Mental HealtH in tHe CoMMunity: the case of Slovenia MENTAL HEALTH IN THE COMMUNITY: ContentS THE CASE OF SLOVENIA Editor Vesna Švab Authors Renata Ažman, Pika Bensa, Živa Cotič, Ana Ivanišević Valetič, Tone Vrhovnik Straka Mija M. Klemenčič Rozman, Janko Kersnik, Janez Mlakar, SURVIVOR’S POINT OF VIEW - THE SLOVENE MENTAL Simona Mlinar, Tina Nanut, Majda Pahor, Edo Pavao Belak, HEALTH SYSTEM ........................................................................................... 5 Nataša Potočnik Dajčman, Maja Smrdu, Tone Vrhovnik Straka, Vesna Švab, Maja Valič, Urška Weber, Špela Zgonc Vesna Švab INTRODUCTION ............................................................................................ 6 translation Gregor Cotič Tone Vrhovnik Straka: THE STATE AND US ................................................. 10 Chapter Alliance for Health: Urša Poljanšek Živa Cotič, Simona Mlinar Graphic design PRESERVING THE RIGHTS OF PERSONS WITH DISABILITIES: Grafi čni atelje Zenit UNITED NATIONS CONVENTION ON THE RIGHTS OF PERSONS Th is publication is published on website: WITH DISABILITIES .................................................................................... 12 www.sent.si Tone Vrhovnik Straka: THE ENVIRONMENT AND US ................................ 19 Ljubljana, 2015 Vesna Švab RECOVERY .................................................................................................... 20 CIP - Kataložni zapis o publikaciji Tone Vrhovnik Straka: MI IN MI .................................................................... 22 Narodna in univerzitetna knjižnica, Ljubljana 616.89(082)(0.034.2) Vesna Švab MENTAL health in the community [Elektronski vir] : the case of Slo- STIGMA ......................................................................................................... 23 venia / authors Renata Ažman ... [et al.] ; editor Vesna Švab ; translation Gregor Cotič, chapter Alliance for health Urša Poljanšek. - El. knjiga. - Tone Vrhovnik Straka: DOCTORS, PHARMACISTS AND US ...................... 25 Ljubljana : Šent, Slovensko združenje za duševno zdravje, 2015 Vesna Švab Izv. stv. nasl.: Obravnava v skupnosti PSYCHOSOCIAL REHABILITATION (PSR) ISBN 978-961-93651-4-4 (pdf) AND COMMUNITY TREATMENT ............................................................... 27 1. Ažman, Renata 2. Švab, Vesna 281649664 Vesna Švab, Milan Krek MENTAL HEALTH CARE IN THE COMMUNITY ...................................... 29 Publisher Šent - slovensko združenje za duševno Zdravje Janko Kersnik Belokranjska ulica 2, 1000 Ljubljana THE ROLE OF A FAMILY PHYSICIAN IN IDENTIFYING info@sent.si • www.sent.si CRISES AND CRISIS INTERVENTION ........................................................ 36 2 3 Tone Vrhovnik Straka: Tone Vrhovnik Straka NON-GOVERNMENTAL PRACTICIONERS AND US ....................................... 40 Survivor’s point of view – Špela Zgonc, Tina Nanut, Ana Ivanišević Valetič INTER-COMMUNITY PSYCHOSOCIAL REHABILITATION Th e Slovene mental health system OF INDIVIDUALS WITH MENTAL HEALTH ISSUES ................................ 42 In the fi rst edition of this book, the user's point of view was contributed by Tone Vrhovnik Straka: FAMILY AND US ....................................................... 48 dr. Tanja Lamovec the north star of psychiatry's survivors in Slovenia. She is, sadly, no longer with us, so the burden of continuing where she left of falls Maja Smrdu, Edo Pavao Belak, Vesna Švab to me now. Originally, I intended to continue from the point where the re-WORKING WITH FAMILIES ....................................................................... 50 spected author has concluded and to summarize her work as well as describe Vesna Švab, Janez Mlakar the developments that took place over the previous decade in survivors' and COUNSELING ............................................................................................... 58 users' movements. Now, I'm forced to conclude that such an approach is me-aningless, as it only leads me to question the reason why we so rarely come Mija M. Klemenčič Rozman, Maja Valič together. I will, therefore, introduce these points as we go along a diff erent SELF-HELP ORGANIZATIONS IN THE FIELD OF MENTAL HEALTH ....... 64 path on which we will investigate each of the areas that directly concern survivors (term is used as defi ned by WNUSP: World Network of Users and Sur-Maja Valič, Pika Bensa vivors of Psychiatry and ENUSP) from three disparate viewpoints. PSYCHOEDUCATION ................................................................................... 75 • From the viewpoint of a user that has been negatively aff ected by the Majda Pahor »system« and feels off ended. Th ese accounts are intentionally presen-ALLIANCE FOR HEALTH: COLLABORATION ted in situ, with vulgarity so common to the depressed male culture. IN HEALTHCARE TEAMS ............................................................................ 89 • From the viewpoint of objective and, consequentially, boring reali-Urška Weber, Nataša Potočnik Dajčman ty that is common to outsiders which are sympathetic to the survi- PREVENTING MENTAL HEALTH DISORDERS IN CHILDREN vor problematic. AND YOUNG ADULTS .................................................................................. 99 • From a wide and optimistic perspective, that emphasizes ideas and plans leading to a bright future for people aff ected by a psychiatric Vesna Švab experience. Th is »calm hypomanic« perspective is intentionally remo- PROMOTION AND PREVENTION IN MENTAL HEALTH ...................... 106 ved from the objective viewpoint. I fi nd the term »survivor« appea- Renata Ažman ling, as it stresses both the independence and the strains that former users of psychiatric services are subjected to. RECOVERY FROM A USER’S PERSPECTIVE .......................................... 113 Th ose interested in a better understanding of the survivor's perspective may wish to focus on the last few sentences of individual segments. If you are, on the other hand, interested in the viewpoint of a veteran of mental health treatment, you may wish to focus on the fi rst few sentences of individual segments. 4 5 Vesna Švab been offering counseling and practical assistance to people with mental health disorders, even though they did not define their efforts as mental introduction health care at the time. With the signing of the Mental Health Act, social work centers were given the power and the funds to legally plan and exe-Over the past few decades, Slovenia has seen the development of various cute community treatment programs for discharged patients. It should be forms of community treatment for people with severe mental illness. The noted that community treatment programs were being established along-beginnings of community treatment are found in the social work move- side other reforms in primary health care, which include the all-important ment during the era of deinstitutionalization. Regionally, the process was institution of referential health care centers with contemporary team-at its most evident in Italy in 1986, where the psychiatric hospital in Tri-based models of treating patients suffering from chronic conditions. (4). este was closed and admittance to institutions was banned by law. In Italy, Other forms of community treatment will be covered later on. people with severe and chronic mental health disorders were cared for in several regional mental health centers, a move which was not mirrored in The current call from international organizations to move treatment Slovenia. The rhetoric justifying the decision not to commence with dein-from institutions to the community (5) makes it essential to define exist-stitutionalization claimed numerous faults in the deinstitutionalization ing models of treatment and compare them, making it possible for us to process and possible negative effects, such as an increase in homelessness have a comprehensive overview of evidence based methods and guidelines and the lack of care for psychiatric patients (1). Despite this, several profes-needed. The reasons for this are professional-the sheer number of avail-sionals managed to revisit the topic over the years, mostly through a his-able alternatives in the mental health psycho-social care field is staggering, toric consideration of the reasons for rejecting community treatment (2) which breeds competitiveness, making it hard to recognize what forms of and pragmatic attempts to implement psychiatric care in the primary level help are actually available in community treatment and what options a pa-of health care.This was reflected in the institution of a network of psychi-tient seeking recovery has. atric outpatient clinics (dispensaries) in 1970s. These centers were meant This book begins with chapters on ethics, legal framework and user de-to ensure that everyone in need of treatment would be able to access it in mands. Further chapters provide an overview of research on recovery, stig-larger settlements across Slovenia. These dispensaries should have been matization and rehabilitation, followed by chapters on available forms of closely connected with existing regional health centers, but they were not community treatment. The chapter on general practice treatment was pre-formed according to expectations. Funds were rerouted from the primary pared and written by prof. dr. Janko Kersnik, who has throughout his sci-health care level to the secondary, meaning that these funds were directed entific and practical career been critical, although also supportive of com-to six psychiatric hospitals, which then further directed their expenditure. munity treatment. He has furthermore been involved in NGO multidisci- The majority of the dispensaries were not to last through the 1990s, as psy-plinary education we provided in order to facilitate community projects. chiatrists were given the option of opening private practices. A number of All proven forms of treatment offered by NGOs are introduced, including smaller psychiatric outpatient practices was formed into a network, which psychotherapeuticcounseling, self-help groups and psychoeducation. A suffered from uneven regional placement, which in practice means that chapter is devoted to the introduction of teamwork, which is a requsite they are mostly available in a few of the largest settlements and, of course, essential for recovery led services. The final few chapters introduce proven the capital(3). Two community networks were developed. The first, non-forms of prevention in mental health, specifically focusing on children and governmental organizations (NGOs), primarily established rehabilitative young adults. Every group of chapters is prefaced by a »survivor's« take services for people with chronic and severe mental health disorders. These on the subject. A survivor is a person who has undergone treatment for a services included the development of care planning methods, day-to-day mental disorder and has personal experience of the system and how it op-care services, housing groups, vocational rehabilitation and employment erates. At the end of each preface, a set of recommendations for those working in and advocacy. NGOs were also heading significant destigmatization cam-the mental health field is laid out in italics. This appeal is supplemented by Re-paigns. The second network consisted of social work centers, which had nata Ažman's essay. She is an intellectual, publicist, reporter and a service 6 7 user, whose texts touch upon the most serious and sensitive of subjects, preventing recurrences of such acts in the mental health field and helping such as self-discrimination and stigma and at the same time offer ways of care providers to reduce the chances of inappropriate and careless treat-overcoming such setbacks. ment of patients in need. Our work needs to consider the goals of working with severe and chronic mental health disorders in the community, which makes the fact that a di- Sources agnosis does not equal identity and cannot define a person, our core prem-ise. Consider the example of Vincent van Gogh, who suffered from severe 1. Bras S & Milčinski L (eds.). Psihiatrija [Psychiatry]. Ljubljana 1986. mental issues. Between the periods when his condition worsened, he could Državna založba Slovenije. be considered healthy, although not precisely in keeping with the defini-2. Darovec J. Psihiatrija včeraj, danes, jutri. [Psychiatry yesterday, today, tion of mental health (a state of physical, mental and social wellbeing). He tomorrow]. Zdrav Var 1992; 31: 5-9. said. “It is perfectly true that the attack returned various times in that last year – but then also it was precisely by working that my normal condition 3. Švab V& Švab I. Barriers and Errors in Implementing Community Psy-returned little by little” (6). chiatry in Slovenia. Ment Health Fam Med. Jan 2013; 10(1): 23–28. Mental illnesses and conditions can, in fact, offer the possibility to reor-4. Poplas Susič T, Švab I, Kersnik J. Projekt referenčnih ambulant ganize one's life and find new meaning in it, which has been proven conclu-družinske medicine. [The project of model practices in family medicine sively through testimonials (7). Such a dramatic acceptance and recovery in Slovenia]. Zdravniški Vestnik 2013; 82 (10): 635-47. from illness is only possible when people we work with are carefully at-5. Evropski plan za duševno zdravje 2013 [European Mental Health Plan tended to and all areas of their life are made our concern. Their symptoms 2013]. Accesed 3. 5. 2015 from web page:http://www.euro.who.int/__ do not suffice. It goes without saying that most find their disorder or ill-data/assets/pdf_file/0004/194107/63wd11e_MentalHealth-3.pdf ness a tragedy, one that needs prevention and treatment, yet this does not 6. Glover J. Alien landscapes?: interpreting disorder minds. Harvard absolve us of the responsibility of making it an opportunity to take advan-2014. Harvard College. tage of it. Our attitude should be one of respect for the subjective experiences of those that went through treatment.The diagnosis requires recog-7. Spaniol LR, Gagne C, & Koehler M. Psychological and Social aspects nizing that the person experiencing mental illness is usually the victim of of Psychiatric Disability. Center for Psychiatric Rehabilitation. Boston their sensitivity to a trigger or cause that can be identified with careful 2001. Boston University. listening and questioning.We psychiatrists still use our intuition as part of 8. Kaplan JT & Iacoboni M. Getting a grip on other minds: Mirror neu-the diagnostic process, as a reflection of the human capability for empathy. rons, intention understanding, and cognitive empathy.Social Neuro- The method, as a counterpoint to the more quantifiable diagnostic tools, science 2006; 1 (3-4): 175-83. can be explained by acknowledging the existence of “mirror neurons” in 9. Jaspers K. General Psychopathology. Baltimore 1997. Johns Hopkins our brain. These allow us to experience another's condition intimately (8). University Press. Karl Jaspers’ claim (9) that schizophrenics are strange, cold and distant, even inexplicably so, is simply wrong in light of this understanding. Rath-10. Pinfold V, Thornicroft G, Huxley P & Farmer P. Active Ingredients in er, it reflects the truth of a pervasive failure to reach our patients on a Anti-Stigma Programmes in Mental Health. International Review of personal level (6). The quality of our work improves by carefully listening Psychiatry 2005; 17(2): 123–31. to personal testimonies. These are also the strongest weapon available in overcoming stigma and discrimination (10). The history of psychiatry is rife with accounts of neglect, abuse, injustice and discrimination (6). The way we approach our work is directed at 8 9 Tone Vrhovnik Straka The service user’s recommendation The state and us The state, through an open dialogue with survivors, taking account of detailed analyses that show the economic damage caused by suicide, poverty, exclusion, The Slovene Mental Health Act, which was signed into law in 2009, fore-disability, sick leave and other parameters that are affected by the state of saw that the government prepares and the National Assembly accepts a mental health nationwide, provides resources for a regionally allocated pre-resolution on a national mental health program within the calendar year. vention, treatment and diagnostic programs aimed at mental health issues. I feel nothing but loathing for those who are directly responsible for the Focusing on early diagnosing of mental illness in children and young adults, lack of progress in this endeavor, as no programs of nondiscriminative aid it brings back regional counseling offices and dispensaries. It strengthens the distribution have been set, the paradigm shift from institutional to com-network of psychotherapy workshops and provides funds for them from the munity help has not come into being, with similar delays affecting the spe-health system itself. Community treatment teams focusing on community cial care programs aimed at the young and the elderly. The government work are dispatched and strengthened, along with their NGO counterparts. officials are directly responsible and are legally liable for the failure of the The participation of survivors in all aspects of mental health is legally defined-mental health act and its paragraph 111. this results in an increasein the quality of life not only among the mentally ill, but also among the public at large. Slovene survivors consider the day the Mental Health Act was signed into law a significant one-the act precisely defined in which cases the state is allowed to transfer patients to a closed ward in psychiatric hospitals, time and other limitations have been imposed on “special” treatment methods available, it defined the accepted way to deal with underage patients and, most importantly, introduced the PatientRepresentative concept. This new institution is meant to be a patient's ally, especially in forced institutionalization cases. Not only has the profession made its displeasure known, particularly in view of the massive increase in required paperwork (including reports on methods and treatments used, the time spent applying them and legal notifications), the patients themselves also feel disappointed.Not only since most patients in closed wards have no idea that they have a right to a representative, but mostly because the state has decided that representatives and »treatment coordinators« should simply be the employees of the nearest available social work center or an NGO. People who do not always have the patient's best interests at heart. The government has displayed its concern with its Patient Rights Act of 2008, yet I can find no data that would show whether the patients are even aware of the options that this gives them or whether they have successfully been applied. Slovenia is a signatory of the Convention on the Rights of People with Disabilities and is now formally bound to discuss any and all legal and other initiatives that affect the disabled population with them. This is not the case. 10 11 Živa Cotič, Simona Mlinar rehabilitation. This was the result of change in attitude towards mental health, which resulted in the current three-fold perception of reduced ca-Preserving the rights of persons with disabilities: pabilities. The first is the traditional medical model, which assumes that united nations Convention on the Rights of disability is always unwanted and must therefore be cured. This, in turn, Persons with Disabilities1 means that those with reduced capabilities deserve our compassion, not our respect (6). Medical model of disability is based on stigmatization, The United Nations Convention on the Rights of Persons with Disabilities which can lead to further psycho-social issues (7), and discrimination. In is an international convention that comprehensively regulates and pro-practice it functions in a manner that excludes persons with disabilities tects the rights of persons with disabilities. The Convention was adopted from society. It comes as no surprise that this model has been