결 관 계를 구축했다. 이러한 연결 관계를 통해 서비스 사용자가 지역 사회에서 자신의 위치를 재정립할 수 있도 록 돕는다 (1). 참여 2008년에 두 개의 자조 그룹(Groupes d’Entraide Mutuelle)이 설립되었는데, 이 그룹은 서비스 조직에 정신 건강 문제를 경험한 사람들의 실질적인 참여의 출발점이 되었다. 이 그룹들은 보건부로부터 자금을 지원받 았으며 동쪽 릴 구역과는 독립적이었다. 그들의 목표는 일상 생활, 여가 및 사회 활동에서 동료 지원을 촉진 하는 것이었다. 이 그룹들은 이후 지역과 국가 사용자 및 보호자 협회로서 동쪽 릴 구역의 파트너가 되었다. 2010년 지역정신건강의회(the Local Mental Health Council)의 창설은 (위에서 논의한 바와 같이) 정신건강 문제를 경험한 사람들과 그들의 가족 및 보호자의 참여를 더욱 강조했다. 2012년에는 2명의 동료 지원 인 력(Médiateurs de Santé-pairs)이 정신건강팀의 전문가로 고용되었으며, 현재는 5명의 동료 지원 인력으로 확대되었다. 또한 2012년에는 전문가, 서비스 사용자 협회, 동료 지원 인력 포함해 정신건강 문제를 경험한 사람들의 참여를 전담하는 작업 그룹이 만들어졌으며, 이는 다음과 같은 여러 혁신으로 이어졌다: 지역사회 워크숍 형태로 서비스 사용자들을 위한 포럼으로 정신건강과 서비스 조직, 의사소통 도구를 논의, 제안 양 식 및 모든 이해관계자가 초안을 작성하고 서명한 회복 헌장. 2015년 서비스 이용자들은 서비스의 경영진 회의에 직접 참여하는 4명의 대표를 선출하여 제안 및 불만 사 항을 해결하고 사용자 포럼을 조직한다. 현재 동쪽 릴 서비스 사용자들의 대변인 역할을 하는 6명의 대표자 가 분기별 서비스 사용자 포럼과 제안 상자를 통해 의견을 수집한다. 또한 강압적 개입의 사용을 추적하는 바람직하지 않은 이벤트 형식을 조사하고 검토하는 일에도 참여하며, 해당 구역의 운영 위원회 회의, 경영 진 회의 및 작업 그룹에 참여한다. 대표자들은 인권 및 회복 접근 방식에 대한 교육을 받게 되며, 매달 해당 구역의 전문가들과 회의를 하고 서비스가 다루는 현안 및 불만 사항에 대해 논의한다. 대변인 중 한 명은 WHO 퀄리티라이츠(QualityRights) 교육을 받은 바 있다 (4). 퇴원 시, 퇴원 설문지를 통해 병원에서 체계적 으로 피드백을 수집하고, 전체 서비스를 사용하는 사람들이 작성하는 만족도 설문지 (12)를 통해서도 피드 백을 수집한다. 제안 상자는 모든 서비스에서 사용 가능하며, 익명의 코멘트나 불만 사항들을 제기할 수 있 다. 이러한 발전은 지역 보건 청(the Regional Health Agency)의 “사용자 권리(Users Rights)” 상을 인정받았 으며, 대변인 교육 및 의사소통 도구 개발을 위한 보조금 혜택을 받았다. 2017년에는 정신건강 문제를 경험한 사람들 혹은 서비스 사용자 및 간병인 단체의 구성원들이 주도하는 “경험을 통한 전문가(experts by experience)”라는 교육 프로그램이 개발되었다. 해당 프로그램은 청력, 섭 식 장애, 업무 및 번아웃과 같은 주제에 대한 서비스의 전문가들을 위한 교육을 제공한다. 이 세션들은 매달 열리고 있으며 서비스 이용자의 시선에서 전문가들에게 도움이 되는 것 (혹은 도움이 되지 않는 것)을 알리 는 걸 목표로 한다 (다음 섹션 참조). 서비스 사용자 위원회는 EPSM의 제도적 차원에서 서비스 사용자의 권리가 존중되어지는 방식을 감시하고 서비스 의사 결정 기관에 대한 서비스 사용자의 이익을 대변한다. 회복 접근 방식 동쪽 릴 네트워크는 특히 회복에 관한 운영 그룹과 해당 구역 서비스의 회복 지향 도구 홍보에 관한 운영 그룹을 가지고 있다. 2014년부터 모든 서비스는 회복 접근 방식에 의해 명시적으로 안내되고 있다. 동쪽 릴 구역의 모든 전문가는 정신건강 문제를 경험한 사람과 외부 게스트를 포함하여 회복 기반 치료 전문가의 프 레젠테이션과 워크샵을 통해 해당 회복 접근 방식에 대한 교육을 받는다. 교육은 모든 서비스 사용자가 교 육을 받도록 하기 위해 매년 20-30명의 그룹으로 이루어진다. 동쪽 릴 정신 건강 구역은 지속적으로 회복 접근 방식을 지원하기 위해 새로운 방법들을 탐구한다. 예를 들 어, 사용된 첫 번째 도구 중 하나는 회복 기간 온라인 플래폼으로 바로미터(Barometer)라고 불렸다. 해당 플 랫폼은 약물 뿐만 아니라 개인의 일반적인 삶의 질, 사회적 관계망, 그들의 성취와 강점에 집중해 이를 보장 하는 것을 목표로 한다. 그 사람과 만약 지원자를 필요로 한다면, 그 사람은 자신의 회복을 돕는 구체적인 목표를 만들기 위해 함께 일할 수 있고, 지속적으로 진행 상황을 추적하도록 보장한다. 이 도구는 사람들이 그들의 온라인 의료 파일을 통해 공식화된 사전 계획과 회복 계획을 세울 수 있도록 권장하기 위해 사용된 다. 해당 서비스는 다양한 방식으로 권한 부여를 촉진할 수 있도록 한다: 예를 들어, 전문 직원을 위한 교육 세션을 매달 정신건강 문제를 경험한 사람들에 의해 열린다. 이 모든 도구들은 동일한 목표를 제공한다: 사 람들이 스스로 필요하다고 여긴 요구에 최대한 붙어있으면서, 필요할 때는, 그들이 그들 자신의 바람을 분 명히 하고 치료에 대해 스스로 결정하도록 돕는 것이다. 서비스 평가 동쪽 릴 구역의 서비스 네트워크는 상세한 회계 감사 수치를 유지하고 있으며, 연간 목표는 잘 설정되어 있 고 측정 가능한 지표를 사용하여 매달 추적된다. 이 네트워크의 중요한 성과는 네트워크에서 치료를 받는 사람의 수가 상당수 증가했음에도 불구하고 2002-2018년 사이 (497명에서 341명으로) 연간 병원 입원율이 꾸준히 감소하고 있는 것을 볼 수 있다. 또한 같은 기간동안 입원 기간이 26일에서 7일로 감소했다 ([Medical information service], [EPSM Lille Métropole], unpublished data, [2018]). 2018년에는 222명 중 34명이 제롬 보쉬 클리닉에서 퇴원 설문을 완료하였다. 1~10점 평가에서 만족도 평 가 결과는 8.06 (SD = 1.94)으로, 79.6%가 입원 당시 기분과 비교하여 기분이 좋거나 훨씬 나아졌다고 응 답하였다 ([Medical information service], [EPSM Lille Métropole], unpublished data, [2018]). 지역 SMPP 센터는 또한 80%의 사람들이 연락이 닿은 후 48시간 이내에 초기 평가를 받고 있음을 보여주 는 효율성 지표를 추적한다. 환자 파일 작성 완료의 품질은 2018년에 80-100%로의 완성도를 보여주었으며, 이는 정확하고 신뢰할 수 있는 모니터링임을 증명한다 ([Medical information service], [EPSM Lille Métropole], unpublished data, [2018]). 2018년 9월, 8명의 구성원 (정신과 의사, (의료)질 국장; a quality director, 전직 병원장, 변호사 2명, 심리학 자, 가족 및 서비스 이용자 포함)으로 구성된 독립 평가 팀이 동쪽 릴 구역의 모든 서비스에서 WHO 퀄리티 라이츠 평가4를 진행했다. 다음과 같은 세 가지 주제가 완전히 달성된 것으로 나타났다: i) 신체 및 정신 건 강의 최고 수준 향유, ii) 강압(coercion), 폭력 및 학대로부터의 자유, iii) 지역 사회에서 독립적으로 살 권리. 다음과 같은 나머지 두 주제는 부분적으로 달성되었다: iv) 적절한 생활 수준에 대한 권리, v) 법적 역량 및 개인 자유과 보안에 대한 권리. 기존의 법적 프레임워크가 이 두 주제의 완전한 달성을 막는 주요 장벽으로 드러났다. 4 이는 5개의 주요 주제에 대한 평가로 25개의 표준과 116개의 기준으로 구분된다. 퀄리티라이츠 플랫폼에서 제공하는 전체 결과 및 권장사항은 다음에서 확인 가능하다: https://qualityrights.org/wp-content/uploads/QualityRights-59G21-report- 2019.docx 동쪽 릴 구역은 지난 40년동안 크게 변화해왔다. 효율성 결과는 네트워크가 잘 운영되고, 체계화되어 있으 며, 비용 효율성이 높다는 걸 보여준다. 지년 수십 년 동안 해당 구역에서 신규로 치료를 받는 사람의 수는 꾸준히 증가했으며, 이는 입원 환자 수 감소와 같이하고 치료를 위한 지역사회 기반 대안을 제공할 수 있는 네트워크의 실질적 역량을 보여준다. 서비스 비용은 프랑스의 다른 지역과 비교했을 때 높지 않으며, 실제 로 주변 구역의 정신 건강 서비스 비용보다 낮다. 동쪽 릴 구역은 프랑스 정부로부터 인정을 받아 프랑스에서 정신 보건 정책을 더욱 발전시키기 위한 모델 로 활용되고 있다. 예를 들어, 2018년에 발간된 정신보건 및 정신의학 로드맵 (Feuille de Route Santé Mentale et Psychiatrie) (13)은 정신 건강 치료 경험이 있는 사람들을 통합하고, 서비스에 대한 회복 접근법 을 촉진하며, 정신건강 질환 및/또는 심리사회적, 지적, 인지적 장애를 가진 사람들을 지역사회에 포함시키 기 위한 정부의 목표를 명시적으로 표명하고 있다. 2019년 4월, 부처 간 대표단이 해당 시행을 담당함과 동 시에 정신건강 분야에 대한 국가 예상을 상당히 증액하였다 (14). 동쪽 릴 구역은 최근 또 다른 의회 보고서 에서 (15)에서도 긍정적으로 언급되었다. 이러한 국가적 인정은 동쪽 릴의 접근법이 이제는 국가적 정책이 되고 있음을 보여준다. 비용 및 비용 비교 서비스는 전적으로 국가가 제공하며 정신건강 서비스 이용자는 국가보건의료시스템으로 완전하게 보장된 다. 서비스 이용자 1인당 평균 비용은 2013-2017년 사이, 2013년 3,131유로(약 US$ 3,684)에서 2017년 2,915 유로(약 US$ 3,430)5로 꾸준히 감소하였다 (4). 이 수치에는 초기 상담에서 입원에 이르는 전체적인 치료 경 로의 비용이 포함된다. 프랑스는 전체적으로 정신건강치료 관련 지출에서 61%가 입원비로 지출된다. 하지 만, 동쪽 릴의 입원에서의 지출은 28.5%에 불과하다 (4). 동쪽 릴의 전체적인 비용은 EPSM 전체 지역에서 가장 낮다. 과제 및 해결책 낙인과 차별의 고착화된 사고방식에 도전 네트워크를 구축하는 데 직면하게 되는 장애물 중 하나는 (전문가 뿐만 아니라 더 넓은 지역 사회에서) 정 신건강 질환을 가진 사람들에게 찍힌 낙인이 강압적인 치료와 열악한 치료 기준이 허용되는 것처럼 여겨졌 다. 정신건강 질환을 가진 사람들은 다른 사람들과 같은 권리를 가진 사람들로 간주되지 않았다. 그들은 일 반적으로 스스로 결정을 내릴 수 있는 능력이 부족한 것으로 여겨졌다. 이러한 만연한 태도를 해결하기 위해 정치인과 지역사회 구성원들이 정신병원을 방문하도록 하며, 낙인을 극복하기 위해 정신건강과 서비스 사용자의 권리에 대해 더 넓은 지역사회의 적극적인 참여를 필요로 했다. 동쪽 릴 구역은 정신건강 질환을 가진 사람들의 개인적, 사회적, 문화적 필요와 다른 시민들과 동일한 인건 을 누릴 권리를 강조하는 “시민 정신 의학” 철학의 발전을 통해 이 문제를 해결했다. 고착화된 생각을 바꾸 5 2021년 3월 환율 기준 는 데 도움을 준 또 다른 측면은 건강을 넘어 네트워크의 초점을 넓히고 개입 범위에 사회 사업, 교육 및 주 거를 포함시키는 것이다. 서비스 사용자와 정신건강문제를 경험한 사람들의 체계적인 참여 또한 인식과 관 행을 점차 변화시키는 데 도움을 준 중요한 측면이었다. 기성적인 국가적 법률 틀의 한계 내에서 일하기 동쪽 릴 서비스 네트워크가 직면한 또 다른 어려움은 강압(coercion)을 허용하는 국가적 법률의 존재가 지 속적으로 이를 막기 위한 정신건강 팀의 노력을 약화시키는다는 점이다. 강압은 어떤 대가를 치르더라도 피 해야한다가 아니라 ‘쉬운 선택’으로 여겨진다. 그 결과, 네트워크는 격리, 강박 및 강제 치료와 같은 강압적 인 치료에 관련해 정신건강 서비스 자체 내의 문화적 변화에 따른 특정 저항에 직면했다. 다행스럽게도, 프랑스의 서비스 구역화는 동 릴의 지역 정신건강 서비스가 입원의 대안으로 자금을 대는 데 서비스의 재원을 사용할 수 있게 했다. 동 릴 네트워크는 서비스 사용자의 의견이 진정으로 반영되는 시스 템을 만드는 것이 강압적 개입을 제한하며 균형을 잡는 역할을 한다는 걸 발견했다. 또한, 정신건강 문제를 경험한 사람들으로부터 교육을 받은 직원이 있는 것은 그들의 인권과 회복 의제의 중요성을 완전하게 이해 할 수 있도록 돕는다. 마지막으로, 강압이 일어났을 때 어떠한 경우에 대해서든 시간을 가지고 자세히 탐구 하는 것은 곧 재발의 가능성이 줄어든다는 것을 의미한다. 서비스 간 열린 소통(open communication) 유지하기 네트워크가 분산되어 있으면, 회복과 인권의 개념이 모든 다른 이해관계자의 중심인 서비스 간의 영구적인 대화 유지에 지속적인 어려움에 직면하게 된다. 이 어려움을 해결하기 위한 주요 조치는 정신건강에 대한 회복과 권리 기반 접근방식에 대한 전문가와 다른 이해관계자들의 지속적인 교육을 포함한다. 또 다른 주요 측면은 지역 건강 위원회 (AISSMC)의 창설이다. 지역 사회 전체의 협의 구조는 의사소통을 개선하고 모든 당사자로부터 동의/지원(buy-in) 얻기 위해 서비스 사용자, 그들의 가족, 정신건강 서비스 직원, 사회 서비스 직원, 선출된 대표자, 예술가, 다른 시민들, 일반의들, 경찰, 법무부 및 교육 부문을 포함한 광범위한 이해관 계자를 포함한다. 구역 간 의사소통을 지원하는 또다른 혁신은 모든 네트워크 서비스 사용자로부터 의견과 코멘트를 분기별로 수집하는 포럼의 설립이었다. 다양한 맥락에 대한 주요 고려 사항 다른 맥락에서 해당 서비스의 설립과 확장을 위해 고려해야 할 주요 사항은 다음과 같다: • 가능하면 서비스 내에서 강압과 입원 “0(zero)” 달성을 목표로 업무를 수행하고, 서비스가 개인의 일정에 맞게 업무를 수행할 수 있게 하는 가용성과 유연성을 특징으로 하는 “무조건적인 케어”를 제공하도록 서비스를 추진한다; • 새로운 서비스 개발과 연구 및 평가 활동에 있어 서비스 사용자/정신건강 문제를 체험한 사람들을 체계적으로 참여시킨다; • 정신건강 문제를 경험한 사람들이 서비스에서 “전문적인” 지위를 가질 수 있도록 지원하고 그들이 다른 이들을 대표할 수 있는 기술을 발전시키도록 돕는다; • 좁은 임상 계획을 피하고 대신에 개인의 개인적, 사회적, 문화적 필요 (주거, 교육, 고용 등)의 전체 범위를 파악할 수 있도록 하며, 이러한 사안들에 대응하기 위해 다른 지역사회 이해 관계자들과 협 력한다; • WHO 퀄리티라이츠 평가 도구 키트 (WHO Quality Rights assessment Tool Kit)를 사용하여 서비스 를 평가하는 것은 서비스 평가하는 매우 유용한 방식을 제공하며, 관련된 모든 행위자에 의해 만들 어진 가장 포괄적인 평가 도구이다; • 직원들이 서비스 사용자의 필요와 요구에 진정으로 응하는 케어를 제공할 수 있을 때 경험하는 자 부심을 중시한다; • 강압 수준, 자살 수치, 병원 밖에서 진료받은 사람의 비율 및 서비스 비용을 포함한 “전체적인 시스 템” 수준에 대한 평가 결과를 고려한다. 추가적인 정보 및 리소스: 웹사이트: https://www.epsm-lille-metropole.fr/recherche?field_tags=All&search_api_fulltext=G21 비디오: Les SISM, c’est quoi ? Avril 2014, https://youtu.be/D7_1SQSiNb4 연락처: Jean-Luc Roelandt, Psychiatrist, Centre collaborateur de l’OMS pour la Recherche et la Formation en Santé mental, Etablissement Public de Santé Mentale (EPSM) Lille-Métropole, France. Email: jroelandt@epsm-lm.fr Simon Vasseur Bacle, Psychologue clinicien / Chargé de mission et des affaires internationales, Centre Collaborateur de l’Organisation Mondiale de la Santé (Lille, France), Etablissement Public de Santé Mentale (EPSM) Lille-Métropole et Sector 21, France. Email: svasseurbacle@epsm-lille-metropole.fr 2.2 트리에스테(Trieste) 지역 사회 정신 건강 서비스 네트워크 이탈리아 맥락 잡기 트리에스테는 대략 236,000명의 인구가 거주하는 도시로 (16), 이탈리아 북동쪽에 위치한 프리울리 베네치 아 줄리아 (Friuli Venezia Giulia) 자치구의 수도이다. 