WHO CC for Research and Training in Mental Health, Dipartimento di Salute Mentale, ASS n.1 Trieste







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WHO CC for Research and Training in Mental Health, Dipartimento di Salute Mentale, ASS n.1 Trieste

1st Year Report - 2011 Activity 1

- Support to WHO-Euro in Central-Asian Republics for service development: from deinstitutionalisation to community services

The WHO national counterpart for Azerbaijan dr Sevil Asadova has been invited to Trieste for a first contact during the conference “Beyond the walls” (April 2011). A small group of leaders will attend the Summer School in Trieste, 19-24 /11/11.

As a second option, it has been discussed with WHO Euro the identification of Turkey as a possible partner, where national policies as well as WHO involvement are pushing for health system changes.

The collaboration of WHO with EU in Turkey is going through the financing agreement between the Government of the Republic of Turkey and the European Commission, under the IPA (Instrument for Pre-accession Assistance) - transition assistance and institution building component. This project is part of the EU acquis communitaries of Turkey accession chapters.

Title: Promoting Services for People with Disabilities (mental illness and intellectual disabilities) / (TR 080104)

Background: New project, first project of six years EU programme.

Beneficiaries: Ministry of Health of Turkey and Turkey Prime Ministry General Directorate of Social Services and Child Protection Agency (SHCEK)

Starting date: 28 October 2010

Duration: 2 years (with possibility of one year extension)

Expected results: Institutional capacity for supporting the mental health reform for people with disabilities (mental illness and intellectual disabilities):

§ Integration of policy and action plans on mental health and disability through assessment of standards, quality of care and needs of mental health and social care services,


§ Development of an integrated pilot model (following EU and WHO standards) for the community based services for people with long-term mental disorders and intellectual disability tailored to the Turkish context, establishing partnership activities with EU countries;

§ Development of workforce through training packages and programmes endorsed by the respective beneficiary institutions (MoH, SHCEK) and related universities.

§ Inter-sectoral coordination among health and social care systems as well as with other key stakeholders.

A delegation came to Trieste, including Vice Secretary of State and top leaders in 2010; then dr G Dell’Acqua presented at a national conference in Istanbul (October 2010) and there were two study visits (November 2010 and July 2011) in Bolu (identified as a pilot area) by two colleagues (dr B Bavdaz and dr G Ridente) of our MH Dept / WHO CC. The second visit was intended as a WHO Consultancy (24-30 July 2011) with the following terms of reference:

-Assessment of the functioning of treatment and care of existing and emerging mental health services in selected pilot area.

-Assessment of the functioning of the network of disability services in selected pilot area.

-Briefing / debriefing meetings with the WHO Country office team at the beginning and at the end of the consultancy.

-Prepare an action oriented mission report within two weeks of the end of mission.

A delegation from Turkey will attend the Summer School in Trieste, 19-24 /11/11 and furthermore there is a plan for a stage of a group from Bolu in October in Trieste.


Activity 2

– Support to WHO-Euro in Central and Eastern European countries for service development: collaboration for comprehensive CMH services.

After several contacts undertaken with WHO National Counterpart for Bulgaria dr Hinkov, he attended the international meeting “Beyond the walls” in Trieste, April 2011. Recently he communicated that there is a policy change for MH (the Natio-nal Center of Public Health Protection has been merged with another Center for Health Information and MH is not anymore a priority). Our WHO CC has been invi-ted to the National conference “Roadmap for the next steps in deinstitutionaliza-tion in mental health service delivery in Bulgaria”, Sofia, 7-8 October 2011 under WHO APW in order to keep the link alive. It has to be explored a possibility to work on a pilot project using EEA Grants and Norway Grants. The DEMoBinc pro-ject of the European Union for residential care has been completed in collaboration with the University of Sofia (coordinated by UCL).