proven inef-by the UN General Assembly in 2006, and ratified by Slovenia in 2006 (1). fective (8). With ratification the Convention became a part of Slovene legal order and The second model, the social welfare model, does not apply a medicinal is directly applicable. Besides Slovenia, 153 other members of the UN rati-viewpoint to disability, yet it still sees disability as an obstacle. This, again, fied the treaty, including the European Union (2). leads to social exclusion (9). The Convention addresses various rights enjoyed by persons with disabili-The Convention represents a paradigm shift, as it is the first international ties; with the intention of ensuring respect their human rights, liberties document to move beyond medical model of disability and rather insti-and dignity. (1st paragraph of the Convention). tutes a social model for disability. The latter requires countries to enforce a series of rights of persons with disabilities and aims at social reintegration (9,10). The social model of disability has the advantage of allowing persons The Significance of the Convention: with disabilities reduced capabilities to fully realize their potentials, as op- From medical to the social model of disability posed to the other two. Society at large also benefits from individuals able Physical and mental disabilities are an issue in every society and often have to effectively contribute to it (10), which is the basis of social inclusion. To social ramifications (3). The perception of disability has changed in the clarify, social inclusion implies that social standards allow individuals to second half of the 20th century with the advances of modern psychiatry. form relationships with each other(11). Traditional medical model of disability was, gradually replaced by models The Convention introduces this social model in the first paragraph that based on individual autonomy. Simply put, the traditional treatment pat-provides the definition of persons with disability people with reduced ca-terns of the early twentieth century, which were mostly based on restric-pabilities as those »suffering from long-term physical, mental intellectual tions placed on persons with disabilities, were replaced by means the mod-or sensorial defects, that in combination with various obstacles, limit them ern world no longer deems inhumane or torturous (4). from equally and efficiently participating in society. Despite the significant In the second part of the 20th century in the Anglo-Saxonworld, commu-improvement that the Convention represents, full inclusion of people with nity therapy was born as a response to the growing public awareness of reduced capabilities still requires de facto protection and enforcement of institutionalization and its issues (5). The subsequent changes in policy the afore-mentioned rights. resulted in the marginalization on institutionalization, which was to be used solely in extreme circumstances. Treatment of persons with disabilities was moved to the community, which allows for better psychosocial Some rights of persons with disabilities The rights listed in the Convention are mostly part of various international 1 This text is a part extraction of: Cotič Ž. The Road to International Implemen-legal documents. In Slovenia, they are also present on the constitutional tation of Supported Decision-making. King’s College London. 2014 level. These rights include the right to life, legal protection, freedom of 12 13 movement, citizenship, and prohibition of torture. All rights that were rehabilitation and rehabilitation services and programs in the areas of defined in the Convention as inalienable, regardless of diminished physical health, employment, education and social services need to be taken. These or mental capabilities. programs need to be timely and based on multidisciplinary assessments of Slovenia is required to enforce and encourage all human rights of the persons’ needs and strengths. Moreover, the programs need to be volun-disabled, without discrimination. These include appropriate measures to tary and a part of community services in urban and rural areas. eliminate discrimination any individual, organization or private enterprise (Article 4 of the Convention). Persons with disabilities and the role of the Committee for the In accordance with Article 8 of the Convention, the state must take meas- Rights of Persons with Disabilities: the Case of Slovenia ures to (i) raise societal awareness regarding persons with disabilities, and encourage respect for the rights and dignity of persons with disabilities; In Slovenia, the aforementioned provisions are of particular importance in (ii) fight stereotypes, prejudices and other unwanted practices relating to the context of psychosocial rehabilitation, community treatment and sup-persons with disabilities in all areas of life; and (iii) promote awareness of ported decision-making frameworks. In the annual report for 2013, the the persons with disabilities' capabilities and contributions. Human Rights Ombudsman of Slovenia has found, that Slovenia should In Article 9 paragraph, the Convention requires States Parties to enable »accept more effective and appropriate measures, that will allow the disa-independent living and full participation in all aspects of life for persons bled population to achieve and maintain the highest possible level of inde-with disabilities. States Parties to the Convention should take measures to pendence, including professional independence and their full inclusion and ensure persons with disabilities access to transportation, information and cooperation in all areas.« (13) Moreover, the Human rights Ombudsman communication technologies and other services in urban and rural areas. has argued for full implementation of the Convention, requiring adoption of a number of appropriate statutory instruments. International treaties Perhaps one of the most important parts of the Convention, Article 12, signed by the state, even ratified Conventions supported by appropriate recognizes that persons with disabilities have full personhood under the laws, are to a significant extent unenforceable without the proper legal law and legal capacity. This provision goes counter to guardianship sys-framework. A clear example of this can be found in the 2010 Equalization tems, which are in force in States Parties (12). Article 12 requires that State of Opportunities for Persons with Disabilities Act (ZIMI), which remains Parties shall take measures to ensure the equal right of persons with dis-unenforceable due to the lack of statutory instruments. abilities to, for example, own or inherit property and control their own financial affairs.Article 19 holds particular significance for Slovenia, as it Other findings that were made by the Human Rights Ombudsman are recognizes the right of persons with disabilities to live in the community. equally concerning, particularly those about visits of social care institu-In accordance with Article 19, persons with disabilities should be able to tions, which were made in Ombudsman NPM2 capacity and accompanied choose where and with whom they will reside. Moreover, when in need by members of the selected non-governmental organizations (NGOs). of community services, which should be available on an equal basis, they These findings included treating those with dementia in closed wards, lack should have access to support services, including personal assistance. All of understanding in admitting patients to closed wards, forced hospitaliza-these measures are in line with social model of disability and should pretions and other safety measures (13). These failings demand a change to vent social exclusion. the existing Mental Health Act (ZDZdr). Independence and social inclusion is strongly connected to the concepts The actual implementation of the Convention and its provisions is thus not of habilitation and rehabilitation, which the Convention addresses in Article 26. States Parties are required to implement measures enabling 2 NPM (National preventive mechanism under the Optional Protocol to the persons with disabilities independence and participation in all aspects of UN Convention Against Torture and Other Cruel Inhuman or Degrading Treat-life. In order to achieve this, appropriate measures such as comprehensive ment or Punishment). 14 15 only reliant on the aforementioned legal framework but on a number of 4. Szasz TS. The manufacture of madness: A comparative study of the in-other laws and programs. In keeping with the Convention, Slovenia must quisition and the mental health movement. Syracuse University Press regularly report on its progress and measures taken to fulfill its obligations. 1997. This report is then sent to the Committee for the Rights of Persons with 5. Scull A. Deinstitutionalization and public policy. Soc Sci Med. Elsevier Disabilities, which was established by the Convention and presides in Ge-1985;20(5):545–52. neva. Based on the report and its review, which includes a dialogue with the country in question, the Committee then adopts recommendations and 6. Lang R. The United Nations Convention on the right and dignities for proposals regarding implementation of the Convention’s provisions. The persons with disability: A panacea for ending disability discrimina-first such report by Slovenia was sent to the Committee as late as 2014, to tion? ALTER-European J Disabil Res Eur Rech sur le Handicap. Else-be reviewed at an upcoming assembly (15). In accordance with the Optional vier 2009;3(3):266–85. protocol, the Committee also has the power to treat any individual or group 7. Baker GA, Brooks J, Buck D, Jacoby A. The stigma of epilepsy: a Euro-complaints that claim a State Party has breached provisions set forth in the pean perspective. Epilepsia. Wiley Online Library 2000;41(1):98–104. Convention. The proposals made by the Committee are considered morally 8. Lord JE, Suozzi D, Taylor AL. Lessons from the Experience of UN and professionally binding, and are commonly put into practice. Convention on the Rights of Persons with Disabilities: Addressing the Democratic Deficit in Global Health Governance. J Law, Med Ethics. A look to the future Wiley Online Library 2010;38(3):564–79. By ratifying the Convention, Slovenia has made an important step in en-9. Bartlett P. The United Nations Convention on the rights of persons suring the respect for basic human rights of persons with disabilities. The with disabilities and mental health law. Mod Law Rev. Wiley Online importance of the Convention lies not only in ensuring rights, but also in Library 2012;75(5):752–78. a paradigm shift in societal perception of persons with disabilities. A shift 10. Dhanda A. Legal capacity in the disability rights convention: stran-of this magnitude, one that is based on respect and successful inclusion, glehold of the past or lodestar for the future. Syracuse J Int’l L Com. could only be considered successful when effective psychosocial rehabilita-HeinOnline 2006;34:429. tion programs are in place, ones that do not rely on institutional care, but rather on community acceptance. 11. Berkman LF, Glass T, Brissette I, Seeman TE. From social integration to health: Durkheim in the new millennium. Soc Sci Med. Elsevier 2000;51(6):843–57. Sources 12. Cotič Ž. Izgubljeno s prevodom: problematika poslovne sposobnosti v 1. Zakon o ratifikaciji Konvencije o pravicah invalidov in Izbirnega pro-Konvenciji o pravicah invalidov. Prav praksa 2014;33(9):16–7. tokola h Konvenciji o pravicah invalidov (Uradni list RS – Mednarodne 13. Annual Report of the Human Rights Ombudsman of the Republic of pogodbe, št. 10/08). Slovenia for 2013 [Internet]. 2014. Available from: http://www.varuh- 2. United Nations. Status mednarodnih pogodb (Status of Treaties) rs.si/fileadmin/user_upload/pdf/lp/Devetnajsto_redno_letno_poro- [Internet]. 2006 [cited 2015 May 17]. Available from: https://trea- cilo_Varuha_CP_RS_za_leto_2013.pdf, 27.7.2015. ties.un.org/Pages/ViewDetails.aspx?src=TREATY&mtdsg_no=IV- 14. Implementation of the duties and powers of the NPM in 2013. Lju- 15&chapter=4&lang=en bljana, June 2014 [Internet]. Available from: http://www.varuh-rs. 3. Shuttleworth RP. Encyclopedia of Medical Anthropology: Health and si/fileadmin/user_upload/pdf/lp/Porocilo_DPM_za_leto_2013.pdf, Illness in the World’s Cultures Topics-Volume 1; Cultures. Ember CR, 27.7.2015. Ember M, editors. Springer Science & Business Media 2004. 16 17 15. Initial Report on the Implementation of the Provisions of the Conven-Tone Vrhovnik Straka tion on the Rights of Persons with Disabilitiew [Internet]. 2014. Available from: http://tbinternet.ohchr.org/Treaties/CRPD/Shared Docu- environment and us ments/SVN/CRPD_C_SVN_1_7019_E.doc, 27.7.2015. I never read the newspaper, but then again, I don't have to. One barely has to turn on a computer on to find out that »one of ours« has shot a policeman, flew a plane into a mountain, strangled a child, stabbed her husband… Calling the media does not work here, seeing as the exciting story of the badly dressed overweight personwith no makeup, who won't getout of bed, does not make for an exciting movie.. If you disagree, please try to find a positive example of a survivor in print or any media. Where is the epic saga of the woman who overcame illness, fought through the pitfalls of modern living and now, having won the heart of a loving partner, has settled down to run a sanatorium in South Africa? In reality, such a story would probably run along the lines of: »I have managed to get out of bed yet again! I went for a walk twice this week!« 18 19 Vesna Švab mental disorders. The value of a survivor's perspective has shown itself so important that it is now an integral part of evaluating effectiveness, suc-Recovery cess rate and financial efficiency (4).Global priorities in the field of mental health are inextricably linked to recovery and are ranked, by importance, When discussing recovery and rehabilitation, a method of supporting re-on »national mental health program«, the »stigma and discriminationa- covery, we often think in terms of improving objective quality of life. By wareness promotion«, »recovery and employment oriented psychosocial this we mean housing, friendship, a sense of security, employment and rehabilitation«and the »shift from institutional to community care«(7). achieving goals. We forget that quality of life is far from an objective absence of pain, but is rather a subjective, unique blend of an active life, sense of control, dignity and identity (1). A brief review of the research on the Medication and recovery recovery of mental health patients shows that they consider being conThe use of numerous successful psychiatric drugs has reduced suffering or nected (social inclusion, inclusion in the community), hope and optimism, even removed it among many of those with mental disorders. Mike Slade, the development of identity, a sense of strength and meaning (2).The de-in his chapter on the role of medication in recovery (8), discusses the im-sires of those who have recovered form a mental disorder are in no way portance of a patient taking responsibilityfor his or her own medication. different from the desires of other people. They want to achieve or keep According to Slade, patients should overtake responsibility for medication roles valued in society-those of employees, partners, family members and use and establish control over their effects and side effects. This means that free citizens with the power to affect change and make decisions. Grading a patient use medication that he is familiar with, and be given the abili-or measuring the success of recovery is then simply measuring a person's ty to choose. The informed choice requires a person to possess sufficient success in achieving social roles and personal goals(3). Consequently, these clear and scientifically accurate information on the subject. Choice is easier norms must be measured against accepted social standards, not by way of when appropriate questions are asked and clear answers presented.We do professional instruments intended to diagnose illness or reduced capability not want to see ourselves as passive, just observing what happens as our (4). Internalized stigma is the biggest hurdle to overcome in this process, brain does our thinking and deciding for us. We do notwant to think, feel and is often exhibited as low expectations from both patients and staff (5). and act at the whim of brain chemicals (1). People can take advantage of It has become clear over the past few decades that we need to change the alternative means of managing their condition. These can include anything way we think about recovery, if there is to be a successful and rational over-from diverting attention to genuine patience offered in a close relationship, haul of the system. People who overcome a mental disorder or illness en-from recreation to expressing creativity. Understanding alternatives shows ter a process perhaps best described with the following phrases: »deeply us that medicine is but one means of preventing recurrences of illness. personal unique process of changing one’s attitudes, values, feelings, goals, It should be noted however that the effectiveness of medication declines skills and roles«. It is a way of living a satisfying, hopeful, and contributing sharply when secondary requirements are not met, such as a safe and sta-life even with limitations caused by the illness. Recovery involves the devel-ble environment, lack of drug abuse, low stress levels in the workplace and opment of new meaning and purpose in one’s life.This identity needs to be many others. Experience shows us that most patients ultimately find bal-created anew, to allow the person in question to live a fulfilling life within ance by combining medication and other forms of managing their disorder, the limits imposed on them by their mental disorder (6).This viewpoint and that only when they decide to do so and take responsibility for it. is the result of firsthand experience, namely of those who have overcome Process of recovery is strongly linked with stigma, discrimination and self-mental illness. The fact that recovery from mental disorders takes such a stigma. complex form led some to believe that it was impossible to rigorously research. Now, an understanding of the process is becoming more and more important to researchers, professionals and those who have experienced 20 21 Tone Vrhovnik Straka Vesna Švab us and us Stigma What can a person do when confronted by a loss of self? While it is true In the past, it was often thought that mental illness makes normal function-that most users will use the internet and the telephone to say a few words ing impossible and that it reduces an individual’s abilities to an extremely about the medication they are using, their therapists and so on, they very low level (9, 10). Schizophrenia, for instance, is still widely debated along rarely actively seek out the company of similar individuals, despite the in-with attempts to prove that it causes a consistent and constant decline in sistence of doctors and family members. Few see the reason for it, as they brain function and abilities. The proof is supposed to lie in the results of ill-feel they are not being listened to. Even those that are lucky enough to be ness outcome analyses, brain scans and patient sensory evaluations.What situated in an area that boasts a day center are forced into groups that dis-the evidence actually shows is that only about 25% of people suffering from cuss topics that are widely considered idiotic. To be forced to recount their schizophrenia show a poor long-term illness outcome, only a few of which day and feelings, unchanged for years, listen to other individuals' treat-experience progressive loss of function (a characteristic of neurodegenera-ment methods and medicine, their financial situation, pension checks and tive illnesses); secondly, magnetic resonance imaging studies show only other banalities. slight alterations in brain structure with the onset of schizophrenia, which Self-organized survivor activities are