트리에스테의 정신건강 서비스의 주요 변화는 1,200명 의 사람들이 수용되었던 구 산 지오바니 정신병원 (old San Giovanni asylum)의 폐쇄와 함께 시작되었다 (17). 역사적으로, 이탈리아의 개혁은 모든 이탈리아 사회 걸쳐 인권 성취를 위한 사회 운동 내에서 나타났 다. 트리에스테에서 자유와 인권은 지역 사회에서 살기 위해 기관의 집단 이주를 포함하여, 정신건강 서비 스의 주요 관심사가 되었다. 정신 의료 기관은 예상의 할당과 지출의 주요한 변화를 수반하는 지역 사회 서 비스 네트워크로 대체되었다 (17-21). 오늘날 정신건강 질환 및 심리사회적 장애를 가진 사람들의 시민권 촉진은 정신건강 서비스의 본질적인 특 징이자 기본 신조로 남아 있다. 해체를 피하기 위해 모든 서비스는 예산 편성, 계획 및 서비스 제공을 담당 하는 정신보건부(Department of Mental Health; DMH)에 의해 조정된다 (22). 2020년에 새로 설립된 보건 의료기관인 아지엔다 산니타리아 대학 줄리아노 이손티나(Azienda Sanitaria Universitaria Giuliano Isontina) 가 트리에스테와 인근 고리치아(Gorizia) 지역6을 담당하는 법적 주체가 되었다. 두 지리적 지역 간에 공통 적인 접근 방식이 있지만 아래 서비스에 대한 설명은 트리에스테가 2020년 더 넓은 조직이 설립될 때까지 발전했기 때문에 트리에스테에 중점을 두고 기술한다. 서비스에 대한 설명 트리에스테 지역 사회 정신건강 시스템 내에서 정신 건강 치료에 대한 “전체적인 사람, 전체적인 시스템, 전 체적인 지역 사회” 접근 방식이 개발되었으며, 이 접근 방식은 더 넓은 지역 사회와 협력하여 모두에게 열 려있고 제약이 없는 완전하게 통합된 지원 시스템 개발에 중점을 둔다. 사람들은 그들의 지역사회와의 연결 을 유지할 수 있도록 자신의 집과 인근에서 최대한의 지원을 받는다. 제도화를 피하고 사람들이 지역 사회 에서 삶을 살 수 있도록 보장하기 위해 (사회적 포용을 촉직하는 조치를 포함한) 인권과 지역 사회 참여를 강조한다. 이는 도시의 사회 자본을 향상시키기 위해 보건 복지 서비스, 사법 시스템, 문화 기관, 지역 및 시 당국과 기타 지역 사회 조직과의 적극적인 참여와 협력을 통해 달성되었다. 동료, 직원, 연수생, 자원봉사자, 가족 구성원 및 사회망과의 광범위한 파트너십 개발도 “전체적인 삶” 접근 방식을 촉진시켰다. 정신보건부 는 주요 운영 원칙에 따라 이러한 파트너십을 조정한다: • 지역 사회의 정신 건강에 대한 책임을 받아들임 • 적극적인 참여와 대응 (대기 목록 없음) • 서비스의 높은 접근성 • 치료의 연속성 • 지역 사회의 위기에 대한 신속한 대응 • 포괄적인 치료 • 팀워크와 이해관계자의 참여에 초점 (23) 6 고리치아는 140,000명의 인구를 보유한 도시로 몽팔콘(Monfalcone) 지역을 포함한다. 고리치아의 정신병원은 1961년에 이탈리 아에서 처음으로 개혁한 병원으로 1970년대에 트리에스테로 이동한 프랑코 바사글리아(Franco Basaglia)에 의해 주도되었다. 정신 건강 서비스 네트워크 요소 지역 사회 정신건강 센터 (CMHCs) 지역사회 정신건강 센터(CMHC)는 정신 건강 서비스 및 시스템 진입의 주요 지점이다. 서비스의 중심부를 구성하는 트리에스테 지역에는7 4개의 CMHC가 있다. 각각의 CMHC는 범위 내 50,000~70,000명의 사람을 수용한다. 각 CMHC에는 약 20-22명의 간호사 및 지원 인력과 사회복지사, 심리학자, 재활 전문가 및 정신 과 의사로 구성된 팀이 있다. 직원 두 명은 야간에 상주한다. 센터의 팀은 다학제적이며 유연하고 이동성이 높은 방식으로 일한다. 직원은 치료를 제공하고 서비스 조정 을 지원하며 사람들을 지역 사회의 다양한 이니셔티브, 서비스 및 기회에 연결지음으로써 회복 증진에 관여 한다. 그들의 가장 중요한 목표는 인퀀 프레임워크에서 치료와 돌봄을 제공할 뿐만 아니라 사회 통합과 포 용을 증진시키는 것이다 (24). 각 CMHC에는 6개의 병상이 있다 (단, 8개의 병상이 있는 몽팔콘은 예외). CMHC는 24시간 운영되며 모든 환자를 수용한다. 하룻밤을 묵는 사람들은 “환자”가 아니라 “손님”이라고 불리며 (24), 지역 사회에서 진행 중인 활동에 이미 참여하고 있다면 이를 계속할 수 있게끔 격려한다. CMHC는 일상적인 방식으로 원한다는 대로 방문객을 호스트할 수 있다. CMHC는 또한 지속적인 치료와 장기적인 지원이 필요한 사람들을 위한 아웃리치 활동을 제공한다. 팀 작업의 대략 50%는 센터에서, 나머지 50%는 지역 사회에서 이루어진다. 08:00에서 20:00 사이에 CMHC는 워크인 서비스를 운영한다. CMHC에 들어가거나 전화를 하는 사람은 보 통 1시간에서 2시간 이내에 신속한 응답을 받는다. 직원들은 순환 근무제(rota system)으로 일하게 되며, 팀 원이 항상 존재하도록 보장한다. 대기자 명단은 없다. 일반적으로 팀이 하루의 일정을 기획할 수 있는 회의가 8:00에 이루어지고 기획에는 예정된 활동 외에도 등 장할 수 있는 새로운 우선 사항이 들어간다. 시간은 서비스에 머무는 손님에게 할당된다. 일상적인 활동에 는 외래 방문, 약물 투여, 비공식적인 연락/대화, 그룹 회의, 점심과 저녁을 함께 하는 것이 포함된다. 손님과 의 (안내, 오리엔테이션, 안심 및 자아 개방을 위한) 오전 회의가 있다. CMHC의 내부 활동에 참여하지 않은 직원은 지원을 제공하거나 주간 치료를 위해 CMHC에 동행하기 위해서 사전에 계획된 가정 방문을 진행한 다. 병원 예약에 동행하는 이도 있고, 연금 수령, 은행 방문, 경찰서 방문 혹은 직장 출근 등 일상 생활 활동 을 이행하는 사람도 있다. 오후에는 교대 근무가 있으며 하루 중 새로운 우선 사항이 생긴다면 새로운 직원 이 활동을 재정립할 수 있다. 1차적 목표는 치료적 환경을 만들고 유지하는 것이지만, 동시에 편안하고 친근한 환경을 만들어 가는 것이 다; 직원과 손님의 상호작용에서 주요 원칙은 “함께 하고”, “함께 있는” 것이다. 수용 평가 (intake assessment) 는 진단 기반이 아닌 문제 기반이며 1인칭 서술을 통해 개인의 삶과 상황을 이해한다. 사용자나 그들의 간 병인이 문제가 시급하다고 생각하는 경우 우선 사항으로 처리된다. 공식적인 절차는 최소한으로 유지된다. 사람과의 첫 접촉은 주로 지역 사회에서 이루어지며, 대부분은 그들의 집에서 이루어진다. 이 경우, 핵심 직 원을 신속하게 배정하고, 가족 및 개인의 사회망에 접촉하게 된다. 팀은 또한 가능한 경우, 네트워크에서 발 생하는 모든 갈등을 조정하고 해결하기 위해 노력함과 동시에 개인의 자율성을 언제나 존중한다. 7 고리치아 지역에는 CMHC가 2개 더 있다 (하나는 고리치아, 다른 하나는 몽팔콘에 위치) 지역사회의 위기에 신속한 대응하기 위해 입원이란 수단은 트리에스테에서는 거의 발생하지 않는다. 위기 상황에 처했으나 가정에서 지원을 받을 수 없는 경우, CMHC에서 단시 손님으로 짧은 시간을 보낼 수 있다. 지속적인 지원과 치료 제공, 그리고 토의와 공동 의사 결정에 대한 강조는 대개 비자발적인 개입을 피할 수 있게 한다. 장기적인 후속 조치와 지원은 언제나 제공된다. CMHC 센터와 팀은 다음과 같은 서비스를 제공한다 (25): • 하룻밤의 환대(hospitality)와 케어 • 주간 케어 • 통원 서비스 • 가정 방문을 통한 가정 치료 • 가정, 지역사회, 또는 CMHC에서의 위기 개입 • 개인 및 집단 치료 • 약물 • 심리사회적 지원과 사회망과의 협력 • 심리사회적 재활 • 가정 그룹에 대한 지원 • 교육, 문화 활동, 직업 훈련 및 현장 실습 지원 • 사회활동, 자조 및 여가활동 종합병원 정신과 서비스와 유닛 (GHPU) 트리에스테에는 1개의 종합 병원 정신 건강 유닛 (Servizio Psichiatrico di Diagnosi e Cura)가 있으며 6개의 병상과 정신건강 서비스의 두 번째 진입점을 제공한다. 해당 유닛은 트리에스테와 고리치아 영토 둘 다 담 당하며, 인구는 대략 375,000명이다. 주로 밤에 응급 상황에 사용된다. 사람들은 보통 24시간 미만으로 머 물며 지역 사회 기반 케어로 옮기기 위해 가능한 한 빠르게 자신의 지역에서 CMHC로 이송된다. 병원에 기 반을 둔 팀은 2명의 정신과 의사가 포함되어 있으며, 그 중 한 명은 유닛장이고, 이와 함께 약 16명의 간호 사가 있다. GHPU의 팀은 종합 병원 연결 서비스도 제공하고 있으며 이들 대부분의 일은 응급실에 기반을 두고 있다. 지역사회 포용 지원 서비스 및 이니셔티브 트리에스테 정신건강 서비스 네트워크는 동료와 간병인을 포함하여, 사회적 협동조합, 자원봉사 및 사회 홍 보 협회와 같은 광범위한 비영리 단체와 협력하여 사람들이 자유롭고 인간다운 삶을 살 수 있도록 하는 것 을 목표로 포괄적인 개입을 제공하기 위해 종합적인 재활과 주거 지원 서비스를 가지고 있다. 재활 및 주거 지원 서비스는 개인의 건강 케어 예산을 통해 시행되는데, 이는 트리에스테 회복 주택 및 기타 여러 유형의 주택을 포함하여 지원되는 주거로의 접근이 보장되도록 사회 협동조합과 접점을 만들고 협력한다. 해당 프 로그램의 목적은 정신 건강 질환 및 심리 사회적 장애가 있는 사람들에게 완전한 지역사회 포용과 참여를 보장하기 위함이다. 개인 맞춤형 건강 케어 예산 개인 맞춤형 의료 예산은 주로 복잡한 필요를 가진 사람이나 젊은 사람들 중 고도로 개인 맞춤화된 프로그 램으로부터 가장 큰 혜택을 받는다고 생각되는 이들을 위해 설계되었다. 여기에는 사람들에게 중대한 영향 을 끼칠 수 있는 사회적 요인과 다른 어려움들을 다룬다. 계획이 수립되는데, 여기에는 개인이 설정한 목표 가 포함되며, 개인과 때로는 그/그녀의 가족과 협력하여 논의되고 합의된다. 후자의 경우, 개인의 허락에만 관여한다. 개인 맞춤형 건강 케어 예산 프로그램을 위한 재정은 정신 건강 및 때로는 복지 예산에서 나온다. 여러 협동조합이 치료의 계획과 제공에 기여한다. 일반적으로 적용되는 영역은 주거, 교육, 훈련, 고용 및 사 회 관계이다 (26). 이 프로그램은 매년 트리에스테에서 약 160명을 대상으로 한다. 이러한 “개인 맞춤형 건 강 예산” (budget individuali di salute)은 후속 프로그램 일부를 지원한다. 숙소 지원 지원되는 숙소는 각각 최대 5명을 수용할 수 있는 여러 개의 작은 거주 아파트나 사람들의 집을 통해 제공 된다. 해당 운영 계획은 어느 주어진 시간이든 42명, 매년 약 100명에게 숙소를 제공한다. 사회적 협동조합 의 직원은 상근을 포함하여 필요에 따라 유연한 지원을 제공한다. 이는 돌봄과 치료의 연속성을 보장하기 위해 CMHC와 협력하여 운영된다. 트리에스테의 회복 주택은 2015년에 문을 열었고, 트리에스테 정신보건 부와 사회적 협동조합의 협력으로 건강 케어 예산 프로그램을 통해 운영되는 프로젝트이다. 보통 6개월의 기간으로 4명에서 6명이 머물 수 있는 공간을 가지고 있다. 정신 건강 서비스와 상당한 접촉을 했고 회복 과 정을 추구하는 데 관심이 있는 18-35세의 사람들에게 열려있다. 트리에스테 회복 주택의 주요 운영 원칙은 다음과 같다: 1. 민주주의, 자기 결정권, 해방 (“내가 없이는 아무것도 없다.”); 2. 자산 및 힘 기반 접근방식; 3. 한 사람에 대해 한 평생 접근하기 4. 정신건강 문제를 경험한 전문가의 인정 5. 3자 만남(trialogical meeting)8 6. 공동 학습 환경 (27) 사회적 기업(협동 조합) 정신건강 서비스는 트리에스테에 있는 약 15개의 사회적 협동 조합의 네트워크와 협력한다 (28-32). 일부 협동 조합은 사회 보건 및 교육 서비스 관리를 담당한다. 이들은 CMHC 팀의 직원들과 긴밀하게 협력하며, 예를 들어 앞서 언급한 숙소 지원을 제공한다. 다른 협동 조합은 다양한 활동 (농업, 공업, 상업 및 서비스) 을 진행하고 주로 사람들의 고용 기회 유지를 주요 목표로 한다. 이러한 사회적 협동조합에서 노동자의 최 소 30%는 다른 노동자들과 동등한 대우를 받는 “사회적 약자들” 이어야 한다 (33, 34). 이 협당조합은 일자리 기회와 교육/직업 훈련을 제공하며, 트리에스테에서는 약 800명의 직원을 고용하고 8 3자 만남은 서비스 이용자, 그들의 가족, 지지자들, 정신 건강 전문가들 간의 만남으로 정신 건강 문제, 그 결과 및 앞으로의 방법 에 대한 열린 토의를 목표로 한다. (자세한 사안은 해당 사이트 참조: https://www.intervoiceonline.org/tag/trialogical-approach) 있다. 2018년에는 292명의 수습생이 근로 보조금을 받았다 (35). 수년에 걸쳐 근로는 청소, 건물 유지, 운송, 카페테리아 종사, 케이터링, 호텔 및 레스토링 서비스, 해변 리조트 관리, 정원 가꾸기, 수공예품, 사진, 비디 오 및 라디오 제작, 컴퓨터 서비스, 서리그래프 프린팅, 행정 서비스 및 개인 서비스와 같은 광범위한 활동 을 포함해왔다 (23). 일례로 트리에스테에 위치한 트리톤 호텔은 전적으로 사회 협동조합에 의해 관리되며 대부분은 트리에스 테 정신보건부의 서비스 사용자들로 구성된다. 다른 예로는 정신건강 서비스 사용자에 의해 운영되는 번화 한 식당인 딸기 필즈 카페 (Il Posto delle Fragole)가 있다. 트리에스테에 있는 오페라 하우스, 공중 라디오 방송국, 역사적 대중목욕탕 그리고 모든 박물관과 공공 정원의 카페들은 정신 건강 서비스 사용자들의 사회 적 협동 조합과의 계약을 통해 직원의 최소 1/3을 서비스 사용자들로 고용하게끔 한다 (30, 32, 36, 37). 트리에스테는 위에서 설명한 핵심 서비스 외에도 주요 보건 케어 기관인 아지엔다 사니타리아 대학 줄리아 노 이손티나(Azienda Sanitaria Universitaria Giuliano Isontina)의 다른 보건 구역 팀과 함께 여러 프로그램 을 제공한다. 여기에는 다음과 같은 내용이 포함된다: • 치료 그룹, 심리교육, 사회 활동 및 가정 방문이 제공되는 주간 센터를 통해 위기 치료를 아우르는 아동 및 청소년을 위한 서비스 • 청소년 및 청년의 정신 질환에 대한 조기 개입 서비스 • 섭식 장애를 겪는 청년을 위한 서비스 • 신체적, 심리사회적 자애를 가진 사람들을 위한 조정된 돌봄 • (인지장애 및 치매가 있는) 재가 지원이 필요하거나 요양원에 있는 노인의 돌봄 조정 • 정신적 고통을 겪고 있거나 정신 질환 진단을 받은 사람들을 진료하는 가정의에 대한 긴밀한 지원 • (공동 개인 맞춤형 케어 계획을 통해 조정해) 정신건강 및 약물 사용 조건에 대한 케어 개선 • 재판을 받고 있거나 유죄 판결을 받은 사람들을 위해 교도소와 재판소에서 근무 • 가족들과 협력 (심리교육 프로그램으로 10개의 미팅/모듈, 자조 모음, 지역 간병인 협회를 위한 훈 련 과정으로 구성됨) 재활 및 주거 지원 서비스를 통해 시행되는 기타 활동 사회적 참여를 증진시키기 위해 재활 및 주거 지원 서비스를 통해 여러 장소에 걸쳐 추가 활동을 조직한다. 활동은 동료 및 간병인 조직을 포함한 자원 봉사 협회에 의해 운영되며 웰빙, 신체 건강 및 스포츠, 사회 참 여, 자조 및 동료 지원, 예술 표현 및 낙인 반대 이니셔티브, 문화를 포함한 젠더 프로그램, 직업 훈련 및 배 치와 같은 설정된 영역에 중점을 둔다. 활동들은 도시의 사회적 공간에서 조직되며, 클럽의 형태로 이루어진다. 체육관을 포함한 4개의 조직된 활 동/클럽은 정신보건부에서 제공하며 협회가 공동 제작한다. 다른 4개의 조직된 활동/클럽은 협회 자체에서 직접 운영한다. 개인 맞춤형 건강 케어 예산은 개인의 특정한 필요에 맞는 매우 개별화된 활동 프로그램을 기획하는 데 사용될 수 있다. 서비스의 기본이 되는 핵심 원칙과 가치 법적 능력 존중 1970년대 개혁 초기부터 트리에스테는 자율성과, 독립성 그리고 자기 의사결정을 내릴 수 있는 개인의 역 량 존중을 증진시키는 데 집중해왔다. 이는 “시민권”에 대한 강조에도 반영되어 있다 (23). 1995년 서비스가 도입한 권리장전에는 정보에 입각한 동의와 기타 책무에 대한 명시적인 약속이 있다. 정신보건부에 일하는 사람들은 유니폼을 입지 않고 자신들과 치료와 지원을 제공받는 사람들 사이의 장벽과 위계를 최소화하려 노력한다. 모든 서비스는 개방적인 정책을 가지고 있으며, 사람들은 자물쇠, 열쇠, 비밀번호 같은 물리적 장 벽없이 드나들 수 있다. 트리에스테와 고리치아의 서비스는 “호스피탈리티(hospitality)”라는 개념을 사용한다. 즉, 서비스 사용자가 CMHC에 머무는 동안 가능한 한 일상생활과 맞닿은 삶을 살 수 있도록 하고 원한다면 센터의 지속적인 일 상 활동에도 참여할 수 있음을 의미한다. CMHC 직원, 협동 조합에서 일하는 사람들, 자원봉사자, 보호자 및 동료들은 모두 낮 동안 센터에 있으며, 누구나 원하는 만큼 사람들과 교류하고 교류할 수 있다. CMHC 중 한 곳에서 위기에 처한 “손님”은 서비스를 떠날 권리가 있음을 알게 되고, 그들이 원한다면 카페에 나가거나 산 책할 수 있다. 