Happy Mental Health in 2018!!! Three wishes for the upcoming year.

2017 has been a very fulfilling year in WAPR. The coming year 2018 is very close. This will be the year of the WAPR XIII World congress. This may be a timely opportunity to express some expectancies and wishes for the coming time in our field.

            As many of us think, the attention to the mentally ill is experiencing a profound change, often characterised as a change of paradigm. There is an increasing awareness of the importance of mental health as potential contributor to disability in general population, and the importance of tackling in the more effective way severe mental health problems as a way to reduce the burden of suffering and disability. Many ideas and proposals have been laid on the table in recent years in areas like prevention, treatment and rehabilitation. But in this opportunity, I will only mention three, from a very subjective way.

            Let us continue understanding the recovery process from mental illness. Beyond treatment as a way to overcome specific symptoms, for the people suffering from severe mental illnesses, recovery means gaining a significative life beyond the residual symptoms treatment cannot eliminate, disability and possible side effects form treatment. The more we learn from users’ experience in successful recovery processes, the best we can use that knowledge in helping new patients in their unique and personal process to recover. This need of new understanding also includes understanding the process to getting ill, understanding vulnerability, the role of adverse biographic events and other traumatic experiences as potential contributor factors to further development of illness. The best we understand the role all these factors, the better we will be able to help patients in tackling them. Understanding will lead to services that better contemplate the extraordinary complexity of getting sick and also in getting better.

            Let us improve accessibility to mental health services. We are aware that many people in the world has a limited access to correct psychiatric treatment, even to a very basic and limited one. As WHO often states –see WHO Atlas database-, in many countries available services are mostly allocated in mental hospitals, that receive the biggest part of public budgets in detriment of community services, more accessible and usually friendlier to people. Improving accessibility entails that policy makers take the responsibility to create mental health plans –whereas they do not exist- and allocating the required budget, in order to ensure that the access to services for the mentally ill is made available in equity basis respect to people with other health problems, usually better funded that mental health. Community services, services allocated near the places where people lives, able to provide quality and continuous services as long as they may be necessary, are the right strategy to improve accessibility to recovery oriented services for the people affected by severe mental illnesses. Year 2017 has offered interesting examples of countries improving dramatically access to mental health services to their citizens –the case of Peru may be paradigmatic-. Let us expect that 2018 may increase awareness of the need to improve access to services and offer similar experiences in other countries.

         Let us succeed in reducing coercive interventions. Coercion and psychiatry have been historically linked for complex reasons. We now know that mental illness is usually a lasting process that begins much sooner that when it is recognised. However, since early signs of mental distress are usually not very specific and are usually neglected, the onset of mental illness is often dramatic and linked to acute conflicts that may involve concerns about security of the patient and of third parties. If we add that madness is an extreme human experience that challenges understanding, and is usually perceived in a stigmatised way, we can understand that coercion is linked to psychiatric interventions, and that psychiatry has received two different tasks- and quite incompatible-: to offer treatment and to guaranty security. That is why along many years, in many psychiatric services all over the world, coercion is widely and uncritically accepted as a “normal” part of the practice. But this perception need readjustment. First, research shows that coercion can be widely and easily reduced by improving training and changing attitudes on staff. Second, although it is difficult to deny that security is sometimes a real concern in practice, it has been proved in different places that a well-trained and motivated team can tackle most emergencies without using coercive methods. And third, the perspective of Human Rights, specially that emerging from the U.N. Convention of Rights of People with Disabilities, obliges to reconsider the use of coercion in psychiatric interventions as a routine practice wherever it takes place. Reducing coercion to the minimum -...may it be close to zero?- may be a good challenge for the new year.

            Let us expect the best for the coming year, and may these three wishes may find their way in it. The WAPR World Congress Madrid 2018 will gather some of the most interesting experiences in the world in these topics and will offer training workshops to make those experiences available to all delegates.

            Happy 2018!

Reforming Mental Health Services in Europe.

Report from the working group "Reforming Mental Health Services in Europe"; Conference “The right and the opportunity to have a whole life”. Trieste, Italy; 15-18 November 2017.

Ricardo Guinea. WAPR President.

Organisers of the conference, leaded by Roberto Mezzina, succeeded in gathering a group of expert professionals from different countries of Europe, and inviting them to present a report on how the different countries are dealing with mental health services, with its transformations and its challenges. The meeting and their reports conformed a varied panel of information, personal opinions and assessments that I will try to summarise.