few in number. The web forum »ne-can be explained as a side-effect of anti-psychotic medication, psychoac-boj.se« is a notable exception to an otherwise troubling situation, as it has tive substances or any number of other factors we are all subject to, such as been operating successfully in the field of self-organization for a number aging. Finally, even evidence ofcognitive deficits (memory, deduction and minor information processing capabilities) does not mean much, as these of years. The rest (the Mostovi project, the “bipolarna.si” portal, bipolar functions do not decline further over the course of the illness. Most pa-users' club and numerous others) have slowly died off over the years. What tients diagnosed with schizophrenia can expect a long-term remission and is left of the structure is almost wholly in the domain of NGO day centers can function effectively in society. The reasonsfor decline can often be at- (Altra, Novi paradoks, Ozara, Šent and Vezi) and in the housing framework tributed to poor access to treatment, reduced participation or simply the that a few of these groups have established. The need for self-organization changing financial and social circumstances that the illness triggers. It re-amongst survivors seems to wax and wane as activists fall prey to health mains a fact that most people suffering from schizophrenia have little ac-issues, the non-profitability of such enterprises, poor relations with the cess to relevant services and social aid they need to attempt recovery and metal health profession and other issues. The relationship that exists behave a sufficient quality of life. The outcome of schizophrenia is hard to pre-tween mental health professionals and survivors is a particular point of dict, as stigmatization and its consequences: poverty, unemployment, and contention with the late dr. Lamovec, who emphasized the need for a criti-institutionalization inevitably impede the progress of every patient (11). cal view of professionals involved in self-help programs. This, of course, Despite evidence to the contrary, many professionals meant to help those is only a part of her proposed framework-she also advocated for a strong with mental disorders still hold the belief that schizophrenia sentences an focus on empirical knowledge and overcoming guilt that mental health individual to an inevitable decline. Families, workplaces and other social patients experience. She maintained that individuals with mental health structures often try to make patients abandon life goals that are shared problems should not consider themselves in any way responsible for their amongst the wider society, such as employment, forming a family, friend-condition. Such a viewpoint was to be replaced by a sense of responsibil-ship or an independent life (12). It seems that one of the parameters of so-ity for future actions and a general atmosphere of »realistic optimism«. cial exclusion amongst the ill is fear, not only of illness, but also of stigma, (Lamo vec, 2006, pg. 183). discrimination and hardship. So far, there has been a distinct lack of research into these fears (13), without doubt caused by the inertia and con-descension that are so widely present in the profession. 22 23 Sources Tone Vrhovnik Straka 1. Glover J. Alien landscapes: interpreting disordered minds. Harvard Doctors, Pharmacists and us College. Harvard 2014. 2. Leamy M, Bird V, Le Boutillier C, et al. Conceptual framework for per-After a month's worth of preparation, report writing, assessing questions sonal recovery in mental health: systematic review and narrative syn-and responses and polite requests, this is usually the extent of conversa-thesis. Br J Psychiatry 2011; 199:445–52. tion I have with my doctor: 3. Slade M. Measuring recovery in mental health services. Isr J Psychia- »How are you feeling? Do you need a refill?« try Relat Sci.2010; 47: 206–12. »I…« 4. Thornicroft G, Slade M. New trends in assessing the outcomes of men- »Take this prescription to the nurse, please, and have a nice day.« tal health interventions. World Psychiatry 2014; 13(2):118-24. 5. Lasalvia A, Zoppei S, Van Bortel T, et al. Global pattern of experienced TThe underlying characteristic of the Slovene psychiatric system is, as far and anticipated discrimination reported by people with major depres-as the user is concerned, waiting. Waiting for a consultation that never sive disorder: a cross-sectional survey. Lancet. 2013; 381: 55–62. comes, waiting for a reduction in the amount of drugs, waiting for reasonable advice about the situation at home, waiting for a decision on whether 6. Anthony WA. Recovery from mental illness: the guiding vision of the or not hospitalization is an option. We petition doctors as if they were mental health system in the 1990s. Innovations and Research 1993; kings, except those of us who can afford to pay for a private practice con-2:17–24 sultation. Perhaps all the extra work the psychiatrists are doing, such as 7. Copeland J, Thornicroft G, Bird V, Bowis J, Slade M. Global priorities legal consultations, makes them so tired that they forget our names or why of civil society for mental health services: findings from a 53 country we are there. survey. World Psychiatry 2014; 13(2):198-200. The fact remains that the psychiatric network has been overburdened for 8. Thornicroft G, Szmukler G, Mueser KT, Drake RE (eds.). Community decades. The low number of practitioners forces them to focus on essential Mental Health.Oxford 2011, Oxford University Press: 31-2. care, into a quick-fix routine. They rarely bother to explain the side effects 9. Bellack AS. Scientific and consumer models of recovery in schizophre-of medicine and how this correlates to weight gain and other problems that nia: concordance, contrasts, and implications. Schizophr Bull. 2006; the mentally ill face. The arrogance that they display is, of course, not lim-32(3):432–442. ited to doctors working in psychiatry, yet I believe that they should share 10. Kraepelin E. Dementia Praecox and Paraphrenia. Barclay RM (transla-more of the blame than their colleagues. I expect them to know much more tor). Edinburgh 1919, UK: E and S Livingstone. about the reasons, forms and progression of the various illnesses that we try to discuss with them, all of which is a distant second to my desire for 11. Reilly TJ and Murray RM. The Myth of Schizophrenia as a Progressive more time spent in consultations. Sadly, because of how we see psychia-Brain Disease Schizophr Bull (2013) 39 (6): 1363-72. trists, there exists a conviction among survivors that doctors are basically 12. Drake RE, Whitley R. Recovery and Severe Mental Illness: Description an extension of the pharmaceutics industry, that they are interested in and Analysis.Canadian Journal of Psychiatry. Revue Canadienne de profit and not medical research that could help those suffering from more Psychiatrie 2014; 59(5):236-42. severe forms of mental illness. We can clearly see that the market for more 13. Sweeney A, Gillard S, Wykes T & Rose D. The role of fear in mental gentle sedatives and other home-use medicine is continuously expanding health service users’ experiences: a qualitative exploration. Soc Psychias general practitioners prescribe more and more of them. atry Psychiatr Epidemiol 2015. Feb 22. [Epub ahead of print] PubMed The inpatient departments of Slovene hospitals remain dark places in PMID: 25702165, DOI 10.1007/s00127-015-1028-z. which reports of physical and mental violence still circulate, where you 24 25 can still hear the terms »atonement«, »obedience« and others. We can see Vesna Švab that psychiatrists simply don't put in enough of an effort. People suffering from severe disorders are limited by the careless, lackadaisical approach Psychosocial rehabilitation (PSR) and community that they display. There is not enough information on successful treatment treatment and goals are set too low. Treatment is considered successful when a patient finds a way to live with The before-mentioned inertia in psychosocial profession is slowly chang-a life-long supply of medicine, not when he is returned to a state of good ing. The past few decades saw a number of initiatives to bring the perspec-mental health. The fact that patients remain polite and do not fight back is tive of recovery into the halls of power. Programs that embody this new no argument for the quality of services on offer. way of thinking have appeared, in Slovenia, in the form of social, non-governmental and psychiatric services. Psychosocial rehabilitation (PSR), according to the American PSR Asso- The service user’s recommendation ciation, is a method that accelerates recovery, community inclusion and The reform of the health care system allowed psychiatrist to carve out an ac-improves the quality of life amongst those diagnosed with a severe and cepted place in the system. They work in clinics and offices, work with psycholo-recurring mental disorder. A mental disorder is considered severe when it gists and neuroscientists to come up with ideal forms of therapy, demand and reduces a person's ability to live a fulfilling life (1, 2).The core principles of achieve teamwork on more complex cases, perform outpatient services, and a rehabilitative approachcan be summarized through the following fifteen-help rehabilitate patients returning to daily routines and work. Cooperation be-parameters: tween the patients and the doctors has never been higher, resulting in a lower 1. Recovery is the ultimate goal of psychosocialrehabilitation. Interven-rate of suicide. The pharmaceutical industry continuously makes advancements tions must facilitate the process of recovery. in treating depression, in developing anti-depressants that do not affect weight 2. Psychosocialrehabilitation practices help people re-establish normal gain in patients and has banned the production and sale of addictive sedatives. roles in the community and their reintegration into community life. Reorganizing itself into a responsible, social branch of industry it has managed 3. Psychosocialrehabilitation practices facilitate the development of per-to achieve great leaps in removing the reasons for youth crises and has set its sonal support networks. sights on maintaining good mental and physical health in the ever-increasing population of senior citizens. 4. Psychosocialrehabilitation practices facilitate an enhanced quality of life for each person receiving services. 5. All people have the capacity to learn and grow. 6. People receiving services have the right to direct their own affairs, including those that are related to their psychiatric disability. 7. All people are to be treated with respect and dignity. 8. Psychosocialrehabilitation practitioners make conscious and consistent efforts to eliminate labeling and discrimination, particularly discrimination based upon a disabling condition. 9. Culture and/or ethnicity play an important role in recovery. They are sources of strength and enrichment for the person and the services. 10. Psychosocialrehabilitation interventions build on the strengths of each person. 26 27 11. Psychosocialrehabilitation services are to be coordinated, accessible, Vesna Švab, Milan Krek and available as long as needed. 12. All services are to be designed to address the unique needs of each in-Mental Health Care in the Community dividual, consistent with the individual’s cultural values and norms. 13. Psychosocialrehabilitation practices actively encourage and support Why community treatment the involvement of persons in normal community activities, such as school and work, throughout the rehabilitation process. The treatment of mental disorders can be done in both the community and in an institution. The vast majority of people suffering from mental disor-14. The involvement and partnership of persons receiving services and ders are treated at home, where their health is overseen by a general physi-family members is an essential ingredient of the process of rehabilitacian and nursing staff, along with other professional employed at the prima-tion and recovery. ry health care level as Kersnik describes in the one of the following chapters. Psychosocialrehabilitation practitioners should constantly strive to im-Even so, most funds allocated to treat mental disorder are spent on institu-prove the services they provide. tional forms of care, which can be easily explained by the amount of human resources used by institutions. Studies show that governmental institutions boast ten times the amount of human resources an average NGO does (Min- Proven PSR methods: istry of labour, family, work, social affairs and equal oppotunities, Slovenia). • Training in living independently and social skills: Learning theories Finances aside, there is a further reason for community treatment. Glover focusing on basic life skill achievement and maintenance are used. (3) tells us that those with mental disorders are not simply strange birds • Patient and family psychological support: This program includes psy-in the garden, but rather equal and, in most senses, similar members of choeducation, to be described later on. society, that in no way wish to be institutionalized. Institutionalization is • proven to harm their mental health, with the proven long-term effects of Housing management: The goal of this program is to provide hous-diminishing their capabilities and confidence. Although community treating in a normal, regulated environment, which may include support ment does not mean that treatment needs less time and is often even more staff if necessary. time consuming than institutional treatment, it does have the benefit of • Work rehabilitation and employment: Supported employment pro- continuously improving functional skills. It has been reported that those grams areextremely successful, contributing to an increase in gener-working in communities show more caution around patients, including a al health and fulfillment. measure of respect, although the situation is not always ideal. Community • Social inclusion and interpersonal relationship counseling: Meant to treatment shows better recovery outcomes than institutional treatment, improve an individual's ability to handle difficulties, by either dimin-but it does require a carefully balanced set of services that have to include some forms of institutional treatment (4,5). Most countries are now in the ishing stressful situations or strengthening the individual. process of making the shift from institutional treatment to community treatment of people with mental disorders. Definitions Community psychiatry: The use of techniques, methods and theories that reveal needs in the field of mental health and attempt to answer those needs in a functionally or geographically limited area. Community services should therefore answer the needs of individuals, not produce new services. 28 29 Community treatment: Treatment meant to ensure versatile and continu-1. Condition Analysis: ous support, preventing institutionalization wherever possible. Other a. Identify the target group; parts of the definition include user participation in creating community b. Overview existing services; treatment services, quality control and other forms. Community treat- c. Establish a dialogue with key personnel; ment is also defined as treatment with evidence based methods (2). As d. Identify those responsible for organizing and financing the network; per the definition, the main alternatives to hospitalization in community e. Identify other mental health services. treatment are at-home treatment and various types of rehabilitative employment and day care. The existing system of mid to large size institu-2. Need assessment study (Percentage and incidents of mental disorders tions is to be slowly replaced by a more adaptable network of alternative in the community); services, which would include psychiatric treatment. 3. Set short-term, long-term goals and priorities while taking non-appar-ent needs into account; Needs assessment 4. Realize goals The World Health Organization (WHO) warns that people diagnosed with (for example in 8). mental disorders are widely discriminated against. Many are exposed to various forms of violence and violations of their basic human rights, The development of community treatment in Slovenia including the right to receive emergency treatment and social aid. They receive poorer education and consequently have trouble finding employ-The last five years have seen the development of four separate models of ment. On average, a mental disorder will shorten a person's lifespan by treating those with severe mental illness in Slovenia. These need to be com-twenty years (6). This is the result of various health issues, stigmatization pared and reviewed according to their success rate and financial solvability. and lack of social assistance. Such assistance needs to be based on actual The four models use comparable methods, with the first two models de-needs, not simply be a copy of existing services.To assess existing needs veloped by the medical and the second two developed by the social sector. among users and their families, epidemiology, demographic and other databases need to be used. The existing WHO guidelines state that mental The first model: Community psychiatric care health patients should be treated on the primary health care level and in the community, which should result in better accessibility, treatment and The accessibility and comprehensiveness of psychiatric care for people financial efficiency (7). When planning new services in the field of mental with mental disorders are much improved by Community Mental Health health, three approaches are usually considered. The first is to analyze data Teams (CMHTs) (5), consisting of a psychiatrist, a psychologist, a social from existent programs. However, individual cases have very little effect worker, nursing staff and occupational therapists. These teams are to be on such analyses. The second approach is to analyze national databases. distributed evenly, covering a population between 50.000 to 100.000 peo-While this approach still suffers from low individual impact, it allows us to ple, depending on the area. They are meant to be response teams that sup-assess regional needs. The third approach is a direct dialogue with service ply the demand for treatment generated by all those suffering from mental users and providers. This approach makes it easy to recognize local needs disorders and in need of immediate psychiatric assistance. CMHTs are to as perceived by the community and its leaders, but can suffer from being spend most of their efforts on treating patients with severe mental dis-too closely involved with local politics, personal desires and other factors. orders, by way of support and treatment at their place of residence while also managing crisis situations and assisting priamry health care person-The following steps should be followed when attempting to establish a ser-nel when treating at-risk patients. The CMHTsare to contact and monitor vice network: patients that have not yet received psychiatric care and are termed at-risk 30 31 by personnel operating on the primary health care level. CMHTswere es-Second Model: Assertive Community Treatment tablished in Slovenia in 2013 as a pilot project in four regions and as an In Slovenia, community therapy is also underway in psychiatric hospi-educational program on treatment and prevention of mental disorders. In tals. Hospital psychiatric teams, working under the Assertive Commu-April 2015, 471 individuals have already been receiving care through the nity Treatment(ACT) model monitor patients with severe and co-morbid CMHT network, 67 of which live in the Koroška region, 152 in Sevnica mental disorders after discharge and ensure timely treatment and assist region, 164 in Novo Mesto region and 88 in Murska Sobota region. in solving anygeneral issues. The monitoring is meant to take place within Four health centers have received funding for CMHTs in their local area, a limited timeframe following a patient's discharge and, within this time due to high