In the meanwhile a cooperation project with Romania started on the basis of the visit to Trieste MH Services from 24 to 28 of May 2010 by a Romanian delegation led by prof.ssa Ileana Botezat, Director of the National Center for MH (a governmental body). The Italian-Romanian Symposium “D.I. as possible resource”, Bucharest, 25-26 November 2010, under Patronage of the Italian Embassy and the Official visit of the Presidency of Region FVG, 23-24 March 201 strengthen cooperation with a start-up financement of Region FVG. On 16-19 June 2011 there was a further visit to Bucharest, Iasi e Sucheava of our WHO CC to assess services and to develop to the Cooperation Plan in a view of an ESF application with another Italian Region (Veneto) and the involvement of 5 Romanian counties led by the “Socola” Hospital in Iasi (directed by prof. Calin Scripcaru). A Romanian delegation will attend the Summer School in Trieste, 19-24 September 2011. The “Socola” Hospital will organize in collaboration with the WHOCC and the IMHCN an International Conference in Iasi, 3-6 November 2011.

Other East European countries involved in cooperation with our WHO CC are:

- Czech Republic There is a pilot project in Psychiatric Hospital (Bohnice has 1 300 beds, serving catchment are about 1.5 million inhabitant) for building up community services, changing a philosophy of inpatient orientation of a staff of the hospital and starting process of transformation-deinstitutionalization. The project is supported by Ministry of Health and Norwegian funds. On the beginning WHO Collaborative Centre Trieste will support a project by helping with study visits in Trieste. All services of


Prague including NGOs have been involved in 2 subsequent visits (November 2010 and May 2011) and two participants to the Summer School. Other possibilities of concrete cooperation will be discussed later.

- Slovenia: an INTERREG project has been presented by University of Ljubljana – Faculty of Social Work and the Trieste WHO CC (name: FREE.ZE) with the aim of deinstitutionalizing residential facilities (social care homes) in the Primorska Region. It has been requested a collaboration for a Master School in Dubrovnik organised by the University of Ljubljana, together with the John Ruskin University, East Anglia, UK. Another plan of collaboration with Trieste WHOCC has been proposed by prof. Vesna Svab of the University of Ljubljana (Community Psychiatry in the Notranjska Region - Integration among social services and psychiatric services, Promoting deinstitutionalisation, Start building community mental health services with the support of the International community, Closing the large social and educational institutions).


Activity 3

- Latin America Network. Support to good practices in collaboration with PAHO, WHO-HQ and WHO-Euro

In Latin America, WHO CC has supported practically the South America Network either in Argentina – with initiatives related to the new mental health act of December 2010 - or in Brazil. Delegations from Brazil and Argentina came to Trieste during the international conferences promoted by WHOCC in 2010 and 2011. As one of the main actions, there is an ongoing training activity for about 60 young professionals per year coming mainly form these two countries which have the possibility to stay free up to three months (see activity 5).

Formal agreements have been developed in partnership through Italian Association “Permanent Conference for Mental Health Worldwide - ConfBasaglia”, that signed particularly two agreements: 1) with the National Institute of mental Health and Addictions of Argentina (Direccion Nacional de Salud Mental y Addicciones – DndSMyA) in order to sustain policies, service development, training for implementation of the new Act; 2) with the Health Departament of the Municipality of Belo Horizionte (Minas Gerais, Brasil) for the development of community services and of practices and policies supporting the rights of vulnerable groups.

Project with Bahia University – Cooperation for research with WHO CC and the

University of Trieste. On 06.07.2010, the Rector of the University of Trieste and the Rector of the Federal University of Bahia have signed the bilateral agreement between the two universities. This agreement provides for exchange of their expertise and field research to compare different business models and reality, but who are inspired by the same principles and the same determinants of health in the community: organization of health services for citizens fighting exclusion and social injustice through integrated health interventions, the eagerness of the people and solidarity. The axes of research are: 1. Deinstitutionalization and the closure of mental hospital, 2. Establishment and implementation of alternative mental health community services for the construction of a territorial network, 3. Development of cooperatives and social housing options, 4. Development of community health services with particular emphasis on vulnerable groups: elderly, children, adolescents, people with disabilities, 5. Rationalization of costs for the conversion of human resources and services, 6. Leading role of social movements, in particular users in the process of deinstitutionalization.