                  On the one hand, we had reports from countries that are succeeding in implementing reforms in the desired directions (i.e., Belgium, Netherlands and to some extent, Spain). P. Janssen reported about the evolution in Belgium to a more deeply community oriented model; by implementing innovative services, such as mobile teams or telephone hot lines to improve and ease accessibility to care. J. Berdsen (Netherlands) reported the wide dissemination of the recovery model in his country (i.e., recovery colleges in preparation), the interest in the open dialogue model, the creation of users’ networks for peer support and the trend to replace coercive treatments for high intensity of care services. Stakeholders from these countries gave the impression of an ongoing trend of reforms in course that is leading to significant improvements in those countries.

Ricardo Guinea and Roberto Mezzina.

However, as the representative from Spain said, the reform of institutions does not lead necessarily to a real transformation of services. For some reason, some old asylums in Spain that were reformed into a residential model, kept the same old style practices in the new reformed facilities. This statement emphasized that professional practices are harder to reform that just changing the shape of the services. This speaker pointed out his concern on some problems: deinstitutionalisation sometimes lead to re-institutionalization; help is often provided in a dis-coordinated way –tipically: discoordination between the welfare system and mental health system. Some reforms often collide with fears, skepticism of even opposition of some professionals or family careers –i.e., reforms that lead to an in deep incorporation in practices of implications of the Human Rights perspective-. An even in these countries where reforms are experiencing advances, some problems seem still very challenging: stigma, homelessness or how to deal with offenders with mental health condition.

                  The vision of stakeholders from some other countries (Poland, Hungary) seem to point out that the situation in some countries is not evolving in the desired direction or in the required rhythm. Sometimes, plans are drafted by policymakers but never implemented; sometimes there is no public perception that some reforms are needed and old style practices remain in an uncritical way. According to the opinion of presenters from those countries, the current general perception there seem to give priority to social control, and a kind of divorce happens between the available services and the needs of the patients –at least from the perspective of a contemporary community approach-. The problem of how the pharma industry takes a leading role in training new professionals in those countries – which may not be an exceptional situation- was also emphasized.

                  Some interventions, due to some special circumstance, seemed to emphasise a different perspective. It was the case of the report by Milos Jankovick, Deputy Ombudsman from Serbia. He presented a hard statement from the perspective of Human Rights. He stated that it is necessary to consider seriously the existence of practices that can be regarded as torture in psychiatry, and presented a strong plea to take this issue seriously.  He reviewed some hot topic in contemporary psychiatry that represent conflict with the interpretation of Human Rights Declaration and the CRPD: the state of detention under mental health condition, and the conditions under which it is done. He stated that it is necessary to review practices regarding detention under mental condition and reconsider some of its circumstances (isolation, physical restriction, detention in cages). Guarantees when mental capacity is compromised by a mental condition should be carefully monitored: protection of legal capacity according CRPD principles and implications, humanitarian conditions when detention takes place. And finally, that it is necessary steady work to reach a reasonable common standard in all different bodies that intervene in psychiatric attention.

                  In his turn, Theodoros Megaloeconomu and Katerina Nomidou (from Greece), presented a touching report about how the economic crisis in Greece has damaged and often has destroyed past achievements, with a huge trend back for social exclusion, increase of violent and coercive treatments, and transinstitutionalization.

                  Other presenters highlighted other points that may be common at some extent to some European countries: the prevalence of ill treatments that deteriorate rather that ameliorate the life of patients, the diffuse limits of mental health when life, social or economic problem are presented as problems of mental health, or when mental institutions are made responsible for social needs of some vulnerable groups.

                  As final remark, I would say that there was a common view about how the community model should be implemented and developed as the best tool to organise accessible and quality services for the population, and that public policy needs to be involved in implementing systems of attention. There was also a quite common view about what we should consider a quality treatment: should be consensual, humanitarian, respectful of the dignity of the person and available. In that framework, some different approaches emerged in a technical point of view. Last, there was a quite common perception from different about the outstanding need to go on in considering how to go on ameliorating services and practices.