suicide index in these regions and other low mental healt in-frame, offer unlimited and continuous support. Every ACT team, in every dicators. An assessment of local needs has been accomplished and help hospital, has achieved a significant reduction in hospitalizations with the offered to those with a history of poor cooperation in treatment. This as-patients they have worked with and thus managed to save budeterial re-sessment showed that most patients find themselves experiencing hard- sources, since hospitalization is the most expensive form of treatment. ship in general, with most difficulties existing outside of their psychoses, but rather in day-to-day life. These include loneliness, idleness, poor self-image, poverty and suicidal tendencies (Item 1). Third and fourth models: Coordinating treatment in the community Coordinating treatment in the community is a process conducted by social care centers once patientsare discharged from psychiatric hospitals. Social Item 1: The needs of patients as treated by CMHTs in RS. Evaluated by pa-workers are educated to perform duties and act within the boundaries of tients, family and professional personel. the Mental Health Act. These care coordinators primarily manage social Table 1: The Camberwell Assessment of Needs Results in CMHTs Slovenia. No. problems that discharged patients experience and also coordinate their of patients (y), unmet needs (x) (122 SMI patients) (9): work with psychiatrists, for which they are fully licensed. A similar style of treatment is also available in a number of NGOs, which have arrived at their model through experience in these areas, beginning in the early 90s. The program they use is based on the planned treatment model that was under developed by the Faculty for Social work at the University of Ljubljana. The same institution educated care coordinators as well. Data gained from this program can be found in the SlovenianNational Mental Health Plan, and can be roughly summed up by the fact that in 2013, 29 coordinators managed 500 instances of care coordination (source: MDSSZ). Work group protocols Admittance: Note: Needs are assessed by patients, caregivers and professional workers • In CMHTs patients that will eventually be enrolled in a community separately. psychiatric care program are identified by general practice physicians, in social work centers and NGOs and through public program demonstrations performed by the group that runs the program (nursing staff, physical therapist, psychiatrist and psychologist) (2). These 32 33 patients can be admitted directly, without a referral. A treatment along with disrespect for independence and personal space. Staff was ac-protocol is prepared for each patient based on needs and goals that cused of being unable to recognize family needs and lack of planned treat-have been identified by the initial multidisciplinary team, including ment excluding patients, families or any external help. Privacy was also the patient, family and external coworkers involved in the treatment viewed as non-existent as services swapped information on patients with process. alarming ease or completely ceased to inform anyone. This situation calls • Within the ACT model, a patient is identified in the institution dur-for a definition of jurisdiction, a consensus on roles in treatment and of ing hospitalization, at which point the diagnostic process is complet-course, appropriate protocols. Patients need to beprovided with the ser-ed and treatment continued. vices they require and be at the focus of the treatment. • Patients are identified when discharged from a hospital. Patients can choose to accept the aid of a treatment coordinator. Sources Monitoring: 1. Anthony WA & Liberman RP. The Practice of Psychiatric Rehabilita- • All three models require that the patient be monitored and treated action: Historical, Conceptual, and Research Base. Schizophrenia Bulle- cording to a plan. All measures that take place during treatment must tin1986; 12 (4): 542–59. be documented and applied precisely as prescribed in the treatment 2. Thornicroft G, Szmukler G. Mueser KT& Drake RE (eds.) Community protocol (CMHT and ACT use treatment protocol notes, CMHTs must Mental Health. Oxford 2011. Oxford University Press. use cyphered notes for insurance companies and keep a log of meas- ures and outcomes, while care coordinators use treatment notes and 3. Glover J. Alien landscapes: interpreting disorder minds. Harvard 2014. multidisciplinary team logs). Harvard College. Outcome evaluations: 4. McDaid D & Thornicroft G.Balancing institutional andcommunity-based care.European Observatory on Health Systems and Policies • are based on the aforementioned data. 2005. Accessed 27.9.2015 at:http://www.euro.who.int/__data/assets/ pdf_file/0007/108952/E85488.pdf. Evaluations 5. Thornicroft G & Tansella M. Components of modern mental health ser-CMHT programs have been analyzed based on the demographic data they vice: a pragmatic balance of community and hospital care. Overview of provided, along with a complete needs evaluation for every enrolled pa-systematic evidence. British Journal of Psychiatry 2004; 185: 283–90. tient with the corresponding clinical assessment taken every 6 months. 6. Thornicroft G. Physical health disparities and mental illness: the scan-In 2010, care coordinators (Centres for Social Work) have performed 642 dal of premature mortality. Br J Psychiatry 2011;199(6):441-2. treatments, 183 of which were performed by multidisciplinary teams. In 7. European Mental Health Plan 2013. Accessed 3. 5. 2015 from web page: 2014, 500 care coordinations were administered. http://www.euro.who.int/__data/assets/pdf_file/0004/194107/ NGOs continue with their work in care planning, maintaining well over 63wd11e_MentalHealth-3.pdf a decade worth of psychosocial assistance, housing assistance, day center 8. http://www.gov.scot/Resource/Doc/158710/0043070.pdf). Accessed care and various social enterprises they have established. online 27.9.2015. All services report that they are focused on recovery and that they provide 9. Thornicroft G & Slade M. Camberwell Assessment of Need, short the best possible treatment, which takes into account patient needs and version, User friendly assessment of need. Nursing Times 1999; desires. This network of services occasionallyallowed double monitoring 95(33):52-3. that led to first complaints from patients. Excessive control was reported, 34 35 Janko Kersnik Early Detection of imminent Crisis The role of a family physician in identifying crises When general practicioners consider their patients' health problems important as warning signs of a future crisis and manage to create a relationship and crisis intervention in which a patient is willing to seek their advice in such a state, early diagnosis can be achieved. A prerequisite for such an approach is knowledge of symptoms or signs that show a patient is undergoing a crisis or that a crisis Introduction is currently in development. Crises can be expected whenever the patient's Crises and crisis interventions represent a professional, organizational social structure undergoes a change (5), making it neccessary for us to closly and humanitarian challenge to all health care workers. Crises cover a broad monitor any patients experiencing such a situation. Special attention must spectrum of scenarios and causes (1-3). In the eyes of the public health sys-be paid to developmental crises, which although a natural and neccessary tem, when dealing with a crisis, prevention, early diagnosis and treatment part of development, are accompanied by emotional upheaval. These cycles (intervention) are extermely important, as well as providing guidance to include adolescence, creating a family, children leaving home and others. patient during crisis and after it. Most of the literature available on the sub-Of course, these crises can be anticipated which is not true for traumatic or ject is psychological or psychiatric in nature, while general practicioners rely coincidental crises, which can be triggered by a number of events (1, 2, 5). only on the process of forced hospitalization as a commecement of a crisis intervention process. Treating crises Preventing crises Treatment of crises is in the domain of psychiatry, where psychologists and psychiatrists treat patients with the intent of reducing poor outcomes Many patients consider the fact that they are assigned a general practicion-and number of hospitalizations (1, 3, 5). Despite the accessibility of psy-er who is available in case of emergency the first step in managing a crisis, chiatry, it is the responsibility of the general practitioner to refer all pa-more so when there is an appropriate relationship between the two parties. tients experiencing a crisis to a psychiatric service, whether said patient is A general practicioner can contribute to reducing the amount of crises and diagnosed during office hours, on call or in the emergency department (6). can achieve early diagnosis . General practitiorner’s efforts can also support and direct other health care professionals in an emergency situation. Most crisis causes and triggers are beyond the influence of either individual or the Crisis intervention health care system, which means that a large part of a general practicioner's responsibility lies in monitoring and directing patients with a known men-Interventions are the responsibility of psychologists and psychiatrists (1-tal disorder, as they are much more likely to experience crisis. 3, 5, 7, 8). GP and his team contribute to crisis prevention simply by being avialable and present, as patients can use consultations and the referal system to fa- The role of non-psychiatrists and non-psychologists miliarize themselves with how the system works, which problems can pre-The role of the general practitioner in forced hospitalization scenarios, an sent themsleves and other facts.The psycho-social aspect of a physicians work is especially significant, as a whole and hollistic treatment, one that extreme measure used in crisis, is widely discussed in all emergency guide-incorporates an interest in a patient's physical, mental and social environ-lines (6). The available sources, however, do not provide crisis treatment ment is proven to be significantly more effective (3). The more a physician parameters for other physicians. The role of non-psychiatrists and non-follows these guidelines, the more likely it is for a patient to seek his council psychologists can, despite this, be described using the guidelines used for early on, allowing them to suppport a patient and prevent a future crisis. crisis intervention teams (3): 36 37 • Threat evaluation Sources • Establish cooperation 1. Kocmur M. Krizna stanja [Crisis interventions]. In: Romih J, Žmitek • Identify issues A, ed. Urgentna stanja v psihiatriji -Suppl.. Begunje 1999. Psychiatric • Hospital: 89-100. Consider emotional state • 2. Pojem U. Krizna stanja v psihoonkologiji [Crisis interventions in psy-Consider possible solutions to the situation at hand chooncology]. In: Romih J, Žmitek A (eds.). Urgentna stanja v psihi- • Plan measures atriji [Crisis intervention in Psychiatry-Suppl.]. Begunje: Psihiatrična • Monitor (If the patient is not transferred) bolnišnica 1999: 32–40. 3. Roberts AR. Assessment, Crisis Intervention and Trauma Treatment: As with all other work, the key to any crisis intervention is establishing The Integrative ACT Intervention Model. 2002: 1–22. trust. A high level of trust will make all other tasks easier. When planning treatment measures we must rely on a number of potential coworkers, in-4. Allen J, Gay B, Crebolder H, Heyrman J, Svab I, Ram P. The European cluding social workers, nursing staff, psychologists, psychiatrists and oth-Definition of General Practice in: Evans P (eds.). WONCA EUROPE ers able to provide appropriate treatment in a crisis situation. (The European Society of General Practice/ Family Medicine); 2005. Available from: http://www.euract.eu/official-documents/finish/3- official-documents/94-european-definition-of-general-practicefamily- Guiding Patients at increased risk of experiencing a crisis medicine-2005-full-version Even though patients who are about to experience a developmental crisis 5. Mrevlje G. Krizna stanja pri mladostniku. [Crisis interventions in ado-are part of this group, patients with severe mental disorders who have ex-lescent treatment]. Obz Zdrav Nege 1984; 18: 264–73. perienced a crisis due to their illness are more at risk. Patients diagnosed 6. Turk H, Kersnik J. Hospitalizacija proti volji bolnika. [Hospitalization with psychotic disorders are especially at risk and so deserve special con-Agains Consent]. In: Grmec Š (ed.) Nujna stanja. Ljubljana: Zavod za sideration. They are to be monitored, encouraged in their treatment, their razvoj družinske medicine, 2008: 239-41. feelings and condition taken into account as well as the possibility of in-7. Anon. Crisis management I : Early Detection and Crisis Prevention. dependence. It is necessary to stay in contact with the family and nurs-Ballart; Ballart health Services, 1997. ing staff in order to achieve a clearer picture of the patient’s condition. Support and a clear statement that we are available to the patient when 8. Mental Health Crisis Planning. Minneapolis, NAMI, 2008. needed are indispensable. Conclusion Despite the fact that crisis interventions are a psychiatric service, general practitioners can significantly contribute to crisis prevention and early recognition. To be able to do so, we must adopt a holistic approach to treatment and acquaint ourselves with causes and triggers that may initiate a crisis. Psychological support and timely and appropriate referrals can significantly contribute to crisis resolution and patient recovery. 38 39 Tone Vrhovnik Straka be and however hard it is to maintain this support does not give NGOs the right to solve these issues by sacrificing our interests. non-governmental practicioners and us I feel that we survivors have no chance of actually forming a strong comI believe that the purpose of NGOs is in fact employing people, not actually munity. If we compare ourselves to cancer or diabetes patients, we can im-helping those with mental health disorders. I have yet to hear of anyone mediately see that their desire to survive or manage their illness is not getting hired after »vocational rehabilitation«. In day centers, at least those only rational and socially accepted but also praised by the general public. It who haven't been replaced by other institutions, we are treated as children. is taken for granted that friends, infrastructure and support groups con-I fail to see the significance of sitting in a circle, discussing the feelings that sisting of well-informed veterans will be provided. These support groups the color red triggers in me. Why are we forced to leave at the end of the are often independent of professionals, based on the concept of humani-day? Are we not, in fact, the purpose of these centers? Why are the em-tarianism and the firsthand knowledge of how important it is to have a ployees constantly whining about how much they could help us if only they sympathetic ear available, especially one that is aware of the importance had more money? I do not think I should care about how much time they of self-help. Psychiatric patients, on the other hand, usually hail from a have to spend applying for grants. I just want a place where people would poorer socio-economic background, one devoid of physicians, lawyers and treat me with decency and kindness, where help would be readily available economists willing to create a shelter for future sufferers. The efforts of and not given in a patronizing manner. What really makes me mad are the those with mental health issues in the field of self-organization are often endless ranks of interns whose treatment of us is completely incompetent. compared to the efforts of alcoholics and drug abusers. I consider this to be an apples-and-oranges situation as such organizations are generally Now, I'm prepared to suffer through a lot, since the girls are young and are viewed as positive by the public-they were established in an effort to stop, basically afraid of us, having virtually no idea what goes on in our heads-free oneself and heal. but I do not think that excuses their attitude. I know that they need hands-on experience and that a faculty has been established at the university to A psychiatric survivor does not have the freedom to declare his psychosis help us with our problems. I'm also sure that if we didn't exist, there would over, his depression dead and buried. be a faculty established to help some other endangered species. Speaking honestly, I do realize that Altra, Novi Paradoks, Ozara, Šent and The service user’s recommendation Vezi along with various incentives are priceless and indispensable to those We survivors, the subjects of NGOs, participate in them on every level. We are of us who have had mental health problems. On a practically observable included in the decision-making process and management, we use them as a level, hundreds of people (unlike their less lucky counterparts living in ar-base for interventions in the field, as a basis for employment. They are used to eas without day centers) are offered shelter, encouragement, education, encourage volunteering, advocacy, the development of sciences and practices in counseling and other forms of aid. Through the years, the amount and in-the field of mental health and to coordinate national and international projects. tensity of aid has changed, which makes sense, as the current economic Together with NGOs and by using their professional skills, we stand against crisis keeps ravaging Europe. NGOs fight over ever-decreasing funds, as evident injustices, demand seats on hospital managerial boards and defend our states tighten their belts in areas that will never be extensively covered by sphere of influence in the disabled community. With the appropriate funding, of the media. NGOs cannot expect support from us, the users and survivors, course. We would also like a place in the Paralympics. which is forcing them into a deal with the state, hopefully an honest one. We are, of course, grateful for all the support and help, but we strongly believe that a just order is needed. The funds should be given to us first and only then to those who wish to help us. Whatever their circumstances may 40 41 Špela Zgonc, Tina Nanut, Ana Ivanišević Valetič The day center program helps individuals achieve social and other skills and leads to an independent and self-sufficient life. Completing this pro-inter-community Psychosocial rehabilitation of gram allows individuals to apply for employment programs and prevents individuals with mental health issues loneliness and isolation, often the consequences of mental disorders. These programs are underway in 13 locations across Slovenia in 6 regions. As a social care program, it accepts both those with long-term mental disorders ŠENT – The Slovenian association for mental health has been running and those who are experiencing a temporary crisis. community programs for people with mental health problems since 1993. Long-term users are usually those suffering from chronic disorders and the These programs have been established to break the vicious circle of re-elderly. Younger individuals after achieving a number of skills and becom-peated hospitalizations and create new opportunities to develop skills and ing empowered find their way to a full life for the most part. knowledge required for an independent and self-sufficient life. To facilitate Day centers provide individuals with the appropriate professional support accessibility and reduce financial burdens, these programs are underway in and assistance. Individuals learn to overcome problems they face on a daily several locations,. basis, to accept their mental disorder and the diminished capabilities ac-Community psychosocial programs use methods that are meant to em- companying it, to strengthen their abilities and finally, to learn that a life