여기에는 물론 특별한 규칙은 없지만, 손님들은 어디로 가고 몇 시에 돌아올 것인지 직원들에 게 알려야 한다. 직원은 동행없이 외출이 가능한지 또는 직원, 친척, 자원봉사자 또는 동료의 적극직인 지원 이 필요한지에 대해 손님과 이야기를 나눈다. 일상적인 돌봄 계획은 개인의 필요와 의지, 선호에 따라 조정된다는 점에서 모든 것에 대한 결정에 대한 논 의가 강조된다. 하지만 심각한 위기를 겪고 있는 손님이 떠나고 싶어하고 모든 형태의 돌봄을 포기한다면 직원은 안전에 관해 합의된 계획으로 협상하고 이를 모색한다. 이는 여러 번의 시도와 대안 제시 끝에 결국 최후의 수단으로 비자발적 치료를 신청하는 법적 결정으로 이어질 수 있다. 서비스를 정기적으로 이용하는 사람들은 가능할 때마다 자신의 약을 자가 투여한다. 많은 사람들이 자신의 약을 센터에서 받아 집에서 복용한다. 그들은 보호자 또는 지지와 함께 사용된 치료법과 관련된 토의 그룹 및 교육 행사에 참여할 수 있다. 다양한 약물의 효과 부작용에 대해서도 자세하게 설명된다. 서면 정보는 전 단지를 통해 제공된다. 따라서, 사람들은 약물과 기타 개입에 대해 정보에 입각한 결정을 내릴 수 있도록 도 움을 받는다 (38). 개인 맞춤 케어 계획은 개인과 네트워크의 적극적인 참여로 개발된다. 임상적 개입 외에도, 이 계획은 개인 의 삶의 개별적인 상황에 기초하며 집 수리, 유지, 청소, 또는 더 적절한 숙소를 찾는 것을 포함한 개인의 생 활 상황부터 현금 보조금, 센터 금고 사용, 일시적인 인상 생활 자금 관리 또는 임차권 유지 같은 개인 재정 까지 모든 관련 필요를 포함할 수 있다. 개인 맞춤 케어 계획은 또한 빨래, 개인 정리정돈, 머리 다듬기와 같 은 개인 위생부터 목적 활동, 교육, 직업 활동, 직업 기회 (예. CMHC에서의 단순 업무, 협동조합 내 일자리, 또는 오픈 마켓 환경) 및 연기, 예술, 음악 및 자수, 헬스, 당일 여행, 휴가, 파티, 영화관 및 극장 방문과 같은 여가 활동을 포함한다 (24). 이 계획들은 또한 재발을 피하기 위한 가장 좋은 방법들과 개인이 어디에서 치료를 받기를 희망하는지를 포 함하여 위기 시에 개인의 희망사항들을 다룬다. 보통 개인은 서비스와 계속 연락하고 (스트레스가 심한 상 황이라면) 필요시 전화하면 된다. 이 계획들은 개인이 복용할 약물에 대해 협상되었던 내용도 포함한다. 형식화된 사전 지시 (39)는 일상적으로 사용되지 않는다. 더 나아가, 어떤 사람이 의사결정 능력이 손상되었 다고 여겨지는 경우, 법적 기관을 포괄하는 법 6/2004의 규정이 적용되고, 지원 관리자 (또는 법적 대리인: 보통 신뢰할 수 있는 사람, 친척 또는 친구)는 판사에 의해 임명될 수 있다. 이는 의사결정 지원(supported decision making)과 동일하지 않는데, 지원 관리자는 후견인적 역할을 더 많이 맡고 개인을 대신하여 의사 결정을 할 수 있기 때문이다. 강압적 관행에 대한 대안 해당 서비스는 모든 형태의 (정신과 입원 및 교도소, 법의학 단체 및 노인의 요양원 수감과 같은) 제도화와 모든 형태의 강압적이고 강제적인 개입을 피하는 것을 목표로 한다. 그러나 이탈리아 법이 정하는 바에 따 라 비자발적 치료(trattamento sanitario obbligatorio)가 사용되기도 한다. 치료, 돌봄 및 지원의 대다수는 자발적으로 평균 CMHC 또는 GHPU의 체류 기간은 짧다 (전자는 평균 13.8 일; 후자는 1.7일정도 이다 (40)). 그러나 CMHC에서 손님에게 제공되는 “호스피탈리티”는 비공식적이고 유 연하며, 필요한 경우 다른 해결책이나 숙박이 해결될 때까지 몇 주 또는 몇 달 동안 지속되기도 한다. CMHC 와 GHPU (16, 23, 41) 둘 다 “열린 문 – 강박 없음”이라는 명시적인 정책이 있으며, 직원들은 대립과 강압 의 사용을 피하기 위해 대화, 단계적 규모 축소 전략 및 스트레스를 받는 손님에 대한 개인 지원 제공에 대 한 교육을 받는다. CMHC의 다양한 장소: 주방, 정원, 개인실은 모두 단계적 규모 축소에 사용되며, 정신병 원이 문을 닫은 이래로 격리는 사용되지 않았다. 2019년, 비자발적 치료의 비율은 트리에스테의 인구 10만 명당 8.11명이었고 (42), 이탈리아 전체 수치는 2017년 10만 명당 15명이었다 (43). 특히, 이탈리아는 유럽에서 조사된 모든 국가 중 가장 낮은 비자발적 입 원 비율을 가지고 있다 (44). 법에 따라 비자발적 치료를 사용하는 상황에서, 동의 하에 제공되는 모든 치료 시도가 실패했을 시, 두 명의 정신과 의사의 요청과 공중 보건 책임자이자 마을의 최고 권위자인 시장의 승 인을 받아야 한다. 이러한 의무 입원은 초기에 7일 동안 지속된다. 트리에스테 (및 그 지역)의 특수성으로, 이러한 일들은 “열린 문” 원칙이 계속 적용되는 CMHCs에서 주로 발생한다. 비자발적 치료는 여러 번 연장 시 7일 연장될 수 있지만, 치료에 대한 동의가 달성된다면 며칠되지 않아 철회될 수도 있다 (33). 한 사람이 의무 치료를 받을 때, CMHC에는 더 많은 직원이 배치되어 위기에 처한 사람의 필요를 충족시키 기 위해 항상 2~3명의 사람(주로 직원이지만 사회적 협력 지원 종사자, 동료, 보호자, 또는 자원봉사자이기 도 함)이 있게 된다. 따라서 밀접하고 개인화된 (일대일) 치료가 진행된다. 또한 가족 구성원이 참여하여 개 인이 일상 생활과 가능한 한 많은 연결고리를 유지할 수 있도록 할 수 있다. 개인은 또한 논의가 된다면 시 내로 외출을 계속해서 떠날 수 있긴 하지만, 의무 치료의 경우, 동행이 함께한다. 이 서비스는 “보호”자로서 가 아니라, 개인의 요구의 대응하는 것을 목표로 한다. 제한된 상황의 경우, 경찰이 상황을 돕고 공동 관리를 하게 되는데, 이것은 즉각적인 위험과 안전 및 건강 보호에 대한 필요가 문제가 되고 있는 것으로 간주되는 법적 요건이다. 법의학 병원들은 2015년 이탈리아 에서 폐쇄되었지만 (41), 트리에스테는 이미 40년동안 법의학 병원에 아무도 보내지 않았었다. 해당 병원들 이 폐쇄된 후, “보안 조치를 위한 거주 시설” (45)가 이 자리를 대체했다. 프리올리 베네치아 줄리아 지역에 서는, 단일 유닛이 아닌 세 곳 (트리에스테, 우딘, 포르데논 지방)에 두 개의 안전한 병상을 배치하기로 결정 되었다. 그러나 2015년부터, 트리에스테로부터 온 단 한 명의 사람만이 해당 시설에 수용되어왔다. 지역 사회 포용 트리에스테의 서비스는 주거, 고용, 교육을 포함한 다른 지역 사회 기반 서비스와 정신 건강의 상당한 수준 의 통합을 달성했다. 정신보건부는 모든 보건복지 서비스와 긴밀하게 협력하며, 사회적 기업, 협동조합, 자 원봉사자 협회 등 비영리 부문과 광범위한 일련의 독립적 파트너에게 자금을 직접 지원한다. 위기 상황에서 도 CMHC에 머무는 사람들은 평소의 일상적인 지역사회 활동을 유지하도록 적극 격려한다. 복잡한 요구를 가진 사람들을 위해 개인 건강 관리 예산과 함께 제공되는 개인 맞춤형 계획을 창의적으로 사용하여 자율 성과 지역 사회 포용을 도울 수 있다. 지역 사회에서 개발된 일련의 프로그램을 통해 서비스를 사용자는 스포츠, 레저, 웰니스, 글쓰기, 영화, 박물 관 및 기타 문화적 활동을 포함한 광범위한 활동에 참여할 수 있는 기회를 제공받는다. 협회와 문화 기관에 의해 언어, 자기 관리, 사회적 정체성 및 지역 사회 삶의 다양한 측면에 대한 다양한 교육 및 훈련 과정이 기 획된다. 이러한 다양한 활동을 통해 사람들은 상호 관계와 새로운 사회적 역할을 경험할 수 있다. 이는 또한 직업 훈련 및 배치, 사회적 협동 조합에서의 근무를 통해 달성된다. 참여 트리에스테의 개혁은 언제나 서비스의 수혜자의 권한 부여에 관심을 가져왔고 서비스 사용자들은 서비스 의 계획, 전달, 평가에 관여한다 (23). 동료들 간 그룹 회의는 적극적으로 권장되고, CMHCs에서 정기적으로 이루어진다. 이러한 그룹의 동료 조력자들은 그들 작업에 대한 보수를 받는다. 보건의료기관 내 지정된 사무실은 서비스 이용자로부터 피드백과 불만사항을 받고, 사람들은 정신보건서비 스국장과의 만남을 요청할 수도 있다. 또한 서비스 사용자와 보호자의 견해를 협회와 사회적 협동조합 대표 들과 함께 대변하는 참여위원회(Participatory Committee)도 있다. 회복 접근 방식 트리에스테 서비스 네트워크는 단순히 그들의 진단에 초점을 맞추는 게 아니라 개인의 “삶 전체”에서의 필 요에 응하는 것을 추구해왔고 치료 원리로서 특히 기관 거주나 수용소로부터의 자유를 증진하기 위해 노력 해왔다. 개인의 자율성, 시민권 및 인권에 초점을 맞추는 것은 트리에스테에서 사용된 “모든 사람, 모든 시 스템, 모든 지역 사회” 접근법의 기본 요소이다. 서비스 이용자들과 함께 개발된 개인 맞춤형 케어 계획은 명시적인 회복 목표 (26)를 포함하여, 사람들이 개 별 프로그램 혹은 전체적인 “라이프 프로젝트”를 기초로 해서 자신의 열망을 탐색할 수 있도록 한다. 필요 할 때 그들은 돈, 일, 훈련, 교육, 생활 장소, 활동 및 관계에 도움을 받을 수 있다. 트리에스테 정신건강 서비스 네트워크 회복 접근법은 다음과 같은 이념을 기반으로 한다. • 전체론적 접근(holistic): 서비스는 진단 분류와 개입 기법보다는 가치와 원칙에 초점을 둔다. 서비 스는 단순히 진단 레이블이 아닌 ‘모든 사람’과 그들의 다양한 필요에 대응하기 위해 노력한다. • 모든 사람/모든 시스템 지향: 맥락적 문제에 주목하고 서비스는 적절하다 여겨지면 개인의 가족 및 사회 네트워크에 함께하고자 한다. 사회적 포용과 문화적 참여를 촉진하는 데 많은 노력을 기울인 다. • 권리 기반: 사회적으로 의미 있는 일을 할 권리와 같은 시민권, 참여권, (법적, 사회적 모두) 시민 권 리에 주목한다 (33). 지난 10년간 서비스의 모든 측면에 공공연한 회복 철학을 접목시키려는 지속적인 노력이 있었다. 2014년 회복 연구 그룹은 회복 헌장을 작성하였는데 (47), 트리에스테 CMHC 네 곳에 속해 있는 사람들로 구성된 포커스 그룹에서 나왔으며 약 100명이 참여하였다. 해당 인원의 대다수가 정신건강 문제를 경험한 적이 있 는 사람들이었다 (48). 서비스 평가 트리에스테의 변화는 1970년대 개혁이 시작된 이래로 상당했다. 1971년부터 2018년까지 (49) 병상 수는 1160개에서 219개로 줄어든 반면 (40), 서비스로 치료받은 사람은 수는 같은 기간 1160명에서 4800명으로 증가했다 (35)9. 자살률도 1971~1994년 인구 10만 명당 25명에서, 2015년 10만 명당 13명으로 떨어졌다 (46). 비자발적 치료의 대상이 되었던 사람의 수는 1971년 150명에서 매년 감소하여 2019년 18명으로 떨어 졌다 – 해당 비율은 인구 10만 명당 8.11명 정도 되는 수치이다 (40). 트리에스테의 법의학 병원에 입원한 사람은 1977년 15명에서 (49) 2006년 이후부터 계속 0명이다 (46). 여러 연구에서 트리에스테 정신건강 서비스 네트워크와 정신병원에서 도시 내 지역사회 기반 치료로의 전 환을 평가했다. 개혁법 이후 첫 번째 후속 연구는 (1983-1987년 시행) 18개의 다른 이탈리아 센터와 비교하 여 트리에스테와 아레초에서 조현병 진단을 받은 20명의 환자로부터 더 나은 결과를 보여주었다 (50). 또한, 27명의 “우선순위가 높은 사용자”10를 대상으로 한 연구에서는 5년 추적 관찰한 결과 높은 사회 회복률을 보여주었다. 증상의 약 20%의 현저한 감소화 사회 기능의 현저한 개선 (점수 50%정도 증가)도 발견되었다. 9명이 경쟁력 있는 일자리를 확보했고, 12명은 자립 생활을 달성했으며, 미충족 요구 정도는 75%에서 25% 로 떨어졌다. 입원 일수도 70%로 감소했으며, 단 한 명만이 중도 탈락하였다 (51). 수년에 걸친 다른 연구들도 트리에스테의 서비스에 대한 중요한 결과를 보여주었다. 13개 센터에서 수행된 전국 조사에 따르면 CMHC가 제공하는 위기 관리는 일주일에 7일 24시간 개방되어, 결과적으로 위기 해결 속도가 빨라지고 미래 재발을 방지하며 2년 추적 관찰 결과에서 보면, 더 나은 임상 및 사회적 결과를 얻은 것으로 나타났다 (52-54). 이는 또한 신뢰할 수 있는 치료 관계, 치료의 연속성 및 유연성, 서비스 포괄성의 중요성을 강조했다. 1984년부터 2005년까지 종합 병원 응급 처치 병동의 응급 프레젠테이션도 50% 감소한 것으로 보고되었다 (24). 항정신병 치료제 약물 준수율은 75% (55)로, 이는 좋은 치료 관계, 사회적 네트워 크 참여 및 “모든 사람, 모든 시스템, 모든 지역 사회” 철학과 관련된 맥락적 요인에 대한 관심과 함께 포괄 적 치료 접근 방식에 기인한다. 질적 연구는 서술적 관점의 치료 스토리 분석을 기반으로 트리에스테의 서비스 네트워크를 연구하는 데도 9 작은 규모의 숙소는 제외하였다. 10 연구 대상자들은 팀에 의해 선정되었다. 각각은 최소 6가지 이상의 특성을 가지고 있었다: 높은 가족 부담, 사회적 네트워크 부 재, 고립, 잦은 서비스 중도 탈락, 이전 형태의 치료에서의 반복적인 실패, 비자발적인 치료 에피소드, 심각한 사회적 표류의 임박 한 위험, 범죄를 저지를 임박한 위험, 불법 향정신성 물질 사용. 사용되었다 (56). 한 국제 연구 그룹은 치료, 사회적 포용 및 살아있는 시민권 사이의 중요한 상호 연결을 시 사했다 (57-61). 개혁 초기에 높은 서비스 사용자 만족률이 보고되었으며 (62), 대학 학위 논문을 위해 수행 된 설문 조사는 CMHCs의 작업에 대해 83%의 만족도를 보여주었다 ([Zanello LE],[Università degli Studi di Trieste], unpublished observations, [2006]). 비용 및 비용 비교 정신건강 서비스 예산은 지역사회 개입 (94%)에 비중이 높고, GHPU로 가는 비중(6%)은 극히 일부에 불과 하다. 2018년 트리에스테의 연간 서비스 비용은 1인당 약 80유로(23)(US$ 94달러)11로, 도합 1,670만유로 (약 US$ 1,960만 달러)에 달하는 것으로 추정된다. 2019년 정신보건국 비용은 구 정신병원 비용의 37%에 달하는 것으로 계산된다 (35). 이는 트리에스테의 전체 보건의료 예산의 약 4%에 해당한다. 서비스 비용은 공적 자금을 지원받는 국가보건서비스가 부담한다. 보건의료기관에 제공된 지역 예산은 이 후 과거 지출액을 토대로 정신보건부로 전달된다. 이는 할당되고 합의된 목표에 따라 협상된다. 이탈리아 전체와 마찬가지로, 민간 의료는 보험 가입자나 이를 직접 지불할 수 있는 사람이 이용할 수 있다. 의료 역시 민간 공인 제공자가 무료로 제공하며, 국가보건서비스가 이를 상환한다. 다만 트리에스테의 모든 민간 의료는 “사무 기반”(상담, 심리치료, 약물)이며, 민간 병원은 없다. 과제 및 해결책 제도화의 유산 극복 1970년대 초부터 트리에스테 정신건강 서비스의 발전은 제도화의 유산을 극복하려는 열망에 의해 주도되 었다 (19). 탈제도화의 장애물 중 하나는 정신병원 내 두드러지는 “눈에서 멀어지면, 마음에서도 멀어진다” 에 대한 지배적인 견해와 이와 관련된 권력 불균형, 인권 침해 및 사회적 베제였다. 처음부터 트리에스테 맥락에서 지역 및 지역 당국의 정치적 지원과 정책은 매우 중요했다. 트리에스테 접근 법의 다른 영향 요인은 (63) 전문가, 관리자, 서비스 이용자, 그들의 지지자 및 보호자, 그리고 기간 외부의 여러 행위자 (자원봉사자, 예술가, 적극적 시민, 가족, 지식인, 비영리 단체)의 연합, 서비스에 대한 서비스 사 용자의 권한 부여 및 가족 참여를 포함한다 (64). 업무 공유가 있는 다중전문팀 접근 방식의 개발, 그리고 전 문적인 역할과 투입 측면에서 유연성의 중요성에 대한 강조 또한 전문 인력에 영향을 미치는 중요한 요인 이다. 여기에 더해 변화에 대한 저항을 극복하는 포괄적인 접근법에 대한 투자 및 직원의 교육, 동기 부여, 전문성 개발에 대한 많은 투자 또한 중요 요인이다 (23). 더 나아가, 트리에스테는 개인 및 일상 생활 요구 (예. 주거, 소득, 교육, 사회적 포용 등)와 정신 건강의 사회 적 결정 요인을 해결하는 사회적 케어와 함께 다부문 접근 방식을 채택했다. 그러나 가장 중요한 요소 중 일 부는 병원 입원을 방지하기 위해 적극적으로 노력하는 것, 건강과 사회적 관리를 통합하는 사람 중심 접근 방식 채택 (36), 적은 수의 병상을 갖추고 단일 종합 팀에 의해 관리되는 24시간 정신건강 센터에서의 서비 스를 참조하는 주요 지점으로, 해당 서비스 네트워크에 기반한 설정된 조직 모델 채택을 포함한다. 11 2021년 3월 환율 기준 트리에스테는 1973년 WHO 탈시설화 시범센터로 지정된 이후 (18), 계속해서 혁신과 발전을 거듭해 왔으며 전 세계적으로 큰 영향을 끼쳤다 (16, 65-68). 트리에스테는 이제 모든 대륙의 국가와 서비스 연계를 구축했 으며 매년 1,000명의 사람들이 이 도시를 방문한다 (23). 