*Participants in the working group: Patrick Janssen, (Belgium), Jan Berdsen (Netherlands), Adam Zawinsky (Poland), Juanjo M. Jambrina (Spain), Judith Harangozó (Hungary), Milos Jankowick (Serbia), Dragan Cabarkapa (Montenegro), Jan Pfeiffer (Chec Republic), Vito Flaker (Lubliana), Theodoros Megaloeconomu, Katerina Nomidou (Greece). Chair, Ricardo Guinea (Spain).

Recovery model: the person in the center of the intervention.

Ricardo Guinea, Chair, Organising Committee.

Placing the person at the center of the intervention is perhaps the simplest way to describe the paradigm shift that the recovery model is introducing on a large scale in contemporary care systems for people with severe mental illness. That the person is in the center, has implications of great importance that are worth highlighting.

What does it consist to be a person? It is a question more for a philosopher than for a scientist. For Adela Cortina ("The frontiers of the person", Taurus Ed 2009, pp.185), "we recognize as a person who has the capacities required for self-consciousness, for the mutual recognition of dignity, to act from freedom and assume responsibilities".

That this idea may be important is underlined by the fact that for many years it was not the person but the disease that occupied the center of the intervention of the models of attention. This is consistent with the way in which reality presents the biomedical paradigm. Under the biomedical perspective, there are things like schizophrenia or bipolar disorder, which are -or should be- medical illnesses; then you have to treat them as such. From this perspective, certain priorities are followed. If this is the case, to face the problem it is necessary the person to be aware of the disease, it is necessary to treat acute situations and do whatever possible to avoid relapses. And for this, a systematic psychopharmacological treatment has shown to be the most effective tool.

However, when studying the testimonies of the people actually recovered, it was found that this idea did not meet the expectations of many of them. In those testimonies, the idea frequently appears that the biomedical approach tends to produce poor life experiences that are often empty of content.

That the person occupies the center, as the model of recovery preaches, takes a different perspective. Recovering, according to one of the most cited definitions, is a highly personal process to overcome and find a new meaning in life, beyond the catastrophic effects of suffering from mental illness - whatever that may be. To recover is to live a meaningful life, a life that is worth living, a life in which the person has opportunities, in which personal projects and preferences and personal choices really account.

Thomas Kuhn ("The Structure of the Scientific Revolutions", 1962) would emphasize that between the two versions there is the typical change of theme proper to the paradigm changes in science. In this case it would be to say that we have reached a certain point in which to work scientifically on the idea of ​​how to cure mental illness is a stalemate where we cannot see where progress might continue. Then the typical turnaround of the paradigmatic change occurs: since we do not progress on the idea of ​​how to cure the sick, we consider instead the idea of ​​how to help them live a dignified life, a person's life.

Although sometimes presented as such, these two visions here outlined are not completely antagonistic. The possibility of reducing the symptoms, even partially, is very valuable so that they do not invade the whole life of the person. Alleviating pain with drugs as much as possible is part of the best of medical deontology, and is a tool that the medical art makes available to people. The key, as is the case with any tool, is in how it is used. A drug can be - and often is - a liberating element for the person who suffers, to the extent that it facilitates being him or her and not the symptoms, the agent takes control of life. Or otherwise it can be a mental anesthetic, that buries the person after a semblance of serenity, as also often happens.

What is clear is that recovery is beyond the mere question of whether or not to follow a certain procedure, be it pharmacological or other treatment. Recovering is in connection with having real opportunities to get a job as a way to participate in the community, with a decent accommodation, with not being segregated or stigmatized by their mental diversity. And also, and this is very important, with the responsibility of the person to use - and how to use - those opportunities in their own and inalienable recovery process.

 What is critical is whether the person is in the center or not, if the help is offered in a way that empowers the person and not the other way around. That is, in my opinion, a central point of the debates around the notion of recovery that we will celebrate at the XIII World Congress. How each actor is able to understand that framework of help from his singular contribution - the professional, the family or the supportive network, peer supporter, the person himself. How to foster collaboration frameworks from the mutual recognition of capabilities, and manage the demands of control that, we should not ignore, emerge frequently.

Adela Cortina, Professor of Ethics and Political Philosophy at the University of Valencia, Spain.

To help us situate the notion of person, which today is at the core of the transformations of the care systems in most countries, we have invited Adela Cortina, Professor of Ethics and Political Philosophy at the University of Valencia, who has Kindly accepted to deliver the inaugural lecture.