power individuals. Empowerment, in this context, relates to the ability to with a mental disorder can still be full and fulfilling. Besides the aforemen-lead an independent life and make decisions, not depend on family and tioned skills, an individual attending a day center will also strengthen and professionals who offer mental health services (1:16). The second most widen their social circle. important goal of such programs is normalization, meaning the ability to An individual attending the program will undergo both team and individual lead a normal life-a life that does not reflect any mental health issues that work. Individual work includes consultations and »venting« sessions. Team-an individual might have, or at least not more so than in the life of a person work includes preparing individual treatment plans (provided they have not free of them (2). been issued by the community treatment coordinator), meant to ensure an Our programs ensure that an individual is treated holistically, meaning individual's independence in fulfilling both simple and complex needs. that his needs in every area of life are taken into account. This type of Teamwork also focuses on learning social skills, by way of either simple treatment requires that a number of professionals that administer treat-conversation or practical education and testing. Practical skills taught in ment and people that the individual considers an integral part of their lives our day centers include computer skills, foreign languages, cooking classes, are included in teams. Team members must ensure that the goals they are nutrition and others. The centers also offer a number of activities meant to pursuing coincide with the needs and desires of the individual undergo-expand an individual’s social circle, including sports. ing treatment and that they offer the minimal amount of support an individual needs to achieve his goals. Such support must be limited to what The decision to enroll in the program falls to the individual, who must also the individual needs and desires and must empower the individual to take decide which activities to attend. Those receiving disability pensions and decisions on his own. other retired people most often enroll in leisure activities, as they consider their free time and their social circle extremely important. Lamovec (1) suggests that the significance of representation lies in enabling an individual to actively confront their problems in a way that they The programs we offer allow the person to make the transition back to an are familiar with. We believe that those experiencing issues must contrib-independent life much faster, yet this does not mean that the journey is ute the most to the eventual solution. The task of social workers lies in short. An individual must accept a new way of life, therapy and its side-achieving cooperation (4). effects and then weave all of these new skills and parameters into their personal routine, which requires changing old habits and ways of thinking 42 43 while maintaining one's sense of self. Any individual that succeeds in fol-Every individual must accept certain rules and guidelines before being ad-lowing the program is then ready for employment, which presents its own mitted. These hold true for everyone admitted at all times, ensuring qual-set of difficulties. Employment under special conditions or protected em-ity and tolerance. ployment is often not accessible in Slovenia. Upon admittance, a new resident creates an individual plan for independent living, with the help of a professional. This plan incorporates goals that are significant to the resident and is then put into motion. Success in fol-Community group programs offer housing, social skills education, self-lowing the plan and achieving personal goals is monitored and evaluated sufficiency training and support. Community group programs are under-on a yearly basis. The evaluation takes the residents opinion and experi-way in 11 units and are meant exclusively for those of age, who because ence into account, as per our empowerment doctrine. of mental disorders occasionally or consistently need assistance in living independently. This is usually the case because they lack appropriate living This form of consistent support, besides following the two methods es-arrangements or social networks. These programs are designed to allow tablished at the beginning of the chapter, also ensures a decrease in hos-the individual to make decisions about their housing, employment and pitalizations. Patients that consistently take their medication and are monitored by those able to recognize symptoms and signs of crisis are at treatment to the highest possible extent. The staff offers assistance when a significantly lower risk than others. We also try to involve family and needed, whether in an organizational capacity or otherwise. other people important to the resident, who help improve their relationA group resides in a house or a number of apartments. 4 to 6 people are ships and aid destigmatization. housed together, two people per room, for security purposes. Single bed-The last step in the program for some of the residents is returning to their rooms are also available, if an individual needs one. An on-site kitchen, homes and continuing to live independently, with appropriate support bathroom and living room are considered communal spaces. Program co- from the community. ordinators ensure an equal distribution of chores and other tasks needed To ensure that, community treatment coordinators are involved before an to maintain the property. individual leaves the program. A plan is made that ensures a smooth tran-All properties currently being used in the Community housing programs sition and minimizes the risk of a decline in mental health or social circum-are located in area with a developed infrastructure, which gives the resi-stances. Day centers also remain an important part of an individual’s life, dents access to a number of leisure activities. as they provide a link to professional aid that may still be requested at any The main condition that needs to be satisfied before an individual is en-time. Due to the poorly implemented housing policy in Slovenia, finding a rolled in a community housing project is partial independence, or at least, place to live remains only a distant possibility for most of the individuals the ability to master such skills. In practice, these skills include basic hy-enrolled in the program. The main cause for the current state of affairs lies in the scarcity of non-profit apartments. Most individuals suffering from a giene and nutrition, the ability to take medicine unsupervised and con-mental disorder receive only social aid or a pension, rendering them unable sistent follow-up visits with their doctor. Rules and conditions must be to buy or rent on their own. Even those that have the financial capacity to followed at all times, and the program must be actively participated in. buy or rent often refuse to do so, as they are afraid that society will be un-The following documents need to be submitted before an individual can able to accept their disorder and that their contract will be terminated as join a community housing project: soon as others find out about their mental state. Most former users there- • A motivational letter, which includes a personal statement, future go-fore stay with their families, which is why or program includes intensive als and a CV work on a user’s relationship with his family. • We are trying to improve and expand our community housing program, A doctor's opinion, as it answers a real need. Smaller, marginalized groups in particular have • A social work center’s report. shown tremendous interest in the project, which will enable them to 44 45 remain a part of society in the future. In this effort, we are limited by the 3. Brandon D, Brandon A, Brandon T. Advocacy: Power to people with system itself, both by the aforementioned housing policy and the existing disabilities. Birmingham1995. Venture Press. employment mechanisms. In practice, it often happens that a person has 4. Čačinovič Vogrinčič G. Jezik socialnega dela [The language of social graduated from the program and is more than capable of taking care of work]. Socialno delo 2003; 42(4-5): 199 -203. themselves, yet they cannot start an independent life as they are simply too poor. Slovenia particularly lacks the advanced mechanisms in place 5. Švab V. Vgraditi rehabilitacijo v sistem skrbi in pomoči [To integrate re-abroad, infrastructure, subsidized rent and financial aid. . habilitation in care management]. Švab V. (ed.). Psihosocialna rehabili-tacija [Psychosocial rehabilitation]. Ljubljana 2004, ŠENT - Slovensko ŠENT's programs are therefore limited and include 11 housing groups, 5 združenje za duševno zdravje. in central Slovenia, 3 in the Savinjska region, 2 on the coast and 1 in the North-West of the country. There are several people in the program that have received individual housing and are thus not part of housing groups. They enjoy flexible support that does not rely on scheduled interventions. Regardless of their status, participation in a ŠENT housing program guarantees equal legal rights to an individual joining a housing group. A contract binding the resident, financier and the contractor is drawn up in every case, ensuring a full measure of responsibility and rights. What separates a ŠENT program from other services underway in vari- ous institutions? Admission to a ŠENT program is very informal, which reduces the anxiety felt by users (5). Although collecting data and documentation is a requirement and a prerequisite for any serious enterprise, we try to maintain a humane approach, characterized by our focus on practical skills and knowledge. As participants master our programs they also achieve independence and all the necessary social skills they require to lead a life free of assistance from either us or other institutions. Because ŠENT is not limited by norms, we offer a much larger degree of flexibility required to make sure that our participants are treated as individuals. We offer aid that is individually tailored to our users and their goals. The treatment of an individual while taking into account his circumstances offers a host of options not available elsewhere. Sources 1. Lamovec T. Psihosocialna pomoč v duševni stiski. [Psychosocial help in mental crisis]. Ljubljana 1998, Visoka šola za socialno delo. 2. Videmšek P. Iz institucij v skupnost : stanovanjske skupine nevladnih organizacij na področju duševnega zdravja. [From institutions to community: group homes of non-governement organizations]. Ljubljana 2013: Fakulteta za socialno delo. 46 47 Tone Vrhovnik Straka The service user’s recommendation Family and us Families are wholly included in the rehabilitation team. They are first educated and prepared, and then the situation is evaluated by a number of professionals. Even though my family wishes me to move beyond my illness, I have no In more difficult cases, additional help is given to the more sensitive members idea how to do so when the world knows what I'm like. The situation at of the family. We try to evaluate whether the family is already benefiting from home does not help, as I'm dependent on my family who make sure that the appropriate social aid systems and then inform the family of any possible I take my medicine, lest I burn down an orphanage, while simultaneously benefits or other issues at hand (such as a transition to a family of a disabled making sure that I do not forget how out of touch and fat I am due to it. individual statues, ownership and inheritance issues, employment options etc.). Money is also an issue, as it cannot deposit my pension or my social aid in In case the affected individual does not have any next of kin, he is gradually in-the bank, seeing as how the social aid will dry up as soon as some bureau-troduced into a housing community and, later on, into a fully independent life. crat decides that I can live off my savings. This leads to bad blood between Through this process, we try to enable families to receive all rights and benefits my parents and me, who worry about my future and my physical wellbeing. that will allow them to lead a full life. A gym membership costs money-money that they do not return when you feel bad and cannot go. This bleak picture of my life shows how unprepared most families that are forced to deal with mental health issues are. Even in the information age, with information freely available, numerous support systems and other benefits, the realization that life has to change takes a long time. These families come from all social and educational classes, yet they are never truly prepared to help in such a situation. The prognosis for mental health patients is, obviously, not good. Most of those, who like me, have developed mental health problems during their school years, will not be able to finish their primary education, much less an university course. They will not have a family of their own and will stay with their parents living off social aid. Some will be lucky enough to find work and will live off their retirement money. I believe that having a mentally ill person in the family will drag everyone down by a step, as most people will see us as a slightly round, sluggish people who are often annoyed and lethargic, maybe even spoiled. Even within the family, most have no means of distinguishing between a simple bad mood and a serious change in our condition. This places a great deal of stress on a family member, especially when they want to campaign on our behalf. How are they to know whether a person is sick or simply spoiled from all the care you've been giving them? 48 49 Maja Smrdu, Edo Pavao Belak, Vesna Švab concern (2), which is important in all forms of treatment and support, including those outside the nuclear family. Working with families Mental illness may completely change the life of everyone in the affected The most important step in introducing a family to life with a severe men-family. This always leads to a number of concerns and questions about the tal disorder is the development of appropriate relationships. This can only treatment and recovery process. The most frequent ones are about (3): be done when those in the family feel no guilt or shame stemming from the • Mental disorders, medical interventions and treatment; mistaken belief that their actions are the cause of illness. Many parents be- • Family dynamics, relationships and feelings in families where a mem-lieve that a permissive upbringing or an overly strict one is to blame. They ber has a mental disorder; sometimes do not realize that there is not one person alive that does not • Protecting ill family members; wish to change something about the relationship they have with their fam- • Sharing experiences and concerns; ily, yet only a handful of people ever suffer from mental disorders. Severe • Outside help; mental disorders, such as schizophrenia or bipolar disorder are primarily • Acceptance; illnesses, and are not caused by families. They are caused by a complex se- • Ways to manage the disorder and factors causing stress; ries of factors, including a person's genetic and physical makeup. However, • Communication; we must remain aware that feelings of shame and guilt are so common that • family and other important people in a patient's life need to be asked about Stigmatization; them, even if they do not approach the topic. As long as these feelings are • Suicide; mitigated, a proper relationship can be formed between the patient and • Financial difficulties. his family. A relationship is considered appropriate when those involved In October 1998, ŠENT organized a round table focusing on family mem- (1): possess proper perspective, accept the illness, are in balance with their bers and caregivers of those with mental disorders. The most significant family and have realistic expectations. conclusions that we made then are listed below: We will summarize several manuals intended for families who include a • families of those with mental disorders do not need therapeutic person with a mental disorder. One of them is the Australian SANE Guide treatment, but rather concrete daily assistance in addressing practi-for Families, a manual that uses the family perspective to provide an ap-cal problems. Professionals mental health service should in part redi-propriate approach. SANE is a national charitiy helping all Australians afrect their efforts from psychotherapy and group work to continuous fected by mental illness lead a better life through support, training, and support at a patient's home; education. • families expect financial assistance and aid from the state, as they are The first thing any family member or a professional should learn is that a taking on a formerly institutional responsibility. Social aid, tax exemp-high level of emotional concern does not benefit the patient or positively tions, security bonuses and other forms of aid could be accepted; influence the treatment. Neither hostile behavior nor an overprotective • professionals are expected to maintain a professional and respectful attitude will help, but neither will a lack of information or support. attitude, provide support and offer trust, especially in when a forced As stated above, families need to be freed from feelings of guilt or shame. hospitalization is in place; There are many approaches to this end, including psychoeducation and • families require organizations to represent their needs and the needs other approaches that increase feelings of security and trust within the of patients; family. Familiy based interventions are proven to be effective in improv- • families require a network of support services to be established and ing prognosis and reducing the number of relapses. Psychosocial support maintained. These services are meant to improve the patients' quali-programs, on the other hand, are very effective in reducing high emotional ty of life and reduce the pressure on the caregivers. 