이탈리아 국가 보건 시스템 상태에 관한 의외 위원 회 (69)와 이탈리아 정신건강 펠로우십 협회는 이후 트리에스테를 이탈리아 전체가 채택해야할 모델로 정 했다 (41). 제도 문화와 권력 관계의 변화 정신건강 시스템은 위계 시스템 위에 세워졌다. 이러한 위계와 이를 유지하는 권력 관계에 도전하는 것은 제도 문화를 극복하는 데 필요했다. 모든 관계자를 포함하도록 논의와 의사결정 과정을 확대함으로써 정신 건강 세계를 민주화하려는 지속적인 노력 덕분에 진전이 있었다. 이를 달성하기 위한 노력으로 초기에는 정 신 병원에서 매일 집회가 열렸다. 정신건강 질환을 가진 사람의 가족과 더 넓은 지역 사회를 참여키는 것도 정신병원의 중심적 위치를 유지해 온 사회적 배제의 힘에 대항하는 데 도움이 되었다. 마지막으로, 서비스 이용자의 목소리를 듣고 행동할 수 있는 방법을 개발하여 사람들이 자신의 치료를 위해 권한과 독립을 되 찾을 수 있는 기회를 만들었다. 질병 중심 이데올로기에 도전 질병 중심 접근법과 관련된 이데올로기는 서비스 이용자의 목소리를 침묵시켰고 이는 곧 그들의 개인적, 사 회적, 문화적 필요에 거의 관심을 기울이지 않았음을 의미한다. 사람들이 지역 사회에서 완전한 삶을 누릴 수 있도록 지원하기 위한 정신건강 시스템의 새로운 형태의 집단적 리더십과 완전히 새로운 일련의 관행의 확립이 매우 중요했다. 또한, 생의학 모델과 좁은 질병 중심 이념만이 아니라, “모든 사람”에 새로운 초점 맞 추기를 육성하기 위한 협회와 사회적 협동조합의 개발을 통해 진전이 이루어졌다. 지속적인 진전 트리에스테 정신 건강 네트워크는 새로운 형태의 제도화, 혹은 단순히 서비스의 “관성”에 대한 서비스로 미 끄러질 수 있는 지속적인 위협에 직면해 있다. 게다가, 가부장주의, 심지어 다른 형태의 학대 행위가 나타날 수 있는 위험은 항상 존재한다. 그 문제들을 인식하고 적극적으로 대처하는 것은 이러한 위험을 피하는 데 도움이 된다. 변화 기간 동안의 직원 지원 임상 모델에 의존하는 쉬운 대비책 대신에, 트리에스테 직원들은 서비스 사용자와 관계를 맺기 위해 직원들 의 개인 자원을 사용하도록 강요 받았다. 이는 덜 구조적이고 불확실성이 더 많은 새로운 접근 방식이었기 때문에 간혹 번아웃과 갈등으로 이어졌다. 해결책 중 하나는 “부담을 분담하는” 문화를 만들어 특정 개인이 나 가족에 대한 모든 걱정과 염려를 혼자서 짊어지지 않도록 하는 것이었다. 또 다른 조직적 해결책은 서비 스 이용자와 직원들 모두가 그들의 의견과 우려가 반영된다는 인상을 가질 수 있도록 조직 내 진정한 민주 주의를 만들기 위한 노력이 있다. 다양한 맥락에 대한 주요 고려 사항 다른 맥락에서 해당 서비스의 설립과 확장을 위해 고려해야 할 주요 사항은 다음과 같다: • 서비스의 긍정적인 영향을 창출하고 유지하는 데 중요한 요소로서 서비스 내에서 비판적 사고와 성찰을 기른다; • 정신 건강 질환에 대한 임상적 이해에서 “모든 사람-모든 삶” 철학으로 전환한다; • 직원 교육 및 개발에 집중 투자한다; • 직원, 서비스 사용자, 그들의 가족과 더 넓은 지역 사회의 사람들이 만나고 서비스의 비전에 대해 논의할 수 있는 기회를 만든다; • (평가척도로 측정한) 임상 결과가 서비스 사용자의 시민권과 관련된 결과만큼 중요하지 않음을 인 식한다. (예. 서비스 이용자의 강압 정도); • 제공되는 개별 서비스와 개입뿐만 아니라 네트워크의 전반적인 작업과 결과를 포착하는 접근 방식 과 방안을 사용하여 서비스 네트워크를 평가한다. 추가적인 정보 및 리소스: 웹사이트: www.triestementalhealth.org 비디오: BBC News, Trieste’s mental health revolution: “It’s the best place to get sick”; https://www.youtube.com/watch?v=5v0jki3GaBw&feature=youtu.be Episode 8 - Lived experience in Trieste, a mental health system without psychiatric hospitals, with Marilena and Arturo: https://www.spreaker.com/user/apospodcast/episode-8-lived-experience-in-trieste-a Roberto Mezzina, 2013; https://youtu.be/UnMSHQDrByl 연락처: Elisabetta Pascolo Fabrici, Director, Mental Health Department of Trieste and Gorizia, WHO CC for Research and Training – Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), Italy. Email: elisabetta.pascolofabrici@asugi.sanita.fvg.it Roberto Mezzina, Psychiatrist, Former Director, Mental Health Department of Trieste and Gorizia, WHO CC for Research and Training – Azienda Sanitaria Universitaria Giuliano, Isontina (ASUGI), Italy. Email: romezzin@gmail.com; who.cc@asuits.sanita.fvg.it 2.3 브라질 지역 사회 정신 건강 서비스 네트워크 캄피나스(Campinas) 지역을 중심으로 맥락 잡기 브라질은 27개의 연방 단위와 5570개의 지방 자치단체가 있으며, 면적 기준으로 세계에서 다섯 번째로 큰 연방 공화국이다. 브라질은 2억 1,100만 명 이상이 거주하는 세계에서 여섯 번째로 인구가 많은 국가이다 (70). 중상위 소득 국가이지만 사회적 불평등 수준이 높다 (71). 보편적 의료는 브라질의 통합 의류 시스템 (Sistema Único de Saúde (SUS))에 의해 제공되는 헌법상 권리이다. 브라질의 정신건강 네트워크는 SUS에 따라 제공된다. 오늘날 브라질의 정신건강 네트워크는 1970년대 말 브라질에서 일어난 주요 정신의료 개혁의 반영이다. 시 민 사회 운동으로 시작된 정신의료 개혁은 제도화된 지료에서 지역사회 내 치료로 전환하고 지지하는 법적 프레임워크, 서비스 규정 및 권리 기반 정신 건강 정책의 개발을 통해 이루어졌다. 제도적 구조와 관행은 점 진적 자원 재배치를 통해 지역사회 기반 서비스 네트워크로 대체되었다 (72, 73). 2002년 정신 건강에 할당 된 연방 재원 중 정신병원에서의 지출이 거의 80%를 차지했으며, 지역사회 기반 정신건강 서비스가 나머지 20%를 차지했다. 이와 대조적으로 2013년까지 정신건강 예산의 80% 가까이가 지역사회 기반 서비스에 투 자되었으며 나머지 20%가 정신병원에서의 지출이었다 (74). 그러나 2017년에 (2016년 정신건강 정책 변경에 따라) 정신병원이 다시 정신건강 네트워크에 공식적으로 포함되었고 지역 사회 기반 서비스의 시행에 대한 연방 정부의 투자 또한 감소하였다 (75, 76). 그러나 공공 정책 시행에 있어 지방자치단체와 주 차원의 자율성 수준과 기관, 법률, 금융 및 시민사회의 정신 의료 개혁 에 대한 강력한 기반 덕분에 이러한 변화가 지역사회 기반 서비스 시행 중단이나 지방 자치 단체 전체로의 정신병원 폐쇄로 자동적으로 이어지지는 않았다 (77). 브라질의 모든 지역사회 기반 정신 건강 서비스는 브라질 정신건강 네트워크의 주요 지침 원칙을 따른다: • 형평성 증진; • 서비스에 대한 개방적 접근을 보장; • 사람 중심의 치료 계획과 다중 전문가의 의견에 기반한 포괄적 치료를 제공하는 권리 중심의 양질 의 서비스; • 사람 중심, 필요 중심의 치료 및 행동; • 인권 존중; • 사람의 자율성, 사회적 포용과 참여, 시민권과 자유 증진; • 정신건강문제를 체험한 사람들의 참여를 통한 지역사회 기반 접근 방식; • 낙인과 편견 퇴치; • 주거, 업무, 교육 및 문화 등 다른 부문과의 공동 행위 및 역량 강화 전략 개발 (78). 지역사회 기반 정신건강 네트워크는 브라질 모든 지역에서 시행되며, 네트워크의 각 요소가 어떻게 시행되 고 사람들이 경험할 수 있는 것은 다양하다. 네트워크를 설명하기 위해 지역(시 단위) 네트워크 모범 사례를 선정하여 어떻게 운용되는지에 대한 실질적인 통찰을 제공했다. 캄피나스 지방자치단체는 다음과 같은 이 유로 선정되었다: 2017년 도시의 정신병원을 폐쇄한 완전한 지역사회 기반 정신 건강 네트워크를 갖춘 지 자체이며, 개인을 지역 병원과 같은 지자체 외부의 정신병원에 후송하지 않으며, 지역 수준에서 잘 작동하 는 포괄적인 통합 서비스 네트워크를 가지고 있고 평가 데이터 또한 존재한다. 캄피나스 – 개요 캄피나스의 인구는 약 120만 명이다. 2010년 기준 월 소득이 국가 최저임금의 절발에도 미치지 못하는 인 구는 30%였다. 전체 인구의 39%가 정식 취업을 했고, 15~64세가 해당 비율의 72%를 차지했다 (79). 1990 년 캄피나스 정신건강 네트워크의 전환이 시작되었을 때, 캄피나스에는 5개의 병원에 걸쳐 1200개의 정신 과 병상이 있었다. 이 과정의 첫 단계는 정신 병원인 Sanatório Dr. Cândido Ferreira의 탈시설화였다. 2000 년대 이후부터는 이 문서에서 서술한 것과 같은 대체 서비스가 시행되기 시작했으며, 이와 병행하여 정신과 병상의 점진적이고 합의된 폐쇄와 그곳에 살던 사람들의 탈시설화가 진행되었다. 2017년에는 Sanatório Dr. Cândido Ferreira 정신 병원이 마침내 폐쇄되었다. 캄피나스의 사례와 함께 브라질의 정신건강 서비스 네트워크에 대한 설명 아래에 기술된 서비스는 개인과 지역 사회 모두의 요구를 충족하는 지속적인 지역 사회 정신 건강 치료 및 지원을 제공하기 위해 협력한다. 캄피나스의 정신건강 포럼은 지역사회 기반 서비스 전문가, 서비스를 이용 하는 개인 및 가족들이 한 자리에 모여 서비스와 관련된 공통 문제와 지역 내 필요에 대해 논의하고 해결할 수 있는 기회를 제공한다. 정신건강 서비스 네트워크는 지역사회 기반 정신건강 센터를 통해 다른 관련 부 문과 서비스 (예. 고용, 문화, 스포츠)와 일반 건강 네트워크에도 연결된다. 정신 건강 서비스 네트워크 요소 지역사회 기반 정신건강 센터 CAPS (Centro de Atenção Psicosocia)로 알려진 지역사회 기반 정신건강 센터는 브라질의 지역 기반 정신 건강 네트워크의 초석이다. CAPS는 어렵거나 위기적인 상황을 포함하여 심각하거나 지속적인 정신건강 질 환 및/또는 심리사회적 장애를 가진 개인에게 지속적이고 맞춤화되며 포괄적인 지역 기반 정신 건강 치료 를 제공한다. CAPS는 권리 및 사회 중심 접근 방식을 가지고 있다. 이들의 주요 목표는 심리 사회적 치료, 자율성 증진, 권력 불균형 해결 및 사회 참여 증가이다. 원칙적으로 CAPS는 사용자를 정신병원으로 이송하 지 않는다. CAPS는 센터 자체 및 지역 사회 범위에 국한하여 활동한다. 한 지역의 CAPS의 개수와 유형은 해당 지역의 인구와 특정 필요에 따라 달라진다. CAPS 서비스는 인근 지 역과 목표 인구에 따라 분류된다. CAPS I은 15,000명 이상의 지역에서 성인 인구를 대상으로, CAPS II는 70,000 이상의 지역에서 서비스를 제공한다. CAPS III12 서비스는 15만 명 이상의 지역에서 성인 뿐만 아니 라 어린이와 청소년을 대상으로 하며 필요한 경우 주7일 24시간 개방되어 있고 필요하다면 하루 숙소를 제 공한다. CAPSi는 어린이와 청소년을 대상으로 하며, CAPS ad는 물질 사용과 관련된 문제와 필요에 대한 지 12 CAPS III에 대한 보다 상세한 설명은 본 지침서와는 별도로 제공되며 기술 패키지, 지역사회 정신 건강 센터: 사람 중심, 권리 기반 접근 방식 증진을 중심으로(Community mental health centres: Promoting person-centred and rights-based approaches), 에서 CAPS III 브라질렌디아(Brasilândia)의 예시를 활용한다. 원을 제공한다. 다른 서비스의 역할을 대체해서도 역할 수행이 가능하다: 예를 들어, CAPS I와 CAPS II 서비 스는 주로 성인 인구를 대상으로 서비스를 제공하는 한편, CAPSi를 사용할 수 없는 지역 기반 지원을 보장 하기 위해 아동 및 청소년에게 치료 및 지원을 해당 두 서비스에서 제공할 수도 있다. 다른 유형의 CAPS도 지역사회의 필요를 충족시키기 위해 결합될 수 있다. 예를들어, 2017년 12월 새로운 법안이 새로운 CAPS 유형을 확립했는데, 일명 CAPS ad IV로, 50만 명 이상의 지역에서 물질 사용과 관련된 문제 및 요구를 가진 사람들에게 초점을 맞췄다. 각 CAPS의 인력은 CAPS의 종류, 인구 수요, 운영 시간 및 특정 요구에 따라 다르다. 각 CAPS의 종류별 최 소 인력 배치 수준은 아래와 같이 법으로 규정되어 있지만, 지자체는 해당 최소 수준 이상의 인력 배치에 자 금을 지원할 수 있다. 인력 배치 필요 요건은 다양한 직원 범주를 나타낸다. 대학 수준에서 교육을 받은 전 문가는 서비스 사용자의 필요에 따라 심리학자, 사회복지사, 작업치료사, 교육학자, 물리교육자, 언어치료사 또는 기타 전문가를 포함한다. 중간 수준의 전문가에는 간호 기술자 및/또는 조수, 행정 기술자, 교육자 및 “기능 보유자”를 포함한다. CAPS 서비스의 최소 인력 배치 수준은 다음과 같다: • CAPS I – 정신 건강 교육을 받은 의사, 간호사, 3명의 대학 수준 전문가 및 4명의 중간 수준 전문가 • CAPS II – 정신과 의사, 정신 건강 교육을 받은 간호사, 4명의 대학 수준 전문가 및 6명의 중간 수준 전문가 • CAPS III - 2명의 정신과 의사, 정신 건강 교육을 받은 간호사, 5명의 대학 수준 전문가 및 8명의 중 간 수준 전문가. 야간 근무의 경우: 3명의 간호사의 관리감독을 받는 간호 기술자, 1명의 중간 수준 전문가 • CAPS ad – 정신과 의사, 정신 건강 교육을 받은 간호사, 선별검사, 평가 및 모니터링을 담당하는 임 상 의사, 4명의 대학 수준 전문가 및 6명의 중간 수준 전문가 • CAPSi – 정신과 의사, 정신건강 교육을 받은 신경과 의사 또는 소아과 의사, 간호사, 4명의 대학 수 준 전문가, 5명의 중간 수준 전문가 모든 CAPS 방식 중에서 CAPS III는 정신건강 네트워크에서 갖춰야하는 핵심 전략 서비스로 간주된다. 하루 24시간, 일주일 7일, 그리고 기숙사 시설과 함께 운영되며 CAPS III의 네트워크는 지역사회의 사용자들에게 언제나 지속적인 치료를 제공할 뿐만 아니라 사용자가 지속적인 (주야간) 지원으로 혜택을 받을 수 있는 네 트워크 내 다른 CAPS에도 제공할 수 있다. CAPS III가 없는 소규모 지자체의 경우, 서비스 사용자는 다른 도 시 혹은 지역에 있는 CAPS III로 이송될 수 있다. CAPS III의 기숙사는 기존의 정신건강 병상으로 간주되거 나 사용되지 않는다. 해당 기숙사는 잠시동안 어렵거나 위기 상황이거나 개인이 추가적이고 지속적인 지원 으로부터 혜택을 받는다고 느낄 때와 같은 기타 다른 상황에서 사용할 수 있다 (78). 사람들은 CAPS가 하룻 밤 지원을 필요하도록 만드는 요인을 사용자가 해결할 수 있도록 사전에 지원하는 최대 14일 동안 쭉 머물 수 있다. 기숙사는 집에 있는 것과 유사한 환경을 제공하는 것을 목표로 한다. 이 서비스를 사용하는 데 있 어 별다른 규칙이나 요구 사항은 따로 없다. 운영 원칙 모든 CAPS 서비스는 세가지 지침 원칙을 따른다. 1. 열린 문 정책 – 사람들은 센터 사용에 대한 첫 미팅 예약 없이 센터에 들어가 CAPS에 접근할 수 있 다. 다른 서비스를 통해 이송될 수도 있고 집에서 방문할 수도 있다. CAPS의 물리적 구조는 환영을 받는 것 같은, 편안한 집 같은 환경을 제공하여 사람들이 편안함을 느끼고 적극적인 참여와 상호작 용을 장려할 수 있도록 돕는 것을 목표로 한다 (80). 비자발적 입원이나 강제력 사용은 CAPS에선 없다. 어떠한 개인도 센터로의 접근이 거부되지 않으며, 여기에는 위기 상황이나 어려운 상황에 처 한 이들도 포함된다. 센터에 방문하기 위해 정신 건강 진단은 별도로 필요로 되지 않는다. 2. 광범위한 지역 사회 참여 – CAPS에 있어, 지역사회 기반이 된다는 것은 비단 해당 지역 사회에서 만 이용할 수 있는 서비스에 국한되지 않으며, 오히려 지역에 사는 개인들 뿐만 아니라 지역에 대 한 완전한 참여와 이해를 필요로 한다. CAPS 팀원들은 지역사회의 사람들과 대화하여 사회 역학을 이해하고 삶과 정신 건강에 가장 큰 영향을 미치는 공통적인 문제를 지도화하여 정신건강과 심리 사회적 필요에 대한 더 나은 이해를 얻는다. CAPS에서 팀원들은 지역사회 자원을 확인하고 활성화 하며 사람들 및 서비스와 파트너십을 구축하여 정신건강케어 이니셔티브를 진행한다. CAPS는 또 한 심리사회적 장애를 가진 개인의 권리 증진과 낙인 및 편견을 줄이는 이니셔티브와 같은 정신건 강과 심리 사회적 장애 주제에 대해 지역사회와 참여한다. 3. 