Also institutions in Colombia (e.g. Nazareth Hospital – Sumapaz) established a twin-ning collaboration with ASS n. 1 Trieste.

All these activity has at the moment no dedicated international financement for co-operation but only local funds for travels and Argentinean and Brazilian funds. A recent financement of the Region FVG (September 2011) is aimed at supporting the process of reform in Argentina.


Activity 4

– Support to WHO Headquarters for mhGAP Project. Provision of technical support to the project entitled "Mental Health GAP" promoted by WHO Headquarters.

- During the international meeting “Beyond the walls”, Trieste, April 2011, experiences in pilot countries for mhGAP have been presented (Jordan, Iran, Palestine, Mozambique).

WHO CC started the translation into Italian and a pilot implementation of the Intervention Guide in Udine.

- In Iran our collaboration will include support to mhGAP implementation.

During two group visits, 27 September-1 October 2010 and April 2011 (during the International Meeting “Beyond the Walls”) representatives of top institutional level of MH in Iran (MoH&ME) and the Director of WHO CC in at the University of Teheran, under the aegis of WHO Representative IR Iran dr. Manenti, Head of Office, had a first hand knowledge of the model of MH Dept Trieste and Udine. Then a mission as WHO consultancy (encompassing field visits, lectures and meetings) has been organised from 26 June to 1 July 2011 with the aims of:

 Assisting the Ministry of Health and Medical Education of Iran to develop a Com-munity Mental Health Pilot project;

 Providing lectures in different workshops with key mental health managers and mental health workers on Community -Mental Health and on the “Deinstitution-alization” experience of Trieste and the Italian Psychiatric Reform;

 Visiting Mental Health facilities in Iran;

 Participating in advocacy activities on Community Mental Health.

A workplan has been proposed for a follow-up, with pilot projects and related on-site and off-site training.


Activity 5

- Training and summer school

“Franca and Franco Basaglia International Summer School” - First module:

September 19-24, 2011, is entitled: “Beyond the walls - how to open the doors of psychiatric hospitals towards community based care and services. Focus on Europe and the East”. Organised by WHOCC in collaboration with

 WHO HQ and Euro


 ConfBasaglia

 Forum salute mentale


It is co-funded by: Friuli Venezia Giulia Regional Administration and WHO (relevant local offices supporting some specific delegations).

The first experimental module, in particular, is dedicated to the partners already in-cluded in the workplan, chiefly those from East European countries and some of the leading countries in the Mental Health Gap Programme (Geneva) which are experi-menting psychiatric care reform and transformation processes.

The summer school, in addition to that, interacts by means of international coopera-tion supporting the development of universally accessible social and health systems especially in those countries with which the Friuli Venezia Giulia has established part-nerships and cooperation relationships.

Hence participants are directors, leaders, experts and policy makers from Romania, Serbia, Bosnia-Herzegovina, Albania, Greece, Czech Republic, Azerbaijan, Iran, Tur-key and other countries.

The first module’s topic focuses specifically on supporting rehabilitation and social in-clusion of people with mental health problems still interned or treated basically in psychiatric hospitals. The living conditions and the lack of civil rights of inpatients, at least in the most outdated institutions, have repeatedly called for official statements and position papers by international bodies and authorities.

The Ottawa, Caracas and Helsinki declarations, as well as the EU’s Green Paper and the Pact on Mental Health and Well-being stated that the old psychiatric hospitals should be replaced with more adequate and modern care methods provided by com-munity based services.

The decade-long activity in the field of development cooperation and the widespread renown of the Friuli Venezia Giulia’s mental health system, in particular for what con-cerns Trieste, the pilot centre of the mental health reform and recovery of social and civil rights for people with mental health problems, have generated a massive de-mand for training from professionals all over the world. In Trieste every year about a thousand of mental health professional attend visits and training courses as well as


international exchanges on research and development of innovative treatment and care systems.

This experimental summer school module has therefore been developed as a first structured training response focused on reform and improvement of mental health care in order to create the conditions to guarantee to inpatients a real access to the right to health and social rights.