50 51 Basic recommendations offered by most manuals are that following goals • family and professional staff should behave in a calm, decisive and should be achieved: friendly fashion. Threats are to be avoided at any cost; Confrontation – confronting the fact that a family member is mentally ill is • in the event that a patient had had suicidal thoughts, a history of self-hard. It means that all the family members will be affected. It usually leads injury or aggression a psychiatrist must be contacted immediately. to feelings of anger, confusion, loss and mourning. These emotions need to The family, including the patient, should have a contingency plan de-be accepted and discussed. signed for such an event. Professional staff should rely on treatment protocols. Developing a balance between: • admitting the illness and its effect and maintaining hope for a recovery; Various approaches to helping families • the desire to help and accepting a patient's independence; • One of the more successful approaches to helping families incorporates showing concern and stop being overbearing or over-engaged; several components: • spending time with the patient and having time for oneself and oth-er members of the family; • An evaluation of issues faced by the family and family inclusion. • encouraging the patient and maintaining realistic expectations. • Education and symptom monitoring. If family members cannot reco- The most important recommendation among these is definitely achieving gnize symptoms and effects specific to the illness at hand, if they do the fine balance between support and concern. A patient must be encour-not know how the illness is treated and what the chances for recove- aged to achieve independence and take responsibility, which can be hard ry are, they have little chance of helping the patient. Sometimes fa-to do. It is therefore highly recommended that a family remain in close mily members mistakenly attribute symptoms to the patient charac-contact with a team of professionals that can provide advice in specific ter instead to the illness or misread their significance. The answer lies situations. in psychoeducation and other forms of education. Discussing emotions • Communication training: Family members should master asking for assistance when it is needed. Stigma can be increased by unwarranted Mental illness usually represents a significant emotional burden on the feelings of guilt and stop family members from seeking aid. Families family. Therefore, it is essential that these emotions and feelings have can also benefit from support groups that offer communication skills an available outlet. Despite the fact that discussing our emotions can be training and confidentiality. Such groups often include members that healthy, an overbearing or overly concerned attitude may negatively influ-can make the family's experience seem normal or average and offer ad- ence the illness' development. It is best for everyone involved that a team vice and assistance when needed. Communication training is further of professionals be consulted before any such discussion. Support groups composed of courses in calm response, patience and understanding. and other self-help options are also available to family members in need. • Goals definition: Realistic expectations need to be established. By re-When the condition of a family member takes a turn for the worse, the fol-moving unrealistic expectations, family members will find it much lowing guidelines may help with dealing with stress of relapse or the first harder to negatively influence the patient. Consider the example of a psychotic episode: patient who has been hospitalized for several weeks. Upon his return • all communication should be clear, honest and understanding. The home, his family will expect a full recovery. He himself might want to patients should not be forced or unnecessarily touched or in any way immediately resume his education or employment. He then adds se- made anxious; veral additional activities to his daily schedule to make up for time lost • a calm and secure environment should be provided and all objects while in the hospital. All this severely increases his stress levels, lea-that the patient can use to harm himself or others removed from it; ding to a relapse. A slower pace of recovery might be more appropriate. 52 53 • Problem resolution: This is an integral part of any approach and is • Creating a relationship: This includes creating an equal relationship, related to emotional control and day-to-day problems resolution. It allowing the patient to take responsibility and set boundaries. People consists of identifying and defining the problem and then forming with mental disorders often feel that they have lost control and are response strategies. A strategy can be formed by organizing existing stigmatized. This is accompanied by a poor self-image that requires knowledge, identifying possible sources of assistance, and identifying that they be treated with respect, no matter how pronounced their relevant skills. Over the course of applying a strategy, progress must symptoms are. Ultimatums on banal subjects are best avoided, while be monitored and the resolution evaluated. It goes without saying as much responsibility as they can bear should be given to them in re-that such strategies are best tested in simple scenarios and a restric-gard to important issues such as medication. While a patient may oc- ted environment. After successful testing, such a strategy can be casionally attempt something that the family believes is beyond his employed as desired. capabilities, they should still allow him to do so. Such situations of- • Behavioral methods of self-control and symptom control: The latter ten turn out surprisingly well. A well-defined daily routine with cor-is important in preventing relapses. Every patient has a unique pat- responding boundaries should be created. These boundaries are es- tern of symptoms that are mostly consistent before every relapse. pecially important when dealing with aggressive patients. It goes Excessive sleeping, anxiety and fear, irritation, difficulties accomplis-without saying that all members of the family should respect these hing mundane tasks, tiredness, confusion, low attention span and sa- boundaries. dness are all typical symptoms and should be noted. • Recognizing a patient's courage and maintaining and expressing hope: • Controlling stress: To control stress levels, a patient and his family Anyone suffering from a severe mental disorder who has gathered must learn what triggers anxiety. The patient may be responsible for the courage to return to life in his own way. We must remember that documenting such experiences in order to recognize them in the fu- many manage to recover from their disorder and lead a fairly normal ture. A log of sensations and emotions and corresponding behavi- life, which is not possible if they are not given enough time. or should be kept. Such a tool allows the patient to find alternative • Self-help: Family members should not forget that they have limits of solutions and ways to avoid stressful situations. Dealing with stress their own and that they require rest, leisure and socializing outside requires strategies that can be developed by the patient and the fa-the family. This must be noted and planned for in advance, as many mily, who must also provide the patient with a safe space to retreat to. families forget about themselves until they are completely exhaust- • Maintaining improvements: A program that reduces critical com- ed. Without replenishing one's strength there can be no help to give. ments and intrusive behavior from the family must be instituted. This program should, at the same time, also provide the patient with the support needed to monitor his medication and take it regular- The influence of illness on siblings, children and partners ly, along with symptom control assistance and developing behavio- In general, the influence of illness on patient's parents is noticeable and well ral skills (3, 5). documented, while it is often forgotten that other members of the family might be influenced. The latter often experience strong feelings of shame A few other general recommendations (6): and embarrassment that force them to distance themselves from the pa- • Cooperation between the patient's family and the psychiatric team: tient and their home. Patients with severe mental disorders often require When a patient actively cooperates this significantly increases the much more attention than their siblings, which can lead to feelings of jeal-possibility of a successful outcome. The family should encourage the ousy and resentment. On the other hand, feelings of sadness and guilt may patient to cooperate and honestly report his condition, feelings and prevail,. Many feel that the illness has taken away the person they once doubts. knew and shared their life with. An illness almost always causes changes in 54 55 family roles. A daughter might become a replacement parent, a wife, who Disorders. In cooperation with the Council of users we have managed to was previously at home, might become the family’s breadwinner. Another get the Mental Health Law passed in 2008, thus at least in part protect-negative influence that an illness might have is the increased stress siblings ing and ensuring users' and family members' rights. The battle was won, experience when trying to compensate for the family's loss (1). but the war still rages. We continue to do work on the behalf of both users and family members and are determined to help all of us achieve a better, The following is a selection of observations made by patients' families: higher quality life. The power us family members have, lies, for the most part, in cooperation between our organizations both within and outside The most common violations of family rights our borders and the users that keep reminding those responsible of all the unsolved issues in the field of mental health. In practice, many families cannot participate in the treatment process. While family members understand that a patient must first consent to the inclusion of family in the treatment process, they still believe that we are Sources the strongest allies a patient can have on his path to recovery. As such it 1. Fuller Torrey E. Surviving Schizophrenia: a manual for families, pa-is both useful and right for families to be included in every phase of treat-tients and providers. Harper Collins Publishers 1983. ment and rehabilitation. They also believe that they should have the right 2. Pharoah F, Mari J, Rathbone J, Wong W. Family intervention for schiz-to accept or refuse the role of caregiver. They believe this is necessary as ophrenia. Cochrane Database of Systematic Reviews 2010, Issue 12. they too have finite amounts of energy and a right to a peaceful retirement. Families might become financially or socially threatened, especial-3. Kavanagh DJ. Schizophrenia. In: Wilson PH. Relapse Prevention, New ly when the cost of treatment and rehabilitation places vast amounts of York 1992. The Guilford Press: 157-90. stress on breadwinners. This leads to a fear of the future, uncertainty, and 4. Bebbington P, Kuipers L. The predictive utility of expressed emotion in anxiety and ultimately increases the possibility of mental disorders among schizophrenia: an aggregate analysis. Psychol Med. 1994;24(3):707-18. those who have none. We believe that we have the right to live decently. 5. Mueser KT, Gingerich S. The complete Family guide to Schizophre- This is in response to the fact that a person with a mental disorder often nia: helping your loved one get the most out of life. The Guilford Press requires family members to give up their own, private space. We have the 2006. right to community mental health care and to access an integrated support 6. Miklowitz DJ. The bipolar survival guide: what you and your family and assistance network present in the community. need to know. The Guilford Press 2010. How to help oneself? My own (Edo Belak) experience shows me that family members must fight for and protect their rights primarily on their own and that the strongest support we can count on comes from NGO's and their own family member organizations. A worthy example of this is the Slovenian Family Members Forum (SFMF), which works as a counseling body to the Slovenian Mental Health Association (ŠENT). SMFM has through its work attracted the attention and the cooperation of numerous other NGOs, culminating in the establishment of the Committee for the Family Members of Those Suffering from Mental 56 57 Vesna Švab, Janez Mlakar We can imagine that a person experiencing symptoms of psychosis is experiencing an immense and overwhelming number of stimulations com- Counseling ing from within. We should attempt to reduce those coming from outside. Even those people not suffering from psychosis can occasionally be over-The goal of psychotherapy is to reduce pain and obstacles to a fulfilling life. whelmed by information, which can lead to crisis, excitement or inappro-It aims to improve self-understanding and self-fulfillment (1). priate behavior. A person suffering from an overabundance of ideas and stress of the nervous system is far more susceptible to outside stimulation. While preparing this chapter on counseling in the field of severe and chronic This is the reason why working with such individuals in group settings is mental health disorders we found that most workbooks on rehabilitation extremely difficult. A group setting overwhelms such an individual with avoid this topic. There are mentions of behavioral and behavioral-cognitive both verbal and non-verbal information, causing the individual to have approaches to symptom management in severe mental disorders such as difficulties with focusing his attention. Most people do not find it strange schizophrenia, yet the word psychotherapy remains neglected in favor of if a person chooses to avoid crowds in malls or at parties, which makes it »psychosocial intervention«. strange that a patient's right to restricted access is often ignored. The theory of psychotherapy is based on the theory of objective relation-The foundation of any psychotherapeutic work is an honest, focused and ships. This theory explains a psychotic state as a regressive state. A regres-nonjudgmental listening. It should also include empathy, accompanied by sive state is one characterized by destroyed logical sequences, vague thought support and acceptance to the highest possible level. patterns and object fragmentation. The division between self and other is Many methods can be used in psychosis psychotherapy, provided that the malleable in this state. People suffering from psychosis therefore feel es-person administering them is qualified to do so. An acceptable qualification tranged from themselves, different and, consequently, utterly alone (2). is no less than a diploma issued by an internationally recognized psychotherapy educational institution, which should in turn be recognized by a relevant national body. These methods include cognitive-behavioral psy- Principles chotherapy, systemic (family) psychotherapy and analytical psychotherapy. The first principle of psychotherapeutic counseling in people who have ex-Psychotherapists working with those suffering from psychotic disorders perienced a nervous breakdown so severe that their sense of reality has should be especially familiar with psychopathology, a branch concerning been compromised is creating a safe and trusting environment. Psycho-itself with the study of symptoms, as recovery can be negatively affected by logically speaking, a psychosis is a regressive process connected with early intensive psychotherapeutic procedures. Regardless of technique, psycho-phases of development. As a child, a person is both in feeling and fact, therapy should always be based on an equal, caring relationship, character-completely dependent on others. His sense of self is, correspondingly, brit-ized by low levels of stress in treatment and high levels of support. tle and vague, as are his conceptions of others. The need for stable and secure relationships is consequently extremely pronounced in those suffering from psychosis. Psychotherapeutic continuum Counseling should be done in a place free of stress and little emotional Psychotherapeutic methods vary in intensity, from high in analytical treat-tension. There are parallels to the most important piece of advice given to ment to lower in cognitive-behavioral treatment. A patient undergoing an-family members of those suffering from mental disorders: »Low levels of alytic treatment is required to form free associations, expose subconscious emotional concern, non-intensive displays of those emotions and a calm-impulses and conflicts. This can be extremely painful, demanding and ing environment are crucial to the recovery. « can be seen in individual analysis, group analysis psychotherapy, transac-tional analysis, psychodynamic therapies and Gestalt analytic approaches. 58 59 Cognitive-behavioral therapy is less stressful and can assist in solving men-Several comparisons with other treatment methods were made. Intensive tal issues by changing thought patterns and, particularly in psychoses, use CBT treatment showed that it was significantly superior to routine treat-rational recognition and control of issues and symptoms. Psychoeducation ment. A nine-month therapy was proven comparable to unspecific support-and controls skills are further down on the intensity scale, as are reveal-ive relationship with the therapist, yet only the group that received CBT ing one's own past, empathic communication and containing of what is treatment retained the progress they made. (7). received. We will not describe each of the methods, as they must be studied Therapists using CBT treatment in treating those suffering from psychosis intensively. Suffice it to say that low-intensity treatments and methods are agree that professional help and methods require a complementary rela-generally better suited to those with severe and chronic mental disorders tionship between the patient and the therapist. Psychotic symptoms cause (3). Regardless of approach, our methods should include support, an um-severe stress that is, in general, not understood by others. This leads to con-brella term for genuine assistance when needed, and expressing care for cealment and loneliness, which makes it necessary for the therapist to es-an individual, and effective communication. Support is given by individu-tablish an accepting and trusting relationship. als, hence the difficulty in describing it. While our personal traits might influence the type of support we offer, it always includes commitment, a demonstration of a caring attitude, acceptance, a message of equality and Cognitive remediation cooperation, a communicated belief in the possibility of recovery, respect The term cognitive remediation has seen a lot of use recently. It describes for one's personal defenses and focusing on capabilities (4, 5). learning, practical individual exercise and group discussions, all aimed at Empathic communication that takes individuals into account, as well as improving cognitive function (8). Put simply, it is memory training that their emotions and control is thus the basis of any psychotherapeutic pro-improves learning and concentration capabilities. Wykes and Reeder, au-cess in psychotic disorders. thors of the workbook on cognitive remediation begin the description of the technique by stressing the importance of the environment therapy takes place in and the importance of the therapeutic relationship. They di- Cognitive therapy of psychotic symptoms rect our attention to the first rule in the technique, which is reducing outIn recent years, the focus of psychosocial treatment of psychotic disorders side stimuli- thus making learning processes easier. The second rule states has shifted from behavioral to cognitive methods. The main subject was that the therapist and the patient should, at least initially, meet alone (9). residual symptoms, hallucinations and delusions in particular. The first pi-This directly contradicts the existing doctrine of group work, which is de-lot tests showed that such treatment is effective in reducing belief in delu-signed to reduce demand on hospitals, day centers, institutions and hous-sions, which led to an expansion in research. Behavioral-cognitive approach ing group staff. is now employed in the wider field of psychosis. Kuipers and associates (6) have found that approximately 50% of those treated showed significant improvements. CBT (cognitive-behavioral therapy) as a mode of psychosocial Working with families treatment is exceptional in the fact that it has no known side effects, and The basis of working with families is the Expressed Emotionality Index that clients undergoing it seem to enjoy participating in it. The positive ef- (EE). In families with a high EE index, i.e. those exhibiting frequent critical fects reported by patients engaged in Kuipers' research showed not only remarks, hostility and overly high levels of concern for the patient, patients stability but also improvement over 18 months of treatment. Conclusive show a higher number of relapses than families with a low EE index. One clinical improvement was shown by 68% of those undergoing CBT treat-of the most important therapeutic methods in severe and chronic mental ment. The number of delusions and their effects were reduced. The frequen-disorders is therefore psychoeducation, which can reduce the EE index (10). cy of hallucinatory experiences was also reduced. Psychoeducation informs families on symptoms, causes and effect of the 60 61 disorder, which most often reduces guilt. The lack of guilt increases stabil-10. Pharoah F, Mari JJ, Rathbone J, Wong W. Family intervention for schiz-ity, reduces stress and, consequently, the EE index. Families with a high EE ophrenia. Cochrane Database 2012. Available at: http://www.cochrane. index find dealing with an illness much harder and can actually increase risk org/CD000088/SCHIZ_family-intervention-for-schizophrenia. of relapse by creating an unpredictable environment (9). The same princi-11. Kuipers L. & Bebbington P. Expressed emotion research in schizophre-ple can be applied to members of the profession seeking to help. The main nia: theoretical and clinical implications. Psychological Medicine 1988; methods of working with families should therefore be supportive and in-18: 893-909. formative in nature. Promoting mutual assistance is essential. Sources 1. Glover J. Alien landscapes: interpreting disorder minds. Harvard College. Harvard 2014. 