탈시설화 – CAPS는 정신 병원과 기타 기관 시설을 대체하도록 설게되었기 때문에 (81), 모든 CAPS 는 복잡하고 어려운 위기적인 상황에 대처할 수 있는 역량과 책임을 가지며 지역사회 기반 관행으 로 치료와 지원을 제공한다. CAPS는 이러한 역할이 전통적인 기관 서비스의 물리적 대안으로 작용 하는 것 이상이 필요하다고 해석하고 서비스, 관행 및 태도를 탈시설화한다. 개인 수준에서 이는 개 인의 인권 인식, 다양한 삶의 방식에 대한 존중, 사용자의 검증 및 권한 부여 실천, 사용자가 자신과 회복 과정에 대한 지식을 알고 있음을 존중하는 것을 의미할 수 있다. 서비스 수준에서는 센터 내 어떠한 문도 잠겨있지 않으며 서비스를 사용하는 개인은 언제든지 센터 내 어느 공간이든 언제든 지 들어가거나 나갈 수 있다. 비자발적 입원이나 격리는 CAPS에서 사용되지 않는다. 강박의 사용 은 CAPS 모델의 핵심 원칙에 어긋난다. 운영 관행 각 CAPS는 서비스 사용자와 더 넓은 지역사회의 요구를 잘 충족하도록 그 관행을 형성할 수 있지만, 모든 CAPS에 걸친 운영 관행에는 중요한 공통점이 있다 (80). 사람 중심의 회복 계획 개발 • 모든 서비스 사용자를 위한 광범위한 사람중심 회복 계획 (Projeto Terapêutico Singular (PTS))은 개인과 팀원에 의해 공동 개발된다. 여기에는 개인사, 개인의 필요와 요구, 사회적 관계, 현재의 삶 의 맥락, 어려움, 강점과 목표가 포함된다. 개인은 미래에 대해 성찰하고 위험을 감수하도록 격려된 다. 개인의 권리를 증진하고 해당 권리들을 누릴 수 있도록 초점이 맞추어져 있다. 계획은 또한 책 임을 공유하는 치료 전략을 설정한다. PTS를 개발하는 것은 사람들이 자시의 회복 과정을 책임질 수 있도록 하는 권한을 부여하는 전략으로 여겨진다. PTS는 지속적으로 검토되고 업데이트된다. CAP의 모든 활동은 사용자의 PTS를 반영한다 (82). 권한 부여 조치 • CAPS는 서비스 내 권력 불균형을 인식하고 해결하고자 한다 (예. 팀원들은 권력 차이를 인식하고 관계에서 권력을 재분배하고자 한다). • 직원들은 대화, 협상, 권리 행사를 위한 긍정적인 기회를 창출한다. 예를 들어, 서비스 사용자들은 지역사회와 관계를 맺고 참여하는 것 (예. 지역 시장에서 구매하는 것), 재정 관리 및 갈등 조정에 대한 실질적인 지원을 받는다. • CAPS 센터는 서비스 이용자, 가족 구성원 및 직원이 참여하는 정기적인 모임을 개최한다. 모임은 CAP에서의 일상과 활동에 대한 논의뿐만 아니라 가난과 낙인과 같은 사용자에게 영향을 미치는 광 범위한 주제 에 대해서도 토론한다. 모임에서 모든 사람은 동등하게 참여하며 모든 사람은 논의 및 결정에 책임을 진다. • 서비스 이용자들은 경영진 회의, 정신건강 컨퍼런스 및 정신건강 포럼에 참여할 것을 권장 받는다. 팀원과 CAPS 사용자 간의 요구에 중점을 둔 미팅 • 첫 번째 환영 미팅 (Acolhimento)에서 목적은 환영과 긍정적 역동성을 만들고 특정 순간에 개인의 필요를 충족시키기 위함이다. 환영 팀원은 서비스를 설명하고 함께 센터가 해당 개인에게 적합한 서비스인지 확인하는 과정을 시작한다. 팀원들은 개인의 필요와 요구, 개인사, 사회적 및 지지 관계 망, 일반적인 정신 건강을 이해하기 위해 그들의 말에 귀기울인다. 첫 번째 미팅에 대한 정보는 기 록되며, 서비스 사용자는 언제든지 이 정보에 접근할 수 있다. 표준화된 정신건강 검진 도구나 평가 도구는 사용되지 않는다. • 이후의 모든 개별 미팅 (치료 활동 포함)은 동일한 접근 방식을 유지하며, 팀 구성원들은 정신 건강 진단, 개인사 혹은 과거 담화에 초점을 맞추기 보다는 해당 시간 동안 개인의 요구를 적극적으로 듣 고 인식한다. 그룹 활동 • CAPS 서비스는 센터와 지역사회 모두에 그룹 활동을 제공한다. 그룹 활동은 친목을 도모하고 관계 를 쌓으며, 공존과 소속감을 고취시킬 수 있는 기회를 제공한다. 각 CAPS는 사용자의 PTS와 CAPS 및 지역사회에 이용 가능한 자원에 따라 어떤 활동을 수행할 것인지 정한다. 활동 유형에는 자기 관 리, 예술, 연극, 무용, 사회 활동, 요리 및 정원 가꾸기 등이 포함된다. • 일부 그룹 활동은 CAPS에 등록된 사용제에 국한되지 않고 더 넓은 참가와 참여를 도모한다. 이러 한 활동은 사교할 수 있는 더 넓은 기회를 제공하고 지역 사회 참여를 증가시키며 낙인을 감소시킬 수 있다. 가정 방문 • 개인들은 잠재적으로 CAPS를 사용하는 것에 대한 첫 번째 미팅 혹은 추가적인 필요를 위해 가정 방문을 진행하게 된다. 이는 센터에 접근하거나 접근하는 데 어려움을 겪는 개인들이 여전히 센터 의 지원에 접근할 수 있도록 보장한다. 가족 지원 • CAPS 서비스는 가족 구성원의 개별 및 집단 치료 전략을 개발한다. 가족 구성원의 역할과 치료에 대한 공동 책임을 지원하기 위해 가족 구성원의 요구를 파악하고 충족시키는 것을 목표로 한다. 참여 공간 제공 • CAPS는 서용자가 서비스에서 낮 혹은/과 밤 (CAPS III일 경우) 을 보낼 수 있는 가능성을 제공한다. 사용자는 진행 중인 활동에 참여할 수 있고 서비스 관행에 대한 의견을 제시하고 다른 이들과 함께 이를 개정할 수 있다. 그들은 다른 사람과 함께 할 수 있는 기회를 가지며 점진적으로 새로운 사회 적 관계, 소속감 및 참여 공간을 만든다. 위기 지원 • 심각한 위기에 처한 개인은 환영과 지원을 받게 되며, 서비스의 비자발적 입원이나 강제력 사용은 없다. 위기에 처한 개인은 절대로 강압적 관행이 사용될 수 있는 다른 서비스로 이송되지 않는다. • CAPS에서 위기는 개인의 삶과 회복의 순간으로 이해되며, 자신의 명시된 희망, 필요 및 선호에 기 반하여 지원받아야 한다. 지원은 열린 대화 (Open Dialogue)의 원칙에 기반한다 (더 자세한 내용은 정신 건강 위기 서비스: 개인 중심과 권리 기반 접근방식을 중심으로 참조). • 팀원들은 개인의 의견을 듣고, 발생가능한 갈등을 이해하고 중재할 수 있다. 지원은 서비스 자체에 서, 개인의 가정에서 또는 지역사회 공간에서 제공될 수 있다. 심리사회적 재활 • 심리사회적 재활은 CAPS의 가장 중요한 측면과 활동 중 하나이다. 이러한 활동은 각 개인의 고유 한 필요 및 개인사, PTS를 반영한다. 치료에는 개인의 일상 활동에 지원자로 동행하는 팀원, 가족이 나 지원 네트워크와의 관계 및 갈등 중재, 개인의 회복에 기여하는 개인이나 집단 활동 제공이 포 함될 수 있다. • 심리사회적 재활의 핵심 지점은 적극적인 시민권 보장이다. 예를 들어, 여기에는 한 개인과 동행하 여, 서류를 가지고 공식적으로 시민으로 인정받을 수 있도록 관료제 탐색 지원을 제공하거나 한 개 인이 공부 또는 일할 수 있도록 기회를 창출하고 그렇게 함으로써 개인의 사회적 참여 증가를 포함 할 수 있다. • 심리사회적 재활은 지역사회 자원으로 이니셔티브를 만들고 개발하는 것도 포함한다. 주거, 사회생 활, 직장 등의 영역에서 재활 전략을 개발하여 개인의 사회 참여를 가능하게 하고 자율성을 향상시 키는 기회를 창출한다. • 이러한 행동은 사람들이 사회로부터 점점 더 인정받고 적극적인 시민 역할을 가질 수 있다는 점에 서 CAPS 서비스에 접근하는 개인들을 위한 새로운 사회적 소속 장소 구축을 목표로 삼는다. 네트워크 조정 및 결합 • CAPS는 독립 생활 시설, 일차적 보건 센터, 응급 서비스 및 병원 서비스와 기타 네트워크 및 기관 을 포함한 기타 정신 건강 및 일반 건강 서비스에 대한 지원을 제공한다. 이 지원의 목적은 각 서비 스 사용자의 PTS에서 역할을 수행하기 위해 다양한 서비스 및 서비스 네트워크의 공동 관리 및 공 동 책임에서의 협력을 증진시키는 것이다. • 정신건강 네트워크의 전략적 서비스로서 CAPS는 권리 증진 및 보장을 목적으로 건강, 교육, 정의 및 사회 지원 네트워크에서 다른 서비스와 지역사회 자원과의 연계 및 파트너십을 구축하기 위한 전략을 개발하고 시행한다. CAPS III에서의 일반적인 낮과 밤 – 캄피나스 캄피나스의 CAPS III에서는 평균 60명의 사람들 (서비스 사용자와 팀원들)이 어느 날이든 서비스에 참여한 다. CAPS III에서의 낮은 웰빙, 자기 관리, 사회적 교류를 증진하고 서비스에 접근하는 개인과 팀원 및 커뮤 니키 간의 관계를 강화하는 다양한 활동으로 활기 넘친다. 일반적으로 CAPS III는 서비스에 오는 사람들을 위한 식사를 준비하고, 그날의 예상치 못한 요구를 들어주고 충족시킬 수 있도록 지원을 제공하며 활동을 제안하고 사회적 교류를 위한 기회 제공하는 등 CAPS에서의 하루가 잘 흘러갈 수 있도록 팀원을 지정한다. CAPS를 사용하는 개인은 하루동안 왔다 갔다 하며 영화를 보고, 이야기를 나누고, 사람들을 만나고, 케이크 를 굽고, 게임을 하고, 함께 신문을 읽거나 식물에 물을 주는 것이 흔하게 일어난다. 게다가, CAPS III 활동은 지역 사회에서 이루어진다. CAPS 팀원들은 Núcleo de Atenção à Saúde da Família 팀과 독립 생활 시설과 같은 다른 지역 사회 정신건강 서비스로 가서 가족 건강 팀을 지원하고 독립 생활 시설 거주자들을 방문하여 지원을 제공한다. 팀원들은 또한 CAPS III 서비스 사용자들과 함께 활동에 동행 하며, 지역 사회에서의 심리사회적 재활 활동과 행동을 실천한다. 예를 들어, 개인과 팀원은 어딘가로 가거 나 (목적지를 계획하고, 버스 티켓 비용을 지불한 적절한 금액을 나누고, 타기에 적합한 버스를 고르는 것과 관련된) 근처 동네 산책을 (집을 떠나 이웃에 대해 알게 되고 주변을 돌아다니며 다른 사람들과 관계를 맺 는 등의 활동) 고를 수 있다. 팀원들은 또한 지역사회 기반의 “공존 센터” 및 문화 센터와 같은 기타 도시 서 비스, 일과 수입 창출을 위한 지원 활동에 개인이 참여하도록 지원한다. 야간에는 개인이 전문가의 지원을 받으며, 해당 시간대 서비스에서는 사람들의 필요를 충족할 수 있는 활동 들을 기획한다. 사람들이 안전하고 보살핌을 받는 환경에서 위기를 결험할 수 있는 환영받는 환경이 조성된 다. 캄피나스의 CAPS III에서 하룻밤 이상을 지내는 기간은 평균 6.7일 (2020년 기준)이다. CAPS 센터는 브라질의 지역사회 기반 정신 건강 네트워크에서 핵심적이고 전략적인 서비스를 제공하지만 네트워크 내의 다른 서비스는 필수적 보완 역할을 수행한다. 지역사회 기반 건강 센터 지역사회 기반 건강 센터 (CBHC) (Unidade Básica de Saúde)는 사람들이 브라질 공공 의료 시스템으로 진 입하는 첫 번째 점점으로 간주된다 (83). CBHC는 일반 지료, 소아과, 산부인과, 간호학 및 치과에 걸쳐 기본 적인 지역사회 치료를 제공한다. CBHC 내에 위치한 가족 건강 팀(Family Health Teams)은 CBHC와 지역사 회 간의 중요한 연결고리를 제공한다. 가족 건강팀의 주요 책임 중 하나는 지역에 있는 모든 가족이 해당 CHBC에 등록되어 가족의 일반적인 건강과 생활 조건을 모니터링하고 의료 서비스를 제공하는 것이다. 가 족 건강 팀의 주요 실무자는 자신이 일하는 지역사회, 해당 지역에 사는 사람들, 해당 지역의 독특한 역학 및 어려음에 대한 이해와 지식을 갖춘 기본 수준의 전문가로 지역사회 의료 종사자 (Community Health Workers (Agentes Comunitários de Saúde))로 지칭된다. 지역사회 기반 건강 센터 – 캄피나스 캄피나스에는 66개의 CBHC(대략 20,000 거주민 당 1개 대응)가 있다. 캄피나스의 모든 CBHC는 CAPS의 서 비스와 연결되고 지원을 받는다. 캄피나스의 일반적인 CBHC의 직원 수는 다양하지만 최소 직원 수는 다음 과 같다: 코디네이터, 의사 (소아과, 산부인과 전문의 포함), 간호사, 치과의사, 간호조무사, 치과조무사 및 지 원 직원. CBHC의 약 1/3에는 정신과 의사, 심리학자 및 작업치료사를 포함한 정신건강 전문가가 있다. 캄피 나스의 소규모 CBHC에는 위에서 설명한 지원 직원 외에도 16-20명 사이의 전문 역할이 있다. 중간 규모의 CBHC에는 47명의 전문가들로 구성되며, 대규모 CBHC에는 84명의 전문가와 지원 직원이 있다. 캄피나스의 모든 CBHC에는 가족 건강팀이 있으며 캄피나스에는 146개의 가족 건강팀이 있다. 가족 건강팀의 최소 직 원 구성은 다음과 같다: 의사, 간호사, 2명의 간호 기술자, 및 지역 보건 요원. 더 나아가, 대부분의 가족 건 강팀에는 소아과 의사, 산부인과 의사, 영양사, 심리학자, 작업치료사, 물리치료사, 사회복지사, 치과의사 및 치과조무사를 포함한 기타 지원 전문가가 있다. NASF (Núcleo de Atenção à Saúde da Família) 팀 NASF는 CBHC의 가족 건강팀에 직접적인 일반 지원을 제공하는 다학제 전문가 팀이다. 이 팀들은 정신 건 강 전문은 아니지만 정신 건강 전문 지식을 포함한다. NASF 팀은 일반적으로 사회복지사, 심리학자, 작업 치료사, 영양사, 체육 전문가, 약사, 물리치료사 및 언어 치료사, 그래도 대개 의사로 구성된다. NASF는 임상 사례에 대해 논의하고, 가족 건강팀과 CBHC 팀과 공유 상담을 진행하고, PTS 계획 개발에 협 력하며, 예방 및 건강 증진 활동을 전달함으로써 지원을 제공한다. NASF는 또한 그들의 전문 분야의 CBHC 전문가들을 위한 역량 강화에 관여하고 덜 심각하고 복잡한 정신건강 요구를 가진 개인들에게 치료와 지원 을 제공한다. NASF가 이러한 요구를 충족시키기 위해 CBHC를 성공적으로 지원할 수 있을 때, 그 지역의 CAPS가 더 복잡한 정신건강 요구를 가진 개인에게 치료와 지원을 제공하는 데 집중할 수 있도록 한다. 이 는 CAPS 서비스로의 과도한 수요를 막는 데 도움이 된다. NASF는 CAPS와 동일한 인권 원칙을 따르고 필요 에 따라 CAPS와 연결 및 함께한다. 그들은 격리, 강박 혹은 어떠한 강압적인 치료를 행하거나 촉진하지 않 는다. NASF는 15,000명 미만의 거주민이 있는 지자체에 특히 중요하다. 브라질 지방 단체의 약 60%를 대표하고 전체 브라질 인구의 12%를 차지하는 이 지자체들은 CAPS 자격을 얻을만큼 크지 않다. 따라서 이 지자체들 내에서 일차적 의료 서비스 수준의 지역사회 기반 건강 센터 조치는 그들이 서비스를 제공하는 사람들의 정 신건강 요구에 대한 주요 치료 및 지원 전략이다. NASF – 캄피나스 캄피나스에는 총 5개의 NASF가 있다. 직원 수는 그들이 지원하고 서비스를 제공하는 지역 사회의 특정한 필요와 요구를 반영한다. 캄피나스에 있는 모든 NASF에는 일반적으로 최소한 다음을 포함한다: 정신과 의 사, 심리학자, 작업치료사, 필요에 따라 추가적인 전문가. 길거리 아웃리치 팀 (Street Outreach Team) 길거리 아웃리치 팀(Equipes de Consultório na Rua)은 CBHC의 일부이며 노숙자 인구에 초점을 맞추고 있 다. 팀은 지원, 의료 서비스, 해당 인구가 노출되는 위험(예를 들어 도시 폭력에서 더 큰 위험, 재정 수입의 부족, 사회적 지원 네트워크의 부재, 약물 사용과 관련된 위험)에 대한 보호를 제공하고 해당 지역 사회의 권리를 수호하고 촉진하기 위한 조치를 취한다. 팀은 일반적으로 노숙자 인구뿐만 아니라 정신 건강 질환, 심리사회적 장애 그리고 약물 사용과 관련된 문제를 가진 사람들에게도 정신 건강 치료를 제공한다. 길거리 아웃리치 팀은 그들의 서비스로부터 혜택을 받을 수 있는 개인들이 자주 방문하는 지역 혹은 지방을 계획, 배치하고, 해당 지역에 직접 방문하여 도움과 지원을 제공하며, 보건 및 사회 서비스로의 이동을 제공한다. 길거리 아웃리치 팀은 지속적인 대화를 나누고 서비스 대상자들의 요구를 가장 잘 충족시키기 위해 CBHC, 가족 건강팀 및 CAPS와의 파트너십을 발전시킨다 (78). 서비스들은 개인에 대한 관련된 정보와 회복 과정 을 공유하고 개인의 필요를 충족시키기 위해 필요한 조치 또는 지원을 확인한다. 길거리 아웃리치 팀은 또 한 약물을 사용하는 개인들을 포함하여 CAPS에 대한 접근을 용이하게 하도록 도울 수 있다. 팀은 4명에서 7명의 멤버들로 구성된다. 팀에는 간호사, 심리학자, 사회복지사, 작업치료사, 의사, 정신건강 문제를 경험한 사회 요원, 간호조무사 및 치과 보건 기술자를 포함할 수 있다. 길거리 아웃리치 팀은 사람들을 강압, 강박 또는 격리가 사용될 수 있는 정신병원이나 다른 서비스로 이송하거나 하도록 지시하지 않는다. 길거리 아웃리치 팀 – 캄피나스 캄피나스에는 2개의 길거리 아웃리치 팀이 있으며, 2020년에는 매달 약 476명의 사람들을 지원했다. 