This edition will be followed by other modules focused on building integrated systems of community services, multidisciplinary work with the health and social sector, in or-der to develop a whole system approach based on the person and his community.

Meetings and conferences:

Among others, there were 2 world wide meetings organised by the ASS n.1 Trieste and the WHO CC / DSM:

“Trieste 2010: WHAT IS ‘MENTAL HEALTH’? Towards a global network of community health. International Meeting, Trieste 9-13 February 2010. It involved about 1500 attendees from about 30 countries.

“Beyond the walls: the transition from hospital to community based care. Deinstitutionalisation and International Cooperation in mental health”

Trieste, 13 – 16 April 2011. The meeting was attended by 300 participants from 28 countries - 21 of them European - representing national and local institutions, pro-jects and civil society organizations, the World Health Organization, the European Commission (Directorate General for Health and Consumers - DG SANCO), govern-ments, NGOs and international networks.During the works, the WHO Collaborating Centre for Research and Training/MHD-A.S.S. n. 1 Triestina was presented and the work plan for the next four years was launched, in line with the priority themes.

The Twinning collaboration with 3 SW England Trusts through IMHCN (UK, 2009-10 – Hertfordshire, September 2009; Study visit to Elderly Services, Cornwall, Jan 2010; Plymouth, Network Conference, March 2010) is progressing in order to sup-port the experimentation of innovations in acute and crisis services and in social enteprises.

The WHO CC contributed to the INTERNATIONAL CENTRE FOR RECOVERY ACTION IN PRACTICE,EDUCATION AND RESEARCH (ICRA-WHOLE LIFE), set up by IMHCN. It has been established to take action in:

 To further the concept and practice of a Whole Life-Recovery approach in men-tal health by believing in the user’s capacity to recover through self determina-tion and professional support.

 To create an evidence base for recovery practice by building a network of Re-covery Communities Development Sites and disseminating the results and


out-comes to other places in the world. (for Trieste: the CMHC of Barcola and the Day Centre of Aurusina are recognized as good practice demonstration sites).  To build a virtual learning centre for the training and education of professionals,

organisations, service users, family members and other stakeholders ICRA- Whole Life will form an International Research Committee that will: Collate and review existing research

Identify, develop and commission new areas of research jointly with users and professionals

For further information: www.icra-wholelife.org.

The ICRA has been launched by seminars in the UK and France. WHOCC will attend the presentation to psychiatrists in Cornwall on 30 September 2011.

-The website of the DSM of Trieste is visited by more than 30.000 users in the year.

-All materials of conferences 2010 and 2011 are available on the website.

- 590 professionals and other lay people in 2010 from 20 countries; 810 in the first six months of 2011 participated to the following initiatives of the WHOCC:

-training/seminars for MH staff in target countries, based on agreement with WHO/MNH

-study visits to model modern services for staff in target countries, based on agree-ment with WHO/MNH (target: health and social care professionals managers, ad-ministrators, politicians, students, associations, carers, users, volunteers)

-On-site short stages and individual/group visits

-On-site medium and long term stages for mental health professionals with free ac-commodation - ---Specialized courses for mental health professionals


Activity 6

– Preparation of deliverables on Deinstitutionalisation and Community-based Mental Health Services.

- The book “Beyond the walls – Deinstitutionalisation in European Best Practices”, edited by L. Toresini and R. Mezzina, includes 18 authors and has been issued in Meran, 2010, as WHO CC Document.

-An advanced draft has been developed of a guide on how to set up community-based mental health services.

-Presentations, visits to services and meetings In New Zealand, December 2010 – some of the most relevant kiwi NGOs for Rehab developed a document in collabor-ation with Trieste WHOCC called ‘La via Trieste’ for the implementcollabor-ation of Trieste model in that country.

-Presentations, visits to services and meetings in Australia, September (Dr Dell’Ac-qua, TheMHS Conference in Sydney) and Dec 2010 – cooperation for PH campus to the community (La Rozelle).