2. Lakerman R. Adapting psychotherapy to psychosis. Australian e-Journal for the Advancement of Mental Health 2006; 5 (1). ISSN: 1446- 7984. 3. Goldsten WN. Analytic vs. dynamic psychotherapy in the ear of managed care. Psychiatric Times 1998; 15(11), www.psychiatrictimes.com 4. Pinsker H. The supportive component of psychotherapy. Psychiatric Times 1998; 15(11). www.psychiatrictimes.com 5. Barber JP, Stratt R, Halperin G & Connoly B. Supportive techniques: Are they found in different therapies? Journal of Psychotherapy Practice and Research 2001; 10(3): 165-72. 6. Kuipers E, Fowler D, Garety PA, Chisholm D, Freeman D, Dunn G et al. London-East Anglia randomized controlled trial of cognitive behavio- ral therapy for psychosis: effects of the treatment phase. British Journal of Psychiatry 1997; 171: 319-27. 7. Sensky T, Turkington D, Kingdon D, Scott JL, Scott J, Siddle R, et al. (). A randomized controlled trial of cognitive-behavioral therapy for persistent symptoms in schizophrenia resistant to medication. Archives of General Psychiatry 2000; 57(2): 165-72. 8. Dernovšek MZ, Smrdu M. Kognitivna remediacija duševnih motenj. ISIS januar 2011http://www.zdravniskazbornica.si/isis/1081/2011/ 2/2/ kognitivna-remediacija-dusevnih-motenj). 9. Wykes T & Reeder C. Cognitive Remediation Therapy for Schizophrenia. East Sussex 2005. Routhledge. 62 63 Mija M. Klemenčič Rozman, Maja Valič SHGs operating within certain fields or organizations often combine into clearinghouses, which offer technical, informational and executive as-Self-help organizations in the field of mental health sistance to individual groups (8, 9). Clearinghouses can combine to form national bodies (e.g.: American Self-Help Group Clearinghouse (10) that oversees and collects data from all existing groups within the country. Introduction These organizations represent both an information center dedicated to Mental health issues profoundly affect all areas of our lives, including educa-SHG and a source of support to individual groups. tion, employment, social status and social circle to name but a few. All of these While Slovenia still lacks a nation-wide organization, there are several changes increase the stress that an affected individual is under and in turn groups that are connected through various organizations, societies and as-present new problems and questions. To ensure that an individual has the sociations. The situation is the same for support groups operating in the highest quality of life possible, it is important that they acquire strategies tht mental health field, including those that provide support to affected fami-allow them to take control over these changes. These strategies are not only lies or individuals. Despite the delay in establishing these organizations, meant to help individuals manage their mental health issues, but also manage they have increased in number over the past few years, along with profes-their effects to the point where they are capable of reclaiming their life. sional interest in their operations. Regardless of the individual’s commitment to these strategies, he or she still needs the help of both family and society. Society can provide an individual with a number of extremely effective exchanges and meetings with Self-Help Groups and Support Groups in the field of mental those who are undergoing similar problems or have already successfully health overcome them. Options available to such individual are support groups (SG) and self-help groups (SHG). These provide a safe environment for an Self-help does not mean that people should rely solely on themselves (i.e.: individual to seek help and support, while assisting others by sharing their individual self-help), but rather the opposite of help from other sources, experiences and cooperating with the group. such as the church, state, nation and other entities. Self-help means that the impulse to help originates within a person. Any entity that organizes itself with the intention to help can thus be engaged in self-help (4). The development of self-help group We consider a group an SHG when people organize themselves into groups Self-help groups (SHG) flowered during the 1970's and the 1980's. The first that offer mutual support and assistance. These are mostly small groups SHG's, Alcoholics Anonymous groups (AA) (1, 2, 4), were established in the that meet voluntarily to solve a specific issue and are, at least not initially, US in the 1930's. The first SHG in Slovenia3 (AA) were established in the a part of a bigger organization (1, 11). In these groups, members often 1980's, yet they did not expand into other areas of life until the change share the same issue and the same goal (recovery), past experiences and in our socio-politic system in the 1990's (5). Among the more prominent stigmatizations. This leads to a high level of understanding and support. examples of these are SHG dedicated to the elderly (6), followed closely by SHG dedicated to mental health issues. Users formed many of these, They are personally committed to and responsible for their work. The while members of the profession intitated others (7). The field was soon members are equals-which includes the leader of the group, as he is usually expanded by dedicated mental health professionals, who established the merely responsible for coordination4 (12, 13, 2, 14). first support groups (SG). 4 More on mental health SHG, their characteristics, organizational methodol-3 See also: Klemenčič Rozman MM. Sami po moč: skupine za samopomoč in ogy and founding practices: Lamovec T. Psihosocialna pomoč v duševni stiski. podporne skupine kot vir moči. [SG and SHG as source of Power]. Ljubljana [Pschosocial help in mental crisis]. Ljubljana 1998: Visoka šola za socialno delo 2015. Pedagoška fakulteta. ter v Campbell P. Kako začeti. [How to start]. Maribor 1996. Ozara. 64 65 SHGs in the field of mental health can be divided into: Criteria SHG SG • Groups that intend to alter the existing mental health system, Ideology Present and intended to None or only in exceptio- • Groups focusing on personal improvement, aid in confronting the nal cases. • Combined groups that mean to affect both social and personal issue. changes (15). Leadership Mainly shared amongst Often by a professional or Support groups (SG) are the other form of mutual assistance groups (16). members a volunteer. Members lead Based on SHG, they overlap in function and organization to some extent only in exceptional cases. (i.e.: people are similarly encouraged to share experiences). SGs offer therapeutic group support involving mental health professionals in addition to Participa-Voluntary Voluntary SHG services (17). tion The differences between SHG and SG are described in Table 1 below. Such Contribu-Voluntary, no contributi- Voluntary, no contributi- descriptions are usually the result of comparing ideal organizations that tions ons or membership fees ons or membership fees are very rare in practice (13). Actual groups in operation most often pos-Professi- Rarely active (except in Group often established by sess a combination of characteristics of both types. An overview of the onal pre-case of membership). a professional. (Equality available literature shows that both SHG and SG operate within the field sence among members. Com- of mental health, with SHG being more common amongst users, and SG petence and education amongst family members. The reason for this is that organization amongst translates into legitimacy, users are mostly led by users themselves, while organization amongst fam-rarely shares the issues ily members are usually established by professionals employed in the field experienced by members) of mental health. The situation is very similar in Slovenia. Member- All facing the same issue. Limited to members of the ship organization managing or Table 1: The differences between SG and SHG according to: Farris Kurtz (13); sponsoring the group) Schopler and Galinsky (17) Meetings Structured, focused on Unstructured Criteria SHG SG the task at hand, the use of specific methods of Definition A group dedicated to A group in which members help. support, education and offer mutual emotional su- personal improvement. pport and share informati- Autonomy Local groups, mainly in- običajno organizirane zno- All members share an on on a common issue. dependent from national traj nacionalnih organiza- issue or condition. organizations. cij ali lokalnih strokovnih delavcev Intention Personal/Social change Emotional support, edu- or both. cation. Behavioral and Normally organized societal changes are not within national organi- considered as important. zations or by local pro- fessionals 66 67 The processes that take place in SHGs and SGs are: Support, information (23). SGs for families significantly contribute to reducing stress and in-exchange, offering a feeling of acceptance and belonging, exchanging expe-creasing feelings of competence in one's own role and positive personal rience, exchanging practical and learning new coping mechanisms. The pro-changes. Family members also feel that they received more emotional sup-cesses exclusive to SHGs are: reforming identity, strength recovery, achiev-port and they perceive improvement in the diseased family member clini-ing comprehension, changing the perspective a member has of the issue at cal condition (18, 24, 25). hand and creating a new community (13). Later on, two of the processes It often happens that mental health professionals recommend self-help, that are rarely mentioned in Slovene literature are more closely examined. while not completely trusting it (26). A Slovene study showed that leaders In certain circumstances SHGs and SGs can be destructive to their mem- (N = 146) of those SHGs and SGs that are removed from professional as-bers.. This is usually an effect of over-revealing intensive and negative sistance estimate that both knowledge and inclinations that professionals emotions (18), pressuring group members to conform, stress connected have of and towards these groups could be improved, while 634 members with obligations to the group, a feeling of being overwhelmed, learning of these groups expressed a high level of satisfaction with their member-inappropriate and non-effective responses, crisis and overconfidence (17). ship (M= 8,44, SD = 1,74, scale 0-10) (27). SHGs and professional assistance in the field of mental health Experiential knowledge Most people that we meet in SHGs in the field of mental health already Many SHGs and SGs occasionally invite professionals to the group in order have some experience with professional help. It seems plausible that peo-to inform and educate their members. While they are aware of the meaning ple join SHGs when they are confronted by the limits of effective profes-of professional knowledge, they are also aware of the fact that professional sional treatment. This means that both people who see SHGs as a parallel knowledge is not the only pool of knowledge available. Personal experience form of treatment as well as those who were directed to one by a profes-is an invaluable resource, especially experience gained in overcoming or sional are present. SHGs are often also composed of members seeking al-surviving a problem. This type of knowledge is different from professional ternative treatment methods and those who use it as a base to seek profes-or layman knowledge (13, 11). Every person who is a member of a SHGs or sional help (19). an SGs has a wealth of experience to draw on. SHGs were initially almost completely independent of professional as- Some SHGs and SGs members choose to complement their experiential sistance and presented an alternative to such treatment. Connections knowledge with professional knowledge, whether through books, articles between the two forms of help (20) started to develop. Today, SHGs and or additional education. Such members may become professionals who share the weight of such an experience and possess vast reserves of experi-SGs are common companions to the more formal methods of treatment ential knowledge. Caron-Flinterman (28) explains experiential profession-offered by the health industry. They are accessed by those seeking help due alism as a combination of a holistic experiential knowledge and knowledge to a health or psychosocial crisis and are established in both prevention that goes beyond the boundaries of an individual's experience. and treatment (1). The situation in Slovenia is the same. The recognition of experiential knowledge of patients began as late as An evaluation of how both approaches work together in the field of mental the 1980s, and quickly developed into a movement. Those supporting health shows that patient membership in a SHGs significantly decreases this movement are convinced that knowledge of medicine, treatment and the number of days spent in a hospital and increases satisfaction with work health in general is no longer being developed solely in clinical settings, and education (21). In cases of addiction, patients attending an SHG have but also by groups of patients using various forms of self-treatment (29). sought professional help less frequently, a decrease in hospitalizations and an increase in abstinence were recorded (22). Younger patients also benefit Today, many counties take care to educate those with experiential knowl-from SHGs as a safety measure, particularly those in risky environments edge in order to provide others with professional help. They are invited to 68 69 be lecturers in various forms of patient education. Slovenia has not come Obsessive compulsive disorder (OCD): A personal experience far in this particular area, even though ŠENT has been running and developing programs in which the lecturers have all had firsthand experience »When things were at their worst and I didn't dare tell my psychiatrist what since 1996. Both “Help and self help in mental crisis”and the “Community I was thinking and how bad it actually was, she suggested that I should talk mental health” programs were spread over several regions; the first ran with someone who has gone through the same thing. How? Nobody I know continuously up until 2006, while the second ran throughout 2014. went through this. The psychiatrist gave me someone's phone number and explained that she and the person on the other hand have an arrangement-Most professionals in the field of mental health approach both users and she was supposed to give the number to those that want to talk about dealing families from a position of authority and strength, not being aware that with OCD. professional knowledge is only a part of what people require. When treatment begins, people like to hear from those who have shared their experi-I hesitated for several days before making the call. Neja answered, and in a ence. They are given hope, confidence and willingness to cooperate. In the minute we were chatting like old acquaintances. Similar problems, similar recovery period, they should talk with an experienced veteran, one that fears… Over the next few weeks I started to feel better, the medicine helped, can help them overcome issues and find coping mechanisms. Later on, this as did Neja. She could offer encouragement like no one else, having completely form of help can be only occasionally employed to help a patient deal with overcome her obsession and compulsions. When I came back to see my psy-specific issues. chiatrist for a check-up I told her that I wanted to do the same thing as Neja. I gave her my number and told her my time was at her disposal. A month later I got my first call. Although OCD caused me no end of trouble, I managed to The Helper Principle make some great friends along the way. We see each other every week. There Helping another has a therapeutic effect both for the helper and the are 8 of us, and we Skype together all the time. We have all already seen one helped. SHGs provide a framework in which such help is accessible to all another, but there's problem. We all live far apart, so I cannot see how we're members, with all the corresponding advantages. People who provide help going to establish a self-help group.« reject the passive role of the »patient« with an active, socially valued role of an individual representing an example to those who are still in recovery. This is only one amongst many stories that prove how effective the helper Accepting help is destigmatized in such situations (30). principle can be and how underused and underappreciated it can be in the mental health treatment process. Experts and professionals should of-The person offering help receives several personal benefits from effectively fer help where it cannot be replaced and it is absolutely necessary. When helping others. A successful intervention or act of help increases feelings people have the option of mutually supporting each other, such processes of competency and value, educates and improves confidence (31). should be encouraged, as they can create new communities that can add Borkmanova (11) expands on the influence of the helper principle by not-immense value to an individual’s life. ing that not only does the principle combine the helper and client in a single person. A new community is built around a client, where stigma is normalized and an individual has the capability to identify as complete Conclusion personnality, restricted capabilities and limits included. Lamovec (12) sim-SHGs can be the first form of assistance that an individual turns to, or an ilarly states that self-help and professional help are not to be judged by the excellent aid to existing treatment and rehabilitation. If an SHG is the first same criteria. She concludes that the two forms are complementary. form of assistance an individual turns to, this gives him the information necessary to find other forms of assistance. An individual will adjust his expectations and find things in general easier to manage. This benefits both the society and the individual. An individual might become a member of an 70 71 SHG as a complementary form of treatment or rehabilitation, or as a means 10. Borkman TJ. Understanding Self-Help/Mutual Aid: Experiential Learn-of receiving additional support and assistance in order to shorten the treating in the Commons. New Brunswick, New Jersey in London1999. ment and make it easier. If the profession and SHGs/SGs manage to estab-Rutgers University Press. lish open and cooperative relationships, both forms can become even more 11. Lamovec T. Psihosocialna pomoč v duševni stiski [Psychosocial help in effective and capable of offering individuals exactly what they need. mental crisis]. 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Mentis M, Messinis L, Kotrotsiou E, Angelopoulos NV, Marneras C, pression, anxiety, eating disorders and personality disorders. Papathanasopoulos P, Dardiotis E. Efficacy of a support group inter- The term “psychoeducation” can be interpreted in several ways, mainly revention on psychopathological characteristics among caregivers of lating to the area of personal and interpersonal relationship and skills, used psychotic patients. Int J Soc Psychiatry 2014: 1–6. Acquired on 25. 