캄피 나스의 길거리 아웃리치 팀의 일반적인 인력 구성은 다음과 같다: • 의료진 1.75명 (70시간과 상응하며, 1명의 정신과 의사와 3명의 내과 의사에 의해 제공됨) • 간호사 2명 • 작업치료사 1명 • 심리학자 2명 • 사회복지사 1명 • 피해 감소 전문가 3명 • 간호기술자 3명 • 행정보조원 1명 • 운전사 2명 • 코디네이터 1명 길거리 아웃리치 팀은 그 날 하루의 활동을 계획하기 위해 매번 근무일의 시작에 만난다. 팀들은 도시의 취 약한 상황에 놓여 있는 사람들이 사는 곳, 일반적으로 공공 광장으로 아웃리치 서비스를 제공한다. 길거리 아웃리치 팀은 매일 이런 지정된 지역으로 이동해서 그들이 근무하는 텐트를 설치하고 상담을 시작한다 (예 를 들어, 간호 및 사회 보조 평가, 다른 서비스와 사회적 활동으로의 이동 등이 있다). 캄피나스의 노숙자들 에게 의료 서비스를 제공함에 있어서, 음악과 카포에이라(브라질의 춤과 같은 무술)와 같은 문화 활동이 의 료, 간호와 정신건강 치료와 함께 존재한다. 길거리 아웃리치 팀에 의해 한 번 평가되면, 개인은 일차적 치 료 네트워크 및/또는 CAPS로 이동되어 그들의 정신 건강 필요 및/또는 약물 사용에 대한 문제를 확인할 수 있다. 해당 서비스는 이후 개인의 필요를 지원하고 충족시키기 위해 통합적인 방식으로 긴밀하게 협력한다. 캄피나스의 길거리 아웃리치 팀은 또한 노숙자 및 임산부와도 긴밀하게 협력한다. 여기에는 지원이 필요할 수 있는 개인 식별, 양육 모니터링 및 보호소와 산과 병원으로의 이동 제공을 포함한다. 2020년에는 캄피나 스 길거리 아웃리치 팀은 임산부이자 노숙 중인 100명의 여성을 지원하여 아기가 산모 또는 대가족과 함께 지낼 수 있도록 했으며 아기가 양육 시설로 보내지는 것을 막았다. 길거리 아웃리치 팀은 더 넓은 네트워크 는, 특히 사회 지원 및 공공 보장 측면에서, 해당 사람들의 치료에 있어 중요하다. 길거리 아웃리치 서비스 에 의해 매달 지원되는 사람들 중 평균 20명이 성인을 위한 CAPS 참석에 동행하고 65명은 CAPS ad에 참석 에 동행한다. CAPS와 길거리 아웃리치 서비스 둘 다 해당 사람들의 치료를 담당한다. 독립 생활 시설 독립 생활 시설(Serviços Residenciais Terapêuticos (SRT))은 정신병원이나 요양병원(custody hospital)에서 퇴원한 장긴 입원 이력(2년 이상 연속)이 있는 사람들을 위해 고안된 지역 사회 내에 위치한 주택이다. 가족 이나 지원 네트워크가 없는, 또는 가족에게로 돌아갈 가능성이 없는 개인에게 SRT는 지역사회 내 독립 숙박 옵션을 제공한다. 해당 서비스는 브라질 정신의학 개혁 과정의 탈시설화 전략의 일부이다. SRT는 최대 10명의 거주자를 수용할 수 있으며, 여성 전용, 남성 전용, 혼성 주택이 있다 (81). 각 거주지에 는 5명의 간병인과 1명의 간호기술자가 있다. 각 개인의 PTS를 사용하여, 자율성, 사회정 포용 증진 및 권리 보장을 목표로 개인과 SRT, CAPS와의 긴밀한 파트너십을 통해 심리사회적 재활을 제공한다. 개인은 SRT에 무기한으로 거주할 수 있다. 이들은 보건 또는 사회 서비스라기보다는 개인의 집으로 간주되며 규제 및 검 열에서 벗어난다. 원칙적으로 SRT에서는 격리, 강압 및 강박은 사용되지 않는다. 독립 생활 시설 – 캄피나스 캄피나스에는 총 160개의 공간을 수용할 수 있는 20개의 SRT가 있다. 현재 캄피나스에는 139명이 거주하 고 있다. 캄피나스에 있는 SRT의 일반적인 직원 구성을 가지고 있는데, 여기에는 SRT에 거주하는 사람들의 요구에 따라 주택 보조, 모니터 및 간호 기숙자를 포함한다. 또한 거주하는 사람들의 요구에 따라, 각각의 집은 고 유한 구성을 가지고 있다. SRT의 일상 생활에서 거주자들은 여가, 종교적 의식, CAPS에서의 활동과 같은 지역사회 내 다양한 활동에 참여하거나 그들의 관심사 추구 및 방문객 초대와 같이 집에 있을 수 있다. 각 SRT에는 매주 토의를 통해 거 주자들이 그 주의 메뉴를 결정한다. 그리고 거주자들은 필요하다면 간병인의 도움을 받아 필요한 식료품을 사러 나간다. 거주자들은 또한 집안일을 관리하지만, 더 심각한 임상 상태와 상당한 지원이 필요한 사람들 이 거주하는 집의 경우, 청소팀이 있다. SRT 주택은 캄피나스 전역에 걸쳐 위치한다. 모든 SRT는 CAPS III와 연결되며 SRT와 CAPS 서비스 간의 지 속적인 대화와 참여가 이어진다. CAPS 팀원은 매일 SRT에 방문하여 주택에 대한 쇼핑 리스트가 최신 상태 인지, 개인 구매가 필요한 사람은 없는지, 모든 거주자가 괜찮은 상태인지와 같은 매일의 삶을 확인한다. CAPS에서 치료를 제공하는 동일한 전문가가 지역사회의 심리사회적 재활 과정에도 참여하기 때문에 SRT 와 CAPS의 연결은 특히 중요하다. 이는 다시, 서비스 및 지역사회 수준에서 개인 치료 계획(PTS)에 대한 전 반적인 개발과 감독을 용이하게 한다. 다만, 각 SRT 거주자는 자신의 필요와 요구에 따라 지역사회의 정신 건강 서비스 네트워크에 참여한다. 귀향 프로그램 (Going Back Home Programme) 귀향 프로그램(Programa De Volta Para Casa)은 장기 정신과 입원(2년 이상 연속으로)에서 퇴원한 사람들 에게 재원을 이전하는 것으로 구성된 탈시설화 전략이다. 이 프로그램의 목적은 무엇을 사야할지, 어디로 가야할지와 같은 선택을 가능하게 하는 소득을 보장함으로써 개인의 계약력을 강화하여 심리사회적 재활 을 촉진시키기 위함이다. 연방 차원에서 지급되는 월 금액은 2020년에는 412 브라질 헤알(R$)(약 US$ 72)13 이었다. 귀향 프로그램 – 캄피나스 캄피나스에서는 현재 총 139명의 사람들이 귀향 프로그램의 수혜자이며, 매달 57,268 브라질 헤알(R$)(약 US$ 10,070)13의 비용이 든다. 종합병원 내 정신건강 병상 종합병원의 정신건강 병상(Leitos de saúde mental em Hospitais Gerais)은 정신건강 질환, 심리사회적 장 애 및 약물 사용과 관련된 문제와 필요를 가진 사람들에게 의료 서비스를 제공한다. 종합병원 내 정신건강 병상에 대한 접근은 중앙집중형 병상관리시스템을 통해 조정된다. 입원은 임상적 기준에 기반하며 입원은 (개인의 임상적 안정성이 퇴원을 허용할 때까지로) 짧은 기간이어야 한다. 병상에 접근하기 위해서는, CAPS 와 같은 정신건강 네트워크 서비스가 병상의 사용을 반드시 요청해야한다. 이는 병상을 사용해야할 특정한 필요가 있는 사람만이 사용할 수 있도록 보장하고 부적절한 병상 이용과 불필요한 입원을 피하기 위함이다. CAPS는 종합병원에 있는 정신건강병상으로 사람을 이동시킬 수 있다. 예를 들어, CAPS를 이용하는 2차적 인 수준의 치료가 필요한 개인이 일반적인 건강과 관련된 동반질환 혹은 어려움 및 요구가 있는 경우에 해 당 개인을 후송할 수 있다. 종합병원의 정신건강 병상은 한 지역의 정신병원 입원에 대한 장벽의 역할을 할 수 있다. 정신건강 병상은 정신건강 요구를 가진 개인이 입원하거나 정신건강 유닛 혹은 병동의 일부일 경우 병원이 마련해 둔 링-펜스형 병상(ring-fenced beds)일 수 있다. 종합병원의 정신건강 병상 수는 최대 25개까지로, 총 병상 수의 15%를 초과할 수 없다. 종합병원의 정신건강 병상은 최소 4개이다. 브라질 정신건강 네트워크의 일환으로, 이 병상들은 앞서 열거한 서비스와 동일한 원칙을 따른다. 하지만, 작성 당시 해당 서비스에는 강압적 치료 사용에 대한 평가 데이터가 없었다. 일화적 정보는 강압적 관행(즉, 기계적 및 화학적 강박의 사용)이 사용될 수도 있으며 이러한 치료는 병원마다 다를 수 있음을 시사한다. 추 가적인 과제는 서비스 전반에 걸친 개인 치료의 연속성을 보장하기 위해 네트워크 내 다른 서비스와 해당 서비스를 효과적으로 통합하는 것이다. 13 2021년 3월 환율 기준. 종합병원 내 정신건강 병상 – 캄피나스 캄피나스의 두 종합병원에는 36개의 정신건강 병상이 있다. 한 병원인, Complexo Hospitalar Mayor Edvaldo Orsi에는 20개의 정신건강 병상이 있고, 다른 병원인, Hospital das Clínicas da UNICAMP에는 총 14개의 병 상이 있다. 정신건강 병상은 두 병원 모두 지정된 병동에 위치해 있다. 이 중 하나의 병동의 인력 수준을 설명하기 위해, 종합병원 Complexo Hospitalar Mayor Edvaldo Orsi의 정 신건강 병동 내 인력 배치는 다음과 같다: • 정신과 의사 1명 (의료적 책임이 있는 서비스 코디네이터) • 의료 감독관 1명 • 간호 감독관 1명 • 당직 정신과 의사 1명 • 간호사 1명 • 간호 기술자 5명 • 작업치료사 1명 • 심리학자 1명 • 사회복지사 1명 캄피나스에서 입원은 일반적으로 위기의 심각성과 개인의 필요를 바탕으로 위기 상황 동안 지원을 위해 사 용된다. 개인은 또한 현재 환경에서 병상을 제거하기 위해, 또는 정신과 치료 및 기타 의학적 특수성이 필요 한 임상적 동반 질환의 존재로 인해 이러한 병상 중 하나로 이동되어질 수 있다. 해당 병상은 특히 취약한 미성년 연구에서 진단 목적 (CAPS ad 서비스 사용자의 치료에 일반적임) 혹은 보호 목적으로도 이용될 수 있다. 정신건강 병상은 CAPS 및 종합병원에서 개인이 혜택을 받을 수 있다고 여겨질 때 종합병원에서 그 사 용이 고려될 수 있다. 예를 들어, 병원은 CAPS의 바쁘고 활동적인 환경에 비해 병원이 어떠한 개인에게는 더 적절한 환경을 제공해줄 수 있고 네트워크에서 CAPS III 내에 기숙사 공석이 없는 경우에도 대안을 제공 할 수 있다. 개인이 캄피나스의 종합병원 정신건강 병상에 입원할 경우, 병원 팀과 개인의 이송 서비스 (예. CAPS) 팀은 해당 개인의 PTS를 지속하기 위해 노력한다. 그들은 사용자의 회복 계획과 그들이 병원에 입원하는 동안 필 요할 수 있는 조정 사항에 대해 논의하게 된다. 예를 들어, CAPS에서 개인에 대한 전문가의 방문은 입원 기 간 동안 일반적이고 권장된다. 개인이 이 병상 중 하나를 사용하는 동안 서비스와 팀원 간의 참여는 계속된다. 종합병원 팀은 서비스 사용 자에게 더 나은 서비스를 제공하기 위해 회의에 참석하고 공유 전략을 논의하기 위해 CAPS에 간다. 종합병원에서 제공하는 치료는 정신건강 네트워크 및 CAPS와 동일한 원칙을 따른다. 위기 상황에서는 언 어적 접근과 약물치료 접근 모두 사용하되, 약물 사용의 경우 개인의 동의가 있어야 한다. 그러나 네트워크 는 극단적인 사황에서는 강박이 사용될 수도 있고 이를 변경하는 것이 중요하다고 보고하였다. 종합병원 정신건강 병상은 위기 상황을 경험하는 개인에게 추가적인 지원을 제공할 뿐만 아니라, 모든 지자 체의 정신건강 서비스와 연계하고 협력할 수 있는 능력을 위해 캄피나스 네트워크에서 중요하다. 응급 및 긴급 서비스 정신건강 네트워크와 관련된 응급 및 긴급 치료 서비스는 이동 응급 서비스, 응급 치료 유닛 (독립형 응급 치료 특수 서비스) 및 병원 응급실을 포함한 일반 의료 시스템의 응급 서비스 네트워크의 일부이다. 일반적 인 지침으로서, 응급 및 긴급 치료 서비스는 정신건강 필요를 가진 개인이 해당 서비스들 중 하나에 나타났 을 때 CAPS와 함께 일한다. 도착 시, 응급 서비스는 개인과 관련된 CAPS에 연락한다. 일단 연락이 이루어지 면, CAPS는 개인에 대한 치료에 책임을 공유한다. 예를 들어, 개인의 필요에 대한 논의, 후속 응급 서비스 조 치, 응급 서비스에서 퇴원 시 지역사회에서 개인의 PTS 재개 등이 있다. 기타 정신건강 네트워크 서비스 리셉션 유닛(Unidade de Acolhimento)은 사회적으로 취약한 상황에 있거나 일시적인 기간 동안 집중적인 치료와 모니터링이 필요한 경우에 약물 사용과 관련된 문제 및 필요가 있는 사람들의 보건 서비스에 CAPS 센터에서 지원을 제공하도록 설계된 지역사회 기반 주거 서비스이다. 해당 서비스에서는 약물 사용 서비스 가 본 문서의 범위를 벗어났기 때문에 더 자세히 설명되지는 않는다. 네트워크 간 이니셔티브 브라질 네트워크의 강점은 이러한 서비스가 지역사회의 진화하는 요구를 충족시키기 위해 공존할 뿐만 아 니라, 개인과 지역사회 측면에서 변화하는 네트워크 간 이니셔티브에 있다. 해당 이니셔티브는 지역사회 차 원에서 정신건강 및 심리 사회적 장애에 대한 인식과 참여를 확대하는 데 도움이 되어왔다. 공존 센터 공존센터(Centro de Convivência (CECO))는 지역사회의 모든 구성원들에게 개방된 지역사회 기반 센터이 며, 심리 사회적 장애가 있는 사람, 인지 장애가 있는 사람, 노인, 사회적으로 취약한 아동 및 청소년의 참여 가 매우 권장된다. CECO의 주요 목표는 공존을 위한 기회 조정 및 촉진이며, 사회적 포용 및 소속을 촉진이 다. CECO는 국가 정신 보건 정책의 일부로 간주되며, 현재 브라질의 일부 지역에서만 시행되고 있다. CECO 는 주 및 지자체 차원에서 자금을 지원받는다. 공존 센터 – 캄피나스 캄피나스 전역에서 5개의 공존센터(CECO)가 있으며, 각각 매달 120명에서 300사이의 인원을 수용할 수 있 다. 캄피나스의 CECO의 일반적인 직원 구성은 다음과 같다: 2명의 전문가(심리학자, 작업치료사, 그룹 리더, 체육교육자 또는 간호사), 감독, 청소 보조 및 코디네이터. 캄피나스의 CECO는 국가 정책적 차원에서 CECO가 인정되기 이전에 지방 공공 정책의 일환으로 설립되었 으며, 지방 차원에서 재정을 지원받는다. CECO는 대개 공원이나 녹지에 위치하며, 심리 사회적 재활, 예방 및 건강 촉진 관점에서 보건, 스포츠, 문화, 교육 및 환경과 연계한다. CECO 활동은 CECO에 접근하는 개인의 포용과 자율성에 기여할 수 있는 두 가지의 주요 주제를 반영한다 – 공존(그룹 활동, 공개 미팅, 사람들 간의 차이에 대한 이해와 관용 증진)과 파트너십(공공 기간과 시민 사 회). 예를 들어, CECO는 CAPS 사용자와 SRT의 거주자 모두가 참여할 수 있는 교육 부문과 협력하여 청년과 성인을 위한 문해력 프로그램을 개발했다. 각 CECO는 매달 각자의 활동 일정을 게재한다. 활동에는 문해, 기타 레슨, 영어, 카포에라, 줌바, 그림 및 공 예 활동, 정원 활동, 영화 워크숍, 요리 등이 포함된다. 모든 활동은 무료로 진행되며, 지역사회에 열려있고 종종 자원봉사자들의 적극적인 참여를 필요로 한다. CECO는 또한 정신건강 서비스와 직접적으로 연계된다. 예를 들어, CECO가 개인의 PTS를 향상시킬 수 있다 고 CAPS가 확인하면 (일부 CECO 활동에 참여하는 것이 개인에게 도움이 될 수 있다는 점에서) 이송이 이 루어질 수 있다. 마찬가지로 CECO도 활동에 참여한 사람이 잠재적으로 CAPS의 서비스로부터 혜택을 받을 수 있다는 게 확인이 되면, CAPS로의 이송이 용이해진다. 근로와 소득 창출 서비스 및 이니셔티브 근로와 소득 창출 이니셔티브는 일할 권리를 보장하고 근로를 위한 훈련과 자격 제공을 목표로 한다. 이러 한 이니셔티브는 사회적 포용과 자율성을 촉진하여 힘을 증대시키고 개인의 생활 조건을 개선한다. 이니셔 티브는 정신건강 네트워크에 접근하는 개인의 주인공주의를 강화하기 위한 심리사회적 재활 전략이기도 하 다. 여러 지역에서 수행되는 이니셔티브 중 일부는 요리, 공예품, 의류 생산, 농업, 재활용, 도장, 서비스 렌더 링, 판매 등이 있다. 이러한 이니셔티브는 연대적 경제 관점에 기반하고 있다 (85). 근로와 소득 창출 서비스 및 이니셔티브 – 캄피나스 캄피나스는 연대경제와 근로 및 소득 창출에 초점을 맞춘 두 가지 서비스를 가지고 있다 - 워크숍 하우스 (Casa das Oficinas)와 워크숍과 근로 센터(Núcleo das Oficinas e Trabalho)가 있다. 이 두 서비스 모두 일할 권리 보장, 자율성 증진, 일을 통한 사회적 포용 함양, 사회적 조합과 협동조합 참여에 초점을 맞춘 활동을 개발한다. 해당 서비스는 집합적이고 참여적인 훈련 활동과 소득 및 일자리 생성 활동을 개발한다. 다른 서 비스의 경우 제품인 워크숍 창고(Armazém das Oficinas)를 상품화하는 데 초점을 맞춘다. 워크숍 하우스(Casa das Oficinas)는 코디네이터, 심리학자, 작업치료사, 감독, 행정 보조 및 청소 보조원으로 구성되어 있다. 요리, 고정 봉제(Gira Mundo), 수공예, 인쇄, 빵 만들기 및 모자이크와 같은 7가지의 근로 및 소득 창출 이니셔티브를 가지고 있다. 매달 약 50명이 해당 서비스를 사용한 다. 워크숍과 근로 센터(Núcleo das Oficinas e Trabalho)는 코디네이터와 행정 보조원으로 구성되어 있다. 근로 및 소득 창출 이니셔티브 각각에는 작업치료사, 심리학자, 사회복지사 또는 건축가 및 감독이 될 수 있는 별도의 코디네이터가 있다. 조직에는 12가지의 근로 및 소득 창출 이니셔티브가 있다: 종이 재활용, 가구 제조, 금속 세공, 모자이크, 이벤트, 농업, 요리 및 레스토랑, 인쇄, 스테인드 글라스, 종교 스테인드 글라스, 봉제 및 유압/세라믹 타일이 있다. 