-The Manual for Prevention of Suicide in Jail: a project with Italian Ministry of Justice. Translation and adaptation of the WHO Manual (SUPRE project) to be distributed in the whole country.

-Trieste WHO CC (dr Mezzina and Dr Ridente) participated to the develpoment of QuIRC (Quality Indicator for Rehabilitative Care) which is an instrument developed to measure the quality of care in longer term residential units. It is currently available in ten languages (Bulgarian, Czech, Dutch, German, Greek, Italian, Polish, Portuguese, Spanish and Engish), with scope for further translations. QuIRC is freely accessibile online at http://www. quirc.eu.

-The Trieste WHOCC participated to the EU conference “Forgotten Europeans, forgot-ten rights”, International Seminar on the human rights of persons in institutional care, organised by the Office of the UN High Commissioner Human Rights (OH-CHR) Brussels on 27-28 October 2010, that issued a guidelines’ book.

As far as the meeting “Beyond the walls” (dedicated to the process of phasing out psychiatric hospitals as places of social exclusion and the shift to community services) is concerned, there are a number of results to be mentioned:

1.The Trieste Declaration 2011.

The Declaration, together with a theoretical background document, was approved and signed by all the delegates attending the meeting. As indicated by the Director of the WHO Department of Mental Health and Substance Abuse in Geneva, Dr. Shekar


Sax-ena, and Regional Director for Mental Health-WHO Copenhagen, Dr Matt Muijen, the Declaration was officially sent to WHO and the European Commission.

2. The Charter of deinstitutionalization actions.

The result of the discussions in plenary and group work consists of a series of over 20 projects and cooperation measures attached to the Declaration. The projects and con-certed actions are an indication of important business to realize the shared intention to change services emerged from the meeting.

The list of project proposals and cooperation actions is constantly updated and is open for further contributions.

It is our goal to build a "Charter of deinstitutionalization actions in Europe and world-wide," and the WHO CC in Trieste intends to follow and support it in cooperation with the international organizations.

3. The "Questionnaire" project.

The Questionnaire on the process of gradual phasing out mental hospitals - previously sent to the rapporteurs to gather evidence, know-how and good practice - will be used to develop guidelines and recommendations for de-institutionalization and train-ing.

In the following months, the QUESTIONNAIRE has been sent to the protagonists of the process of deinstitutionalization in the world and all those who agree to cooper-ate.


Activity 7

– Technical support on Mental Health services and Welfare Innovations ac-tions in Republic of Serbia and the Balkan region

Serbia – An international conference was organised by IMHCN and IAN was

organised with the aid of WHO CC in Nis and Belgrade, May 2010. In that conference there was a representation of the best experiences and models of deinstitutionalisation and CB services in Serbia and in the Balkans. Contacts occurred with their Minister of Health.

During the conference “Beyond the walls” a specific work group meeting on the Post-Stability Pact area took place (as reported in the action plan).

The Region Friuli Venezia Giulia under the request of cooperation from the UNDP / PH of Vlore and Minister of Health of Albania financed an exchange in order to support the deinstitutionalisation that in already in course in that town after several international contributions starting from Trieste WHO CC 8-10 years ago. An Albanian delegation will attend the Summer School in Trieste.

After the invitation of the Director of Skopje PH, Macedonia, dr Bajraktarov, to the International Meeting “Beyond the Walls” Italian Embassy and Minister of Foreign Office financed the participation to the Summer School of 4 Directors from Macedonia in order to foster their process of change in MH.

Delegations from Bosnia and Serbia attended either the International Meeting “Beyond the Walls” in Trieste, April 2011 or the Summer School.


Activity 8 – Support to the WHO Office in Palestine.

Collaboration with WHO in order to assist the Palestinian Ministry of Health in de-veloping a rehabilitation strategy and programme in Bethlehem Psychiatric Hospit-al, in order to establish a model of best practice and improving opportunities for social inclusion for service users and their families.