매달 약 300명의 사람들이 해당 서비스를 사용한다. 이러한 서비스 중 하나에 접근하기 위해, 개인이 CAPS와 같은 지자체 정신 건강 서비스 중 하나로 이송되 어야 한다. 근로 및 소득 창출 프로젝트와 워크숍에 대한 모든 선택사항을 안내 받은 후, 개인은 참여하고 싶은 이니셔티브 또는 활동을 고를 수 있다. 모든 참가자는 제품의 생산 및 판매의 결과로 보수를 받는다. 총 판매 가치는 각 사람의 성과 평가에 따라 참가자 간에 나눠진다. 이 월간 평가는 서비스 코디네이터, 프 로젝트 및 워크숍의 감독, 개인으로 구성된 그룹에 의해 이루어지며, 출석, 시간 엄수, 책임감, 이니셔티브 및 창의성 등의 기준을 고려한다. 다만 캄피나스의 네트워크에 따르면 공식적인 고용시장에 참여할 수 있는 사람의 수는 현저히 적다. Serviço de Saude Dr. Cândido Ferreira는 직접 고용을 통한 대안적인 고용 수단을 개발했다. 이 프로젝트를 통해 2020년 9월 기준 34명이 일자리를 얻었다. 문화적 이니셔티브 – 캄피나스 캄피나스의 정신건강 네트워크에는 정신건강 서비스를 이용하는 개인, CAPS, SRT, CECO 등의 전문가 및 가 족이 참여하는 다수의 집단 및 교차 네트워크 프로젝트도 있다. 이니셔티브의 예시로는 정신건강 서비스 사 용자, 가족, 사회 프로젝트, 직원 및 지역사회 사람들을 한자리에 모으는 라디오 프로그램인 Rádio Maluco Beleza가 있다. 라디오는 다양한 주제를 다루는 다양한 프로그램이 하루 24시간 방송된다. 또한, 사회적 포 용 및 시민권과 정신건강 서비스에 관련된 뉴스 및 이벤트를 다루는 격월 간행물인 Jornal Candura가 있다. 그리고 InterCAPS를 담당하는 스포츠 이니셔티브인 Coletivo de esportes는 시민사회 사회운동을 기념하 고 정신의학적 개혁에 대한 발전을 요구하는 국경일인 5월 18일을 기념하고 캄피나스와 지역의 CAPS를 한 자리에 모으는 행사이다. Coletivo de esportes는 캄피나스의 CAPS 내에서 매주 열리는 축구 선수권 대회 인 Inclusion Cup도 담당한다. 해당 이니셔티브는 정신건강 서비스 및 지역사회 공간에서의 스포츠 활동을 통해 직원, 서비스 사용자 및 가족 간의 주간 만남을 활성화시킨다. 서비스의 기본이 되는 핵심 원칙과 가치 법적 능력 존중 정신건강 서비스에 접근하는 개인의 법적 능력 존중은 브라질의 지역사회 기반 정신건강 네트워크의 원칙 에 내재되어 있다. 서비스 수준에서 이는 개인 주도의 회복 계획, 비자발적인 입원이나 치료의 부재, 권력 불 균형의 사전적 해결, 서비스 내에서와 지역사회 모두에서 법적 능력을 행사하고 누릴 수 있도록 지원하는 점들이 반영된다. 귀향 프로그램(Volta Para Casa)과 SRT는 제도화된 이력이 있는 개인이 사회에서 법적 능 력을 발휘할 수 있도록 지원하고 개인 주도로 복귀할 수 있도록 지원한다. 강압적 관행에 대한 대안 강압적 관행의 사용은 브라질엣서 지역사회 기반 정신건강 네트워크의 원칙에 위배된다. 서비스는 오히려 충돌하고 어려운 상황에서 협상과 조정의 관행을 강조한다. 권력 불균형을 해결하고 개인의 경험, 요구, 필 요, 선호, 개인 주도의 회복 계획에 대한 개인의 지식을 인지함으로써 서비스는 서비스 사용자와 지속적인 대화와 신뢰 관계를 발전시키며 강압적 관행에서 벗어나 서비스 역학을 전환한다. 2020년 NASF, CBHC, SRT 또는 길거리 아웃리치팀에서 강압적 관행의 사용에 대한 보고는 없었다. CAPS에서 강압적 관행의 발생은 드물고 서비스와 팀원들이 용인할 수 없는 관행으로 간주되었다. 다만, 종합 병원에서 강압적 관행 (물리적, 사회적 강박)의 사용은 병원마다 다른 것으로 확인되었다. 이는 변화를 위해 지속적인 관심과 노력이 필요 한 영역이다. 그럼에도 불구하고 브라질의 네트워크는 강압적 관행의 사용을 방지하기 위한 관계 구축의 중 요성과 성공을 보여준다. 지역 사회 포용 개인 차원에서, 개인은 네트워크로부터 사람중심 회복 계획(PTS)의 안내를 받아, 그들의 필요와 선호에 따 라 그들의 지역사회에 참여할 수 있도록 지원받는다. 예를 들어, SRT를 통한 개인의 요구를 반영하여 균형 잡힌 지원이 가능하다. 정신건강 네트워크는 포용이란 집단적 성격을 반영하여 지역 사회를 활발하게 하며, 사회적 포용의 가능성이 만들어지고 그 과정에서 지역사회와 관계의 변형은 지역사회 사람들과의 집단적 행동을 통해서이다. 더 넓은 대중에게 개방된 CAPS 활동, CECO 및 문화적 이니셔티브와 같은 관행은 지역 사회 포용, 다양성 그리고 낙인 감소 촉진을 촉진한다. 서브시간의 파트너십과 서비스 간의 수행되는 지속 적인 치료의 관행은 건강, 정신건강, 고용, 스포츠 및 문화 등 다양한 영역에 걸쳐 지역사회에 대한 사람들 의 접근과 포용을 증진시킨다. 참여 네트워크에서는 CAPS 의회와 같은 집단 대화 전략이 적극적으로 사용된다. 사용자는 네트워크 및 서비스 관행을 포함하여 서비스 네트워크의 설계 및 실행에 참여한다. 이는 서비스 내 사회적 교류, 정신건강 포럼 과 같은 공식 구조, 정신의학 개혁을 위한 시민 조직의 사회 운동을 통해서도 매일 발생한다. 회복 접근 방식 지역사회 기반 정신건강 네트워크의 원칙은 자율성, 사회 참여, 지역사회 포용 및 평등권 증진을 포함하는 회복 접근 방식과 일치한다. 서비스 전반에 걸친 사람중심 회복 계획(PTS)의 사용은 회복 접근방식과 일치 하며, 각 개인이 자신의 희망, 목표 및 포부를 확인하고 자신의 회복 여정을 주도하도록 장려한다. 각 서비 스의 초점과 네트워크 구조, 특히 교차 네트워크 이니셔티브는 지역사회 참여, 고용, 교육, 문화 및 스포츠에 대한 접근과 같은 필수 회복 요소를 포함하는 사람 전체의, 총체적인 접근방식에 도움이 된다. 서비스 평가 브라질 네트워크의 규모와 복잡성으로 인해, 다음은 브라질의 지역사회 기반 정신건강 네트워크와 관련된 모든 연구를 포괄적으로 설명하지는 않는다. 이 섹션에는 브라질의 여러 지자체 및 지역의 정신건강 네트 워크에 대한 평가 데이터가 포함된다 (일반 네트워크 연구와 CAPS 중심 연구로 구분된다). 캄피나스 지자체 의 사례에서도 연구가 제시된다. 이 문서의 목적을 위해 검토된 평가 데이터는 네트워크가 개인과 지역사회 에 고품질 서비스와 지원을 제공할 수 있음을 뒷받침 한다. 지역사회 기반 정신건강 네트워크, 브라질 여러 연구에서 브라질의 지역사회 기반 정신건강 네트워크를 평가했다. 2015년 브라질의 정신건강 서비스 에 대한 연구를 체계적으로 검토한 결과, 환영 및 인도적 태도, 사회적 고립 탈피, 관계 구축, 임상 조건 개 선, 삶의 질 및 정신건강 지원과 관련한 제도화의 대안으로 개발된 서비스에 (예. CAPS) 대한 만족도가 보고 되었다 (86). 또한, 자신감, 정서적 건강, 수면의 질 및 어려운 상황에 대응하는 능력의 개선도 보고되었다. 정신 병원과 정신병원을 대체하는 지역사회기반 정신건강 서비스 및 전략을 비교했을 때, 지역사회기반 정 신건강 서비스가 더 효과적이고 효율적인 것으로 나타났다. 2019년 연구는 CAPS 증가 및 1차 치료 센터 커 버리지와 정신병원 입원율 감소간의 상관관계를 입증했다 (87). 1차 의료 서비스 팀과 CAPS II와의 연계에 대한 연구에서, 지역사회의 위기상황에서 의료의 질이 증가하면서 경찰 행동, 물리력 사용, 응급 및 입원의 비자발적 실행과 같은 강압적 관행의 확대 및 사용을 방지했다 (88). NASF의 역할은 해당 관행을 지원하는 명확한 정책과 관행을 가진 지자체에서 CAPS와 같은 전문가 서비스의 과도한 수요를 방지하고 경증 및 중 증 정신건강 요구를 지원하는 데 효과적인 것으로 나타났다 (89, 90). 시골 지역에서 NSAF 팀의 실행은 또 한 보건 서비스가 제안한 활동에 대한 개인의 참여를 증가시키는 것으로 나타났으며 건강 필요는 보다 종 합적으로 반영되었다 (91). SRT와 같은 주거 서비스는 장기입원을 경험한 개인이 자신의 힘과 자율성을 함 양하고 관계 수립 및 사회 참여를 증가시키도록 지원하는 것으로 드러났다 (92, 93). 유사한 연구 결과는 귀 향 프로그램과 같은 재정 프로그램의 역할이 장기간의 입원 이후 개인의 복귀와 지역사회에서의 삶을 지원 함을 뒷받침한다. (91, 94). 다만 연구에 따르면 네트워크에는 서비스 통합, 지역사회 기반 서비스 센터(CBHC) 지원에서 네트워크가 제공하는 정신건강 조치의 유효성, 거주민의 복잡한 요구와 필요를 관리하기 위한 SRT 간병인 역량 강화 등의 과제가 존재한다 (90, 95). 이러한 연구는 서비스를 제공받는 지역사회의 필요를 충 족시키는 데 얼마나 네트워크가 잘 협력할 수 있는지와 네트워크 시설 간 통합의 중요성에 대한 네트워크 의 변화 범위를 강조한다. CAPS 연구들은 CAPS를 사용하는 개인과 가족 구성원 모두에게서 높은 수준의 만족도를 확인했다. 만족도를 측 정했을 때 (1-5의 척도로), 2018년의 한 연구는 4.6의 결과를 보고했다. 전문적인 역량, 요구에 초점을 맞춘 첫 미팅 및 치료 제공, 존경과 존엄성 있는 대우와 관련된 질문은 가장 높은 수준의 만족도를 기록했다 (96). CAPS는 또한 개인의 자율성, 회복에 대한 공동 책임, 주인공주의의 확장을 장려하는 것으로 나타났다 (97, 98). 가족 구성원들은 서비스, 치료의 질과 그들이 받는 지원에 대한 만족도를 보고했다 (99, 100). CAPS 사용자 1,888명을 대상으로 한 2010년에 진행된 전향적 코호트 연구에서, CAPS 관행이 어려움 겪거 나 위기 상황에 처한 사용자를 지원하는 데 효과적임을 발견했다 (101). CAPS에 참여한 후, 24%의 사용자 는 위기의 부재를 보고했고, 60%의 사용자는 위기 발생 빈도의 감소, 그리고 70%의 사용자는 낮은 강도를 보고했다. CAPS에 참여한 시간이 길수록, 마지막 정신과 입원 이후 경과한 시간이 더 길어졌다. CAPS의 시 행은 자살 위험을 14%만큼 감소시킨 것으로 드러났다 (102). 2018년 부문 간 교차 연구에서 4개의 지자체 의 917명의 CAPS 사용자를 인터뷰했다. “모든 도시에서 CAPS에서 치료가 시작된 후 정신과 병원에 입원한 사용자가 10% 미만”인 것으로 밝혀졌다 (103). 지역사회 기반 정신건강 네트워크, 캄피나스 캄피나스에 대한 연구는 시스템과 개인 차원 모두에서 네트워크의 유효성을 입증했다. 캄피나스에서 CAPS III 장기 사용자는 위기 발생, 약물 사용 및 정신과 입원 횟수가 감소한 것으로 드러났다. 비집약적 CAPS 사 용자는 약물투여 횟수 감소를 경험하였다. 서비스를 사용하는 개인과 가족 구성원 모두 위기 시점과 심리사 회적 재활 측면에서 서비스에 대한 높은 수준의 신뢰를 보고했다 (104). 특정 CAPS 관행도 긍정적으로 받아 들여졌으며, 특히 CAPS III의 하룻밤 숙박 시설에 대한 가용성과 신뢰 및 모든 CAPS 사용자에 대한 “실무자 (reference practitioner)”를 할당 받았다 (105, 106). 부문 간 교차 연구에서, 95%의 CAPS 사용자는 CAPS에 참여한 이후 정신과 입원을 한 적이 없다고 보고했으며, 73%의 사용자는 위기 상황에서 CAPS를 찾았고, 0% 의 사용자가 정신병원을 찾은 것으로 보고했다. 해당 연구는 정신병원의 대체로써 캄피나스의 지역사회 기 반 네트워크의 전제를 뒷받침한다 (103). 정신건강 네트워크와 일반건강 네트워크 간의 긍정적인 통합의 중 요성도 확인되어 네트워크 간 지식과 경험을 공유하고 치료의 연속성이 가능하게 하였다. (107). 비용 및 비용 비교 정신건강 네트워크는 보다 광범위한 보건서비스 네트워크의 일부이며, 통합보건시스템(SUS)에 따라 전달된 다. 이 보편적 보건시스템은 연방, 주, 지자체 차원에서 재원을 조달하며, 공적 조세 시스템을 통해 유지된 다. 주민들이 네트워크 내 어떤 서비스에 접근하여 사용하여도 직접적인 비용은 들지 않는다. 캄피나스 네트워크 비용 2019년 캄피나스의 연간 보건 예산은 약 12억 브라질 헤알 (약 2억 1,300만 달러)14였다. 지역사회 기반 정 신건강 네트워크는 총 예산의 6.6%를 할당받았으며 이는 8,000만 브라질 헤알 (약 1,400만 달러)에 해당한 다. (해당 수치에는 일반 병원의 정신건강 병상 비용이나 광범위한 CBHC 비정신건강 비용은 포함되지 않는 다.) 이는 캄피나스의 1인당 연간 약 67 브라질 헤알 (약 12달러)의 비용과 동일하다 (약 120만 인구 기준). 과제 및 해결책 열악한 의료 보장 증가 캄피나스에서 지역사회 기반 정신건강 네트워크를 구축하는 데 있어 초기 과제는 정신건강을 포함한 일반 건강의 적용 범위를 다루는 공중보건시스템의 부재였다. 이 문제를 극복하기 위한 첫걸음은 1980년대 브라 질이 1988년 보편적 공중 보건 시스템 (SUS)을 시행하면서 건강(및 정신건강)을 헌법적 권리로 인정하고 확 립하면서 시작되었다. 생의학 모델 및 정신병원 우세에 대한 저항 캄피나스에서 지역사회 기반 네트워크를 구축하는 데 가장 큰 장애물은 생의학 모델과 정신병원 우세로, 인 권 침해, 사회적 배제, 정신건강 문제가 있는 사람들에 대한 권력 부정으로 이어졌다. 탈시설화와 자유 우선 원칙에 초점을 맞추고 모든 차원의 보건 체계에서 지속적인 치료를 촉진하는 것을 목표로 하는 인권 기반 14 2021년 3월 환율 기준 국가 정신건강 정책의 수립을 통해 탈시설화 과정에 착수했다. 다른 접근 방식들은 다양한 차원에서 모색되었고 포함되었다: 정신병원 폐쇄와 지역사회 기반 서비스 개발 에서의 성공을 포함한 탈시설화 경험을 보여주고 촉진하는 것, 정신병원의 규모를 줄이고 지역사회 기반 서 비스를 확대하기 위한 과정을 지속적으로 평가하기 위한 프로그램을 수립하는 것, 더 나아가 개혁의 강력한 수단에는 재정의 방향을 정신병원에서 점진적이고 단계적인 접근 방식을 사용하여 지역사회 기반 서비스 의 개발로 바꾸는 것을 포함했다. 마지막으로, 개방적인 대화와 다른 국가들로부터의 경험에 대한 표현은 사고방식을 변화시키고 앞으로의 가능한 길을 보여주는 데 도움이 되었다. 탈시설화에 대한 정치적 저항 해소 네트워크가 직면한 또 다른 심각한 어려움은 지자체와 지역사회 차원에서 정신과 병상의 탈시설화와 폐쇄 에 대한 지역 정치적 저항의 존재였다. 다른 부문과 제도들도 법체계를 포함한 제도화를 지지하는 태도와 관행을 견지했다. 이러한 장벽을 극복하는 데 도움이 된 주요한 측면은 정신건강 문제를 가진 사람들의 권리를 보장하고 지 역사회 기반 정신건강 서비스를 구현하기 위한 규제 규범을 법으로 제정하는 것이었다. 또한 서비스 이용자, 가족, 정신건강 네트워크 직원들 간의 의사결정을 민주화하고 토론을 장려하기 위해 국가적, 지자체적 차원에서 정신건강 컨퍼런스를 개최하는 것도 이러한 정치적 저항을 해소하는 데 도움이 되었다. 이 네트워크는 정신건강 시스템의 모든 단계의 이해관계자들에 의해 논의되고 토론되었으며, 이는 승인과 약속의 단계를 만들어냈다. 마지막으로, 시민사회 운동은 네트워크의 진보성을 진전시키기 위해 활 동을 계속한다. 인권에 대한 열악한 인력 지식 해결 또다른 지속적인 과제는 지역사회 기반 정신건강 서비스에서 일하는 새로 영입된 전문가들이 인권에 대한 지식과 이해가 부족하는 점이다. 다른 부문을 포함한 모든 이해관계자들과 지속적인 대화에 참여하여 우려 를 해소시키고 지역 차원에서 해당 어려움을 해결하기 위한 실질적인 지원을 제공하는 것은 정신건강 맥락 에서 인권에 대한 이해를 향상시키는 데 도움이 되었다. 추가적으로 효과적인 해결책은 다학제적 접근방식 을 강조하는 학술 프로그램과 레지던트 프로그램에 대한 교육을 받는 사람들을 위한 CAPS 현장 실습을 기 획하는 것이다. 다양한 맥락에 대한 주요 고려 사항 다른 맥락에서 해당 서비스의 설립과 확장을 위해 고려해야 할 주요 사항은 다음과 같다: • 시스템의 모든 차원에서, 특히 정신건강 서비스, 가족 및 시민사회 운동에 접근하는 사람들과 지속 적으로 함께하여 필요한 네트워크 서비스를 식별한다; • 개인의 요구에 대한 전체 범위 (예. 정신, 신체, 고용, 교육, 지역사회 참여)를 충족시키기 위한 전체 적 사람 중심 접근방식 수용한다; • 적절한 환경에서 정신건강 요구의 범위를 충족시키기 위한 계층화된 서비스 (즉, 낮은 복잡성 요구 를 충족시킬 수 있는 NASF 지원을 통한 일차적 의료 센터, 높은 복잡성 요구의 경우 CAPS)를 고려 한다; • 각 영역의 정신건강 네트워크를 안내하는 총괄 조정 기구(브라질의 경우 CAPS와 CBHC)를 구축한 다. 