A study visit with a training component took place in November 2009 in Bethlehem (4 staff from Trieste WHOCC) and in June (6-11) 2010 in Trieste a subsequent visit of ten staff from Gaza and West Bank, accompanied by the WHO Project Officer, was hosted for a study visit which included a training for social entreprise.

WHO Project Officer for West Bank and Gaza was invited to present the outcomes of that cooperation at the International meeting “Beyond the walls”, 13 – 16 April 2011.

The University of Naublus invited a colleague of the MH Dept. / WHO CC (dr Barbara Bavdaz), to teach at their course for CMHealth in 2009 and 2010.


Other WHO Connections:

 Dr Saxena, Director of Dept of MH and Substance Abuse – WHO HQ, Geneva visited our services and our WHO CC during the International Meeting in Trieste in April 2011.

 Dr Matthis Muijen, Director of WHO Euro for MH, was involved in the confer-ences in Bucharest and Trieste (April 2011) and he contributed to the develop-ment of the Trieste Declaration 2011.

 There is a request by WHO HQ to participate to the ICD XI draft last phase of elaboration, together with WHO CC of Region for the Family of International Classifications.

 The WHO CC Director has been invited as main speaker at the EU-WHO em-powerment conference in Leuven, 27 October 2010

 The WHO CC Director is invited to the mhGAP conference in Geneva, 10 October 2011.

Collaboration with other WHO CC

 Italian WHO CC in MH have been invited to all events. Prof Tansella will be one of the Teachers of the Summer School.

 WHO CC of Lille is a partner either in networking for best practices or for the European Network of User Organisations. Trieste WHO CC has been invited to a conference in Lille for recovery on 31st of August 2011.

 WHO CC in Lisbon has been invited to discuss a possible collaboration/synergy for training (e.g. the International Master on Mental Health Policy and Services is a Universidade Nova de Lisboa).

 For suicide prevention, the WHO CC in Switzerland proposed a cooperation. There is also a plan to collaborate with WHOCC in Karolinska Institute in Stock-holm.

Collaboration with WAPR and IMHCN.

-There is a plan for professional training of mental health service staff in South

Eastern Europe as continuation of the Stability Pact established in the region in the

past. The countries involved in the project were: Albania, Bosnia, Bulgaria, Croatia, Montenegro, Republic of Moldova, Romania, Serbia, Slovenia, Macedonia, Turkey. The lead project is WAPR with other international agencies, such as Trieste WHO-CC and the International Mental Health Collaborating Network; they could work together in order to promote in collaboration with EU and WHO a long-term new Stability Pact Project.


-Launch of the “Beyond the walls” - Network of European Psychiatric Hospitals

in Transition: Nis, Vlora, Armentieres, Schaerbeek, Socola, Prague, Skopje, etc.

They should support themselves, compare their process of transformation and evaluate it - under the umbrella of WHO. A first meeting will take place during the Summer School in Trieste.

-The “Conferenza Permanente per la Salute Mentale nel Mondo (Permanent Conference for Mental Health Worldwide) – ConfBasaglia”, an association based in Italy is developing with WHO CC of Trieste a transnational collaborative project for the recovery of the campuses / parks of ex-Psychiatric Hospitals in several countries (e.g. Italy, Serbia, Palestine, Argentina, Brasil, Australia, UK) can be involved as a partner in a formal agreement. Deinstitutionalisation, social economy and entepreneurship, valorisation of the historical sites, restitution to the community are the guidelines of that action, that can have a strong emblematic value and a real impact on thousand of Hospitals all around the world.

Provisional name: The seven doors.

-The WHO CC is supporting the campaign for the abolishment of Forensic

Hospitals in Italy (“Stop OPG”) and the construction of individual projects as

alternatives to Forensic Hospitals with the support of many associations operating for the rights of the people deprived of personal freedom.

Further plans:

-Linking DI movement in mental health with DI movement in general / DI of other group as people with learning disability, children, for example by using European DI Expert Group network and lobbying.

Campaigning for better use of European Funds.

Supporting of developing platform of couple of pro-DI EU member states governments.

Linking DI with already existing relevant EU policies and strategies as European Pact for Mental Health and Wellbeing.



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