추가적인 정보 및 리소스: 웹사이트: https://www.gov.br/saude/pt-br http://www.saude.campinas.sp.gov.br/ 비디오: Morar em Liberdade: Retratos da Reforma Psiquiátrica Brasileira - FIOCRUZ (Portuguese)/ Living in Freedom: Portraits of the Brazilian Psychiatric Reform - FIOCRUZ (English) https://www.youtube.com/channel/UCD2xLN_GIeJRWqOs8yWLDPQ/videos Memórias da reforma psiquiátrica no Brasil - FIOCRUZ (Portuguese)/Memories of psychiatric reform in Brazil - FIOCRUZ (English) http://laps.ensp.fiocruz.br/ Rádio ‘Maluco Beleza’ – Campinas (Portuguese)/Radio ‘Maluco Beleza’ – Campinas (English) https://www.youtube.com/watch?v=ujRDWeL_cnM 연락처: Coordination of the Area of Mental Health, Alcohol and other Drugs, Brazil. Email: saudemental@saude.gov.br Coordination of the Technical Area of Mental Health, Municipal Health Secretariat, Campinas, Brazil. Email: dptosaude@campinas.sp.gov.br Serviço de Saúde Dr. Candido Ferreira, Campinas, Brazil. Email: contato@candido.org.br 3. 앞으로 나아가기: 개념으로부터 우수한 통합 정신 건강 서비스 네크워크 사례로 이 섹션의 목적은 독자들에게 서비스 네트워크의 설정 또는 전환을 개념화하고 계획 수립 및 추진하는 과 정을 용이하게 하는 몇 가지의 주요 실천 단계 및 권장 사항을 제공하기 위함이다. 이 과정에서 사회 문화 적, 경제적 및 정치적 요인을 포함한 여러 맥락 특정 요인들이 중요한 역할을 하는만큼 이를 수행하기 위한 포괄적이고 완전한 계획을 의미하지 않는다. 서비스를 보건 및 사회 부문으로 통합하는 것에 대한 자세한 내용은 지역사회 정신건강 서비스에 대한 지침서: 사람 중심 및 권리 기반 접근방식 촉진의 지침 및 실행 단계 섹션에서 제공된다. 서비스 네트워크를 설정/전환하기 위한 실행 단계: • 사회적, 정치적, 경제적 맥락에서 서비스 네트워크를 설정하고 전환하는 데 중요한 전문 지식을 가 진 다양한 이해관계자 그룹을 구성한다. 이러한 이해관계자는 다음을 포함할 수 있지만 이에 국한 되지는 않는다: ➢ 보건 및 사회 부문의 정책 입안자 및 관리자, 정신건강 문제를 경험한 사람들과 그 조직, 일반 보건 및 정신건강 실무자와 관련 조직, 법률 전문가, 정치인, NGO, OPD, 학술 및 연 구 대표와 전통 치유자, 신앙 기반 조직의 지도자, 보호자 및 가족 구성원과 같은 지역사 회 게이트키퍼 • 모든 이해관계자가 모든 기술 패키지에 요약된 우수 사례 서비스 및 네트워크를 철저히 검토하고 논의하여 각 서비스 및 네트워크를 심층적으로 이해할 수 있는 기회를 제공한다. 이는 사회적, 정 치적, 경제적 맥락을 고려할 때 네트워크에 통합되기를 원하는 가치, 원칙 및 특징을 확인할 수 있 는 기회이다. • 관심있는 서비스와 네트워크의 관리자/제공자 연락을 취하고 네트워크를 설정/전환하는 방법에 대한 정보와 조언을 얻고 네트워크의 뉘앙스를 이해한다. 서비스 및 네트워크가 개발될 지역적 맥 락을 염두에 두고 어떻게 작동하는지에 대한 구체적인 질문을 한다. 이는 우수사례 서비스/서비스 네트워크 및/또는 화상 회의를 통해 가능하다. • WHO 퀄리티라이츠 대면 교육 자료 (https://www.who.int/publications/i/item/who-qualityrights- guidance-and-training-tools) 및 e-training 플랫폼을 사용하는 개인 및 네트워크 설정/전환과 관 련될 그룹에게 정신건강, 인권 및 회복에 대한 훈련과 교육을 제공한다. 주요 이해관계자의 태도와 사고방식의 전환은 변화에 대한 잠재적인 저항을 줄이고 정신건강에 대한 인권 기반 접근방식과 일치하는 태도와 관행을 발전시키기 위해 매우 중요하다. • 주거, 고용, 교육에 대한 접근 및 정신건강 뿐만 아니라 전체적 건강에 대한 적절한 보건 서비스 제 공에 국한되지 않고, 이해 관계자 논의에서 확인된 정신건강 질환 및 심리사회적 장애를 가진 사 람들의 필요 지원을 통합적으로 다루는 데 필요한 보건 및 사회적 부문에서의 역할과 책임에 대해 논의하고 합의한다. 서비스 네트워크를 설정/전환하는 데 필요한 질문: • (예를 들어, 위기 대응 서비스, 지역사회 정신건강 센터, 병원 기반 서비스, 지역사회 아웃리치 서 비스, 동료 지원 서비스 및 생활 지원 서비스에서의 가용성과 권리 존중 및 회복 촉진에 있어서의 운영 방식과 관련하여) 해결해야할 서비스 네트워크에서 어떤 격차를 확인했는가? • 기존의 지역사회 기반 정신건강 서비스 중 당신의 서비스 네트워크에서 전환하고자 하는 것은 무 엇인가 (다른 6개의 기술 패키지에 제시된 서비스 참조)? • 서비스 제공의 공백을 메우기 위해 새로운 지역사회 기반 정신건강 서비스가 만들어야 하는 것은 무엇인가 (예시로 다른 6개 기술 패키지에 제시된 서비스 참조)? • 이러한 서비스 개혁을 정신건강, 일반건강, 장애 및 기타 관련 영역에서 개발 중인 정책 및 전략으 로 구축할 기회가 있는가? • 네트워크를 통해, 그리고 네트워크에 포함된 각 서비스 범주 내에서 어떤 치료/개입을 제공할 계 획인가? 예시는 다음과 같다: ➢ 지역사회 포용과 관련된 개입 (아래 지역사회 포용 섹션 참조) ➢ 지원 필요성 및 사용자가 동의한 경우 이뤄진 진단에 대한 평가 ➢ 트라우마 정보 치료 ➢ 사람 중심 치료 계획 ➢ 심리치료 (예. 인지행동치료) ➢ 문제 해결 및 행동 활성화/활동 일정관리 ➢ 개인 및 그룹 기반 지원 상담/치료 ➢ 향정신성 약물 및 기타 약물 (약물 처방 및 약물에서 안전하게 벗어나기 위한 지원 포함) ➢ (서비스 사용자의 동의 하에) 가족, 친구, 지원자와의 대화/만남 ➢ 집과 지역사회로 돌아가는 사람들을 위한 과도기적 지원 ➢ 긴급 핫라인 전화 ➢ 동료 지지 ➢ 기타 • 당신의 서비스는 사람들이 가지고 있을 수 있는 신체적 건강 질환을 어떻게 평가, 제공 또는 (다른 병원으로) 보낼것인가? • 어떠한 추가적인 인력이(정신과 의사, 일반의 등을 포함한 의사, 심리학자, 간호사, 사회복지사, 동 료지원 종사자, 작업치료사, 아웃리치 종사자, 지역사회/비전문 종사자, 행정직원 등) 필요하고 그 리고 이들이 인권에 부합하는 질과 증거 기반 서비스를 제공하기 위해 필요한 새로운 기술과 교육 은 무엇인가? • 네트워크 내 모든 서비스 및 지원과 상향 및 하향 (환자) 의뢰 체계를 포함한 지역사회의 다른 서 비스 및 자원과의 상호관계는 어떠한가? • 서비스 네트워크에 대한 전반적인 조정 메커니즘은 무엇인가? • 네트워크 운영, 특히 서비스 통합과 네트워크 내 서비스 전반에 걸친 원칙과 가치의 일관성을 지 원하기 위해 어떤 메커니즘이나 논의가 필요할 것인가? • 법적 역량, 비강압적 관행, 참여, 지역사회 포용 및 회복 지향을 실현하기 위해 어떤 전략과 교육을 실행할 것인가?15 법적 능력 • 네트워크의 각 서비스에 지원되는 의사결정 매커니즘이 마련되어 당사자의 의지와 선호에 따라 의사결정이 이루어지도록 어떻게 보장할 것인가? • 네트워크의 모든 서비스에 걸친 치료 결정과 관련하여 서비스 사용자의 사전 동의에 대한 일관된 인권 지향적 접근을 어떻게 보장할 것인가? • 모든 네트워크 서비스는 사람들을 다음과 같이 어떻게 보장할 것인가: ➢ 치료와 돌봄에 대한 다양한 선택사항에 대해 정복에 입각한 결정과 선택을 할 수 있는지 ➢ 약물의 효능 및 잠재적 부자용을 포함한 약물 및 기타 치료와 관련된 모든 중요 정보를 제 공받았는지 • 네트워크 서비스가 각 개인의 사전 계획을 존중하는 절차를 가지고 있는지를 어떻게 보장할 것인 가? • 네트워크 서비스는 사람들이 필요한 경우 불만을 제기할 수 있도록 어떤 종류의 메커니즘을 구축 할 것인가? • 네트워크 서비스는 프로보노 법률 대리와 같은 유형의 서비스를 필요로하는 사용자를 대상으로 법률 자문 및 법률 대리에 대한 접근을 어떻게 용이하게 할 것인가? 비강압적 관행 • 서비스 네트워크 전반에 걸쳐 긴장 및 갈등 상황에 대한 비강압적 대응과 단계적 완화에 대한 전 직원의 체계적인 교육을 어떻게 보장할 것인가? • 서비스 네트워크는 사람들이 민감성과 고통의 징후를 탐색하고 대응하기 위한 개별화된 계획을 작성할 수 있도록 지원할 것인가? • 서비스 이용자의 요청에 ‘아니오’ 대신에 ‘네’라고 답할 수 있도록 ‘네라고 말하기’, ‘할 수 있어요’ 문화를 서비스 네트워크 전반에서 어떻게 만들어 나갈 거인가? • 서비스 네트워크는 인권 원칙에 맞게 운영되는 안락실(comfort room)과 대응팀을 어떻게 통합할 것인가? • 서비스 네트워크는 위기를 경험하거나 어려운 상황에 처한 개인에 대한 인권과 회복 지향적 지역 사회 기반 대응을 어떻게 접목시킬 것인가? 참여 • 정신건강 문제를 경험한 사람들이 어떻게 직원, 자원봉사자 또는 컨설턴트로서 서비스와 서비스 15 더 자세한 정보는 섹션 1.3 참조: 지역사회 정신건강 서비스에 대한 지침서: 사람 중심 및 권리 기반 접근방식 촉진 네트워크 내에서 팀의 필수적인 부분이 될 것인가? • 다양한 서비스와 네트워크 차원의 고차원적 의사결정에서 정신건강 문제를 경험한 사람들은 어떻 게 대표될 것인가? • 어떻게 서비스 이용자로부터 피드백을 체계적으로 수집하여 네트워크 서비스에 통합할 것인가? • 네트워크 서비스는 서비스 이용자를 지역사회의 동료 네트워크와 어떻게 연결지을 것인가? 지역사회 포용 • 서비스 네트워크는 사람들이 전환 고용 프로그램, 고용 지원 프로그램, 또는 적절한 독립 고용을 통해 일자리를 찾고 소득을 창출할 수 있도록 어떻게 지원할 것인가? • 서비스 네트워크는 주거 서비스에 대한 접근을 어떻게 용이하게 할 것인가? • 서비스 네트워크는 지역사회 기반 교육 기회와 자원에 접근하여 교육을 지속할 수 있도록 지원되 는 교육와 원조를 어떻게 용이하게 할 것인가? • 서비스 네트워크는 사회적 보호 혜택에 대한 접근을 어떻게 용이하게 할 것인가? • 서비스 네트워크는 사회, 문화 및 오락 프로그램, 이니셔티브 및 이벤트에 대한 접근을 어떻게 용 이하게 할 거인가? • 서비스 네트워크는 기관의 장기 거주자들을 포함한 개인들의 탈시설화 지역사회로의 복귀를 어떻 게 지원할 것인가? 회복 • 서비스 네트워크는 사람들이 전체적인 삶과 경험의 맥락에서 고려되고 치료와 지원이 단순히 치 료, 진단, 증상 감소에만 초점을 맞추지 않도록 어떻게 보장할 것인가? • 서비스 네트워크는 다음과 같은 다섯 가지의 회복 차원이 서비스 제공의 필수 구성 요소임을 어떻 게 보장할 것인가?: (1)연결성, (2)희망과 낙관, (3)정체성, (4)의미와 목적, (5) 자기 권한 부여. • 사람들은 회복 계획을 수립할 수 있도록 어떻게 지원 받을 것인가?; 이는 그들의 희망, 목표, 어려 운 상황에 대처하기 위한 전략, 고통 관리, 건강하기 위한 전략 등을 충분히 생각하고 기록할 것인 가? • 서비스 네트워크 전반에 걸쳐 사람들이 정기적으로 회복 계획을 검토하고 업데이트할 수 있도록 어떻게 지원할 것인가? 서비스 네트워크는 다른 이해관계자 및 지역사회에 정신건강에서의 인권 기반 접근 방식에 대한 교육과 지원 활동을 제공할 것인가? ➢ 서비스 네트워크는 시민사회단체를 포함한 지역사회 내 조직에게 교육과 지원을 제공할 것인가? ➢ 서비스 네트워크는 비전문 보건 서비스를 포함한 다른 보건 및 사회 서비스 직원에게 교육 및 지 원을 제공할 것인가? 인식 제고 및 옹호 ➢ 서비스 네트워크는 가족, 학교, 고용주, 지역 조직 및 기타 지역사회 환경을 포함하여 정신건강 및 인권에 대한 제고를 수행할 것인가? ➢ 서비스 네트워크는 정신건강 질환과 심리사회적 장애를 가진 사람들의 권리를 위해 정신건강과 인권에 대한 옹호 활동을 수행할 것인가? 그리고 개인이 자율적으로 살아갈 수 있는 지역사회를 만드는 것을 궁극적인 목표로 개인들이 지역사회에 참여할 수 있는 긍정적인 기회를 만들 것인가? 여기에는 정신건강에 대한 낙인을 감소시키고 지역사회 참여를 위한 긍정적인 기회를 만들기 위 한 행동이 포함된다. 서비스 네트워크는 지역사회의 사회적 역학을 이해하고 사람들의 삶과 정신건강에 가장 큰 영향을 미치는 빈번한 문제(예. 경찰 폭력, 마약 밀매 관련 위협, 경제적 어려움)를 지도화하기 위해 어떤 조치를 취할 것 인가? • 프로세스 문제, 제공될 전체적인 서비스에 기반한 서비스 네트워크 설정 단계, 서비스 네트워크의 비전 및 운영에 대한 세부 정보와 다음 사항을 포함되는 제안/개념 노트를 준비한다: ➢ 인력, 교육 및 감독 요건 ➢ 이 서비스가 다른 지역의 정신 건강 및 사회 서비스와 어떻게 관련되는지 ➢ 회복 접근 방식과 함께 법적 역량, 비강압적 관행, 지역사회 포용 및 참여의 인권 원칙이 구현 될 수 있도록 보장하는 전략 ➢ 서비스의 모니터링 및 평가에 관한 세부사항 ➢ 서비스 비용에 대한 정보와 이전에 있었던 서비스의 비용과 어떻게 비교되는지 • 정부 보건 및 사회 부문, 건강 보험 기관, NGO, 민간 기부자 등을 포함한 모든 선택사항을 탐색하 면서 서비스 네트워크를 설정하거나 전환하는 데 필요한 재원을 확보한다. • 자금 조달 메커니즘을 사용하여 인권기반 접근 방식을 고수하고 지속 가능한 우수 사례 서비스 네 트워크의 전환 또는 구축을 지원한다. • 행정, 재정 및 법적 요구 사항에 따라 서비스 네트워크를 설정하고 제공한다. • 서비스 네트워크 내의 다양한 서비스를 지속적으로 모니터링하고 평가한다. 그리고 서비스 사용 자의 만족도, 삶의 질, 지역사회 포용 기준 (고용, 교육, 수득 창출, 주거, 사회적 보호), 회복, 증상 감소, 질 및 인권 조건 평가 (예. 퀄리티라이츠 평가 툴킷 사용), 및 강압적 관행 비율 (자발적 치료, 기계적, 화학적, 물리적 강박)을 측정하고 연구를 발표한다. • 공개 포럼 및 청문회를 개최하여 사람들이 전체적인 서비스 네트워크 및 서비스 내의 개별 서비스 에 대한 시각, 아이다어 및 우려를 공개적으로 표현하고 이러한 우려를 해결할 수 있도록 하여 주 요 이해관계자와 대중 구성원과의 대화와 지속적인 소통을 구축한다. • 모든 관련 이해관계자 그룹(정치인, 정책 입안자, 건강보험기관, 매체, 정신건강 문제를 경험한 사 람들, 가족 NGO, OPD 및 전반적인 지역사회)와 함께 서비스 네트워크를 옹호하고 증진시킨다. 여 기에는 또한 전통 매체와 소셜 미디어 둘 다를 통해 적극적으로 접근하는 것을 포함한다. 서비스 네트워크의 성공을 공개적으로 강조하는 것은 사람들을 참여키시는 좋은 전략이 될 수 있다. • 서비스 네트워크의 지속 가능성을 보장하기 위해 필요한 전략과 체계를 마련한다. 62 Comprehensive mental health service networks References 1. 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Rev Saúde Pública. 2020;42:907-13. doi: 10.1590/S0034-89102008005000051. 107. Bigatão M, Pereira MB, Campos RTO. Ressignificando um castelo: um olhar sobre ações de saúde em rede [Resignifying a castle: a look at health actions in network]. Psicologia: Ciência e Profissão. 2019;39:e185242. doi: 10.1590/1982-3703003185242. 발 행 인 이유상 / 용인정싞병원 진료원장, WHO 협력센터 센터장 이효진 / 의료법인용인병원유지재단 용인정싞병원 이사장 번역 및 편집 발 행 처 용인정싞병원 WHO 협력센터 Yongin Mental Hospital, WHO Collaborating Centre for Psychosocial Rehabilitation and Community Mental Health 발 행 일 2024년 2월 16일 주 소 17089 경기도 용인시 기흥구 중부대로 940 전 화 031-288-0114 홈 페 이 지 https://www.yonginmh.co.kr 본 번역본은 세계보건기구(WHO)에 의해 작성되지 않았습니다. WHO는 본 번역본의 내용 또는 정확도에 책임이 없습니다. 영문판 원본 [Comprehensive mental health service networks]. 제네바: 세계보건기 구; [2021 ]. License : CC BY-NC-SA 3.0 IGO는 법적 구속력이 있는 정식 문서입니다. 이 번역 원본은 CC BY-NC-SA 3.0 IGO 에서사용할 수 있습니다. 용인정싞병원WHO 협력센터 통합 정신 건강 네트워크 Comprehensive mental health service networks