3. by individuals to resolve present and future psychological issues, increas-2015 from: 10.1177/0020764014547075 ing their general satisfaction (1). The understanding of the term changed 25. Norcross JC. Integrating Self-Help into Psychotherapy: 16 Practical with time and adjusted according to therapeutic needs. The modern defi-Suggestions. Prof psychol res pract 2006; 37: 683–693. nition incorporates all aspects of psychoeducation, including systematic, 26. Klemenčič Rozman, MM. Tipologija in značilnosti skupin za samopo-didactic-psychotherapeutic interventions for the aim of familiarising the moč in podpornih skupin v Sloveniji [Self help and support groups patients and their families with the illness and treatment processes. Psy-characteristics in Slovenia]. Doktorska disertacija. Ljubljana 2011. choeducation further helps them understand and manage the illness re- Pedagoška fakulteta. sponsibly. The origins of psychoeducation can be traced back to behavioral therapy. The current understanding of psychotherapy includes elements of 27. Caron-Flinterman JF. A New Voice in Science: Patient participation in client-focused therapy as well. In the field of psychotherapy, psychoeduca-decision-making on biomedical research. Amsterdam: Vrije Univer- tion stands for those components of treatment that emphasize communi- siteit, 2005. Acquired on: 17.3.2015 from: http://dspace.ubvu.vu.nl/ cation between those afflicted and informing others about the treatment bitstream/handle/1871/9047/7326.pdf?sequence=1 of different illnesses (2). 28. Jouet E, Las Vergnas O, Flora L, Petan M. Priznavanje izkustvenega Psychoeducation represents a part of the treatment for those with mental znanja bolnikov in bolnic [Acknowledging experience of patients] . disorders. Family members and others who live or interact with patients Soc. delo 2012; 51: 87-101 are often included (3). 29. Riessman F. The “helper” therapy principle. Soc. Work 1956; 10: 27-32. There are many different programs of psychoeducation and ways of imple-30. Skovholt T. The client as helper: A means to promote psychological menting them. They all share certain goals. Programs for psychoeducation-growth. Couns psychol 1974; 13: 58–64. are meant to (4): • Increase knowledge aboutmental disorders and treatment options. • Improve insight into mental disorders. • Improve understanding of how medications work. • Explain the importance of taking medication. 74 75 • Improve patient persistence in the treatment process. by dr. Švab. Other printed materials are available and those attending usu- • Improve physical health and mood. ally take notes. • Improve stress and problem management. The programme is led by members of a multidisciplinary team. • Reduce the possibility of relapse and hospitalization. • Quickly diagnose relapses. First Meeting • Create plans to prevent crises and relapses. Purpose: Establishing a partnership • Influence the speed of recovery and the level of inclusion in the community. Goals: • Enable those with mental disorders to make informed decisions. • Empathic assessment of psychopathology and functioning; • Improve cooperation and communication between patients, family • An introduction toproblems and obstacles faced by patients and fam-members and specialists. ily members in daily life • Reduce the family members’ psychological burden. • Establishing an authentic, caring and empathetic relationship • Evaluating the needs of the patients and family members Psychoeducation programs can be implemented either individually or in • groups. Lectures and workshops are usually performed in sets of 4-16, Discussing possible obstacles preventing participants from attend meetings; once or twice per week. Meetings typically last an hour toan hour and a half at and are mostly run by doctors and psychologists who can be assist- • Enabling open communication ed by members of other professions (5, 6). Many experts include patients • Establishing reciprocity between the therapist and the patient in their programs. These’ veteran’’ patients are encouraged to share their • Displaying the willingness and the abilityof responding to the pa- experiences and can improve the level of trust in the treatment process. tients’ and family members' needs (service access, house calls, pa- tient-doctor communication) A sample of Slovene psychoeducation programs • “The patient is always right.” Psychoeducation for patients with severe and chronic mental Second Meeting disorders (7, 8) Purpose: To recognize and restructure the existing knowledge about and perception of mental disorders, strengthen recognition and communica-The program in question is aimed at patients and families affected by tion among patients, family members and professionals. schizophrenia, schizoaffective disorders, bipolar disorders and delusional disorders. Even though the same materials are used, patients and family Goals: members attend separate meetings. The psychoeducational program was • Acquire information and record symptoms that patients and family designedby prof. dr. Vesna Švab, through the Slovenian Mental Health As-members already recognize sociation. Patients were involved with the program as equal partners. The • To structure their knowledge within the framework of accompany- program is still underway in various institutions throughout Slovenia. ing materials The psychoeducational meetings are weekly and last for 90 minutes. The • To standardize the terminology. literature used in these meetings is the ‘’Priročnik o shizofreniji’’ written • To encourage communication with treatment providers 76 77 • To adjust information delivery (flexibility) • Explain the various types of antipsychotics, antidepressants, stabiliz- • To specify duration of acute symptoms (from-to) ers and sedatives and their side-effects. • To encourage questions • Learn about medication side-effects • To achieve cooperation • Structure pre-existing knowledge on medication types • Describe the limits of psychiatric prescriptions Third Meeting • Motivate patients for long-term treatment Purpose: To identify and structure pre-existing conceptions and knowledge relating tocauses of mental illness in order toovercome prejudice. Fifth Meeting: Rehabilitation, Psychotherapy Goals: Purpose: Assist patients and family members in finding and using evidence- • Gather pre-existing conceptions and about mental illness, its causes based forms of treatment. Help motivate them to undergo psychiatric re-and triggers. habilitation and strengthen cooperation. e. • Organize pre-existing knowledge by classifying factors as biological, Goals: psychological or social • Learn about which therapeutic methods, beside psychopharmaco- • Present the vulnerability – stress model to the participants therapy, are considered effective • Emphasize the significance and dominance of biological factors • Structure pre-existing knowledge and introduce proven methods. • Explain the dopamine hypothesis and expand on it by explaining the • Get opinions on methods to be used in the community and methods influence of other neurotransmitters to be used in hospitals • Stress the importance of social and psychological factors on the • Find out about the treatment and support services patients are al- course of the illness ready familiar with • Explain the significance of self-control • Structure and introduce existing services in the local area • Achieve cooperation • Introduce the community treatment work group • Reduce feelings of guilt • Introduce the principles and method of psychiatric rehabilitation • Improve cooperation and achieve better accessibility Fourth Meeting: Treatment Purpose: To identify and structure all pre-existing knowledge relating to Sixth Meeting: Warning Signs psychiatric medication, its side-effects and how and when it is prescribed. Purpose: To recognize and learn more about warning signs in individual pa-To motivate patients to take an active part in the treatment and hold intients. Prepare a list of such signs and make a plan of individually tailored formed discussions with specialists. measures in case of crisis (i.e.: A crisis plan). Goals: Goals: • Learn about medication and other therapeutic methods • Enumerate the warning signs • To structure said knowledge into segments: psychopharmacotherapy, • Elaborate ondifferences between warning signsand ways in which psychotherapy, rehabilitation. they appear 78 79 • Every individual prepares a list of warning signs Workshop content: • Comparison • First Workshop Define possible intervention methods • • Prepare a crisis plan for every individual in the group Program introduction. • Meet & Greet. • Recognizing symptoms of BD Seventh Meeting: Family members' role Purpose: Reduce prejudice and feelings of guilt. Manage the level of emo-Second Workshop tional concern. • Typical traits of BD • Goals: Causes of BD • Explain that family members are not responsible for the illness (Re-Third Workshop search overview) • Medication used in the treatment of BD • Explain that family members can affect the course of the illness • Acquire information on how family members can assist patients Fourth and Fifth Workshop • Define the term »Expressed Emotion Index« and why people respond • Relapse: Early recognition differently • Early prevention of relapse • Explain cultural differences • Relapse diminishment techniques. • Reduce expectations Sixth Workshop • Explain that there is a real chance of recovery • Importance of a healthy lifestyle and good relationships in prevent- • Define recovery ing relapses in the long term • Allow family members to form self-help groups • Inform the participants about all forms of assistance and provide a Psychoeducational workshops for depressive mood disorder list of options that are available In 2014, the National Institute of Public Health began introducing work-Psychoeducational workshops for bipolar affective disorder shops entitled “Support in Dealing with Depression” as part of the national programme “Together for a healthy society”. The workshops in question The workshops at hand were designed for individuals affected by bipolar are now being held at a number of institutions across Slovenia. affective disorder (BD) and their family members. Knowledge of this par-The psychoeducational workshops on depressive mood disorder are thus ticular disorder can help reduce symptoms and raise the general quality ofa being implemented in every region, contributing to preventive pro-person’s life. It's important for participants to learn about self-observation grammes in the primary healthcare network. All workshops are led by and symptom management, as these measures can significantly reduce the qualified nurses. possibility of relapse. The basic aim of the workshops is informing individuals and family mem-The program takes the form of 6 separate workshops, lasting 2 hours each. bers of those affected by depression about depression, its characteristics, All workshops are held at the Furlan Health Centre in Ljubljana. its course and treatment. They invite participants to share, exchange 80 81 experiences and support each other, crucial components of any successful Second meeting: treatment. Workshops help individuals • An introduction and review of instant relaxation techniques, suffering from depression and their family members to identify the main • An explanation of the cognitive-behavioral model of anxiety/depres-issues, support coping strategies and support active participation in treat-sion, ments. • An introduction to cognitive-behavioral therapy, Workshop content: • Task: Monitoring anxiety triggers, noting automatic thoughts and 1. Recognizing the causes and symptoms of depression. behavioral processes. 2. Getting familiar with the various treatments available. Third meeting: 3. The influence of negative thought processes on the mind, the body and • Recognizing situations that might be dangerous to the patient and first behavior. signs of anxiety, 4. Preventing relapse. • Discussion on experiences and interpretionsof the physical symptoms of anxiety, http://cindi-slovenija.net/ hosts the manual »Prepoznajmo in premaga- • Discussing strategies for managing anxiety, jmo depresijo«. A newer edition is currently being prepared (10). • Sharing opinions and experiences, • Task: Noting dangerous situations, automatic thought patterns, physi-Psychoeducation for neurotic, stress-related and somatoform cal symptoms and behavior. disorders Fourth meeting: Psychoeducational programme for neurotic, stress-related and somato- • Seeking alternative means of relaxation, form disorders has been conductedin Psychiatric Hospital Begunje, spe- • Encouraging activities that bring contentment and pleasure, cifically in ward B1, where individuals affected bydepression and anxious disorders are being treated. • Identifying thought patterns and convictions that prevent a patient from enjoying such activities, The programme takes three weeks to complete and takes place from Mon- day to Thursday, with daily meetings of 10-12 participants lastingabout 90 • Task: Patients identifyand plan for activities they enjoy, as well as minutes a day. those they stopped engaging indue to their illness. Meetings begin with an overview of the participants’ current mood, an Fifth meeting: overview of their therapeutic tasks and a short review of previous work- • Continuing the discussion of hobbies and various other beneficial ac-shops. tivities, First meeting: • An introduction and review of the STOP technique, • Patient introductions, • Task: Review the STOP technique, • Discussion of anxiety and its signs, • Bibliotherapy: The therapist provides a list of recommended litera- • An exchange of opinions and experiences, ture. • An introduction to various relaxation techniques, • Task: Review relaxation techniques at home. 82 83 Sixth meeting: Twelfth meeting: • Identifying emotions, • Patients share opinions and experiences, • Discussing the adaptive function of emotions, • The therapist encourages patients to enroll in a self-help group (7). • Differentiating between normal and pathological emotional responses, • Task: Identifying emotional and behavioral responses in threatening Psychoeducational programmes described above are by no means the only situations. way of educating and gathering information relating to an illness or a disorder. The term psychoeducation covers a variety of meansof providing in-Seventh meeting: formation, including flyers, workbooks, manuals and, of course, the World • Discussing anger, accepting and giving criticism, Wide Web. We would recommend resorting to Internet for anyone inter- • Task: A review of relaxation techniques. ested in the use of psychoeducational material. A wide variety of materials is available in both Slovenian and English. Eighth meeting: • A list of books, manuals and other materials available in the Slovene lan-Discussing praise and self-praise and their influence on mood and be- guage: havior, • An exchange of opinions and experiences between patients. Identifying prejudice in praise, ANXIOUS Online Obvladajmo anksioznost [Let’s Ccope • Task: Focusing on the good in oneself and others, rewarding and DISORDERS materials with Anxiety]. A Manual for Workshop praising oneself and one’s family members. Leaders ; www.nebojse.si Ninth meeting: Anxiety – assistance in dealing with anxiety; www.nebojse.si • Patients exchange experiences of successful use of the techniques they learned, The Anxiety disorder toolbox; • www.nebojse.si Patient praise each other and discuss their mood and emotions, • How to help children suffering from Task: Reinforcing anxiety management relaxation techniques. anxiety disorders ; www.nebojse.si Tenth meeting: “Jaz in moja OKM” [Me and my OCD-Chil- • A discussion of ruminations, dren] – Pfizer; www.karakter.si • Learning the cognitive deflection technique, Obsessive Compulsive Disorder (OKM) – • Task: Reinforcing the cognitive deflection technique, focusing on ob-Mylan; www.karakter.si servation without judgment. General anxiety - Mylan; www.karakter.si Eleventh meeting: Panic disorder[Panic Disorder]- Mylan; www.karakter.si • Patients share opinions and experiences, • Teaching creative visualisation, • Task: Reviewing creative visualisation before sleep. 84 85 ANXIOUS Printed C. Elliott. Premagovanje anksioznosti za DEPRE- Printed L. Smith. Depresija za telebane DISORDERS telebane; Pasadena (Coping with Anxiety SSION [Depression for Dummies); Pasadena for Dummies) D. Burns. Kako smo lahko srečni in K. Rebolj. Panična motnja: tris; Ravnoves- zadovoljni. [How to be Happy and Con- je [Panic disorder, Tris, Balance] tent]. Ljubljana, Mladinska knjiga C. Elliott, L. Smith. Obsesivno kompulziv- B. Cobain. Ko nič več ni važno: priroč- na motnja za telebane [Obsesive Compul- nik za mladostnike z depresijo. [When sive Disorder for Dummies]; Pasadena Nothing Matters Anymore: Manual for DEPRE- Online Prepoznajmo in premagajmo depresijo Adolescents with Depression]. Didakta SSION materials [Facing and Recognizing Depression] – BIPOLAR Printed Fink C., Kraynak J.. Bipolarna motnja za IVZ; www.cindi-slovenija.net MOOD telebane; [Bipolar Disorder for Dummies]. Obvladovanje depresije za najstnike DISORDER Pasadena [Coping with Depression for Teenagers]; ŠENT. Od znotraj navzven - vodič do www.nebojse.si samoobvladovanja bipolarne motnje Orodje za depresijo [Manual for razpoloženja. [From the Inside Out – Depression]; www.nebojse.si Coping with Bipolar Disorder] Soočanje z diagnozo depresije [Facing SCHIZO Printed Švab V. Shizofrenija - Informacija za A Depression Diagnosis]; www.nebojse.si PHRENIA družine [Schizophrenia: Information for Families]. Šent Preprečevanje ponovitve depresije [Relapse Prevention in Depression]; Švab V.. Priročnik o shizofreniji [Schizophrenia Manual]; Šent Sodelovanje z zdravnikom pri zdravljenju depresije [Participation in Treatment of J. Levine, I. Levine. Shizofrenija za Depression]; www.nebojse.si telebane (Schizophrenia for Dummies); Pasadena Zima v srcu: Ko se materinstvu pridružita depresija in tesnoba, radost pa odide sta- OTHER Online Kratek program KVT v 7 korakih [A Short rejšimi [Frozen Heart] – IVZ; www.ivz.si materials Seven-Step CBT course]; www.nebojse.si Depresija med starejšimi Ko te strese stres [When you are [Depression in Elderlly]– IVZ; www.ivz.si Shattered by Stress] – IVZ; www.ivz.si Spregovorimo o depresiji in samomoru Printed Švab V. Duševna bolezen in stigma med starejšimi [Let's TalkAbout [Mental Illness and Stigma]. Šent Depression in the Elderly]–IVZ; Branch R. Kognitivno-vedenjska terapija www.ivz.si za telebane [Cognitive Behavioural Therapy for Dummies]. Pasadena 86 87 Sources Majda Pahor 1. Guerny B, Stollak G, Guerney L. The practicing psychologist as educa-tor – an alternative to the medical practitione model. Prof. psychol. alliance for health: collaboration in 1971; 2: 271-272. healthcare teams5 2. Bäuml J, Froböse T, Kraemer S, Rentrop M, Pitschel-Walz G. Psych-Modern healthcare and social care have embraced the term of inter-profes-oeducation. A basic psychotherapeutic intervention for patients with sionalism that has joined the previously established term of professional-schizophrenia and their families. Schizophr Bull 2006; 32 (Suppl 1): ism; D’Amour and Oandasan (2) define inter-professionalism as a process S1-S9. Acquired on 18.4.2015: http://www.ncbi.nlm.nih.gov/pmc/ar-characterised by constant interaction and exchange of information and ticles/PMC2683741/ knowledge among team members to form a comprehensive and intercon- 3. Winkler A. Izobraževanje bolnikov s hudo in ponavljajočo se duševno nected response to the needs of users, specific groups and the entire popu-motnjo ter njihovih svojcev [Education of patients with severe mental lation and increasing their level of inclusion. The basic reason for inter-disorder and their families]. In: Švab V (ur). Psihosocialna rehabilitaci-professionalism is the fact that health problems are usually complex and ja [Psychosocial rehabilitation]. Ljubljana 2004. Šent: 32-6. multilayered and call for coordinated actions by different experts (1). 4. An Evidence-Based Practice of Psychoeducation for Schizophrenia. Psy-Work can generally be coordinated in two ways: chiatric Times. Acquired on 18.4.2015: http://www.psychiatrictimes. • a hierarchical way that presupposes vertical levels of decision-making com/articles/evidence-based-practice-psychoeducation-schizophrenia and implementation with professionals in subordinate and superor- 5. Wood SD, Kitchiner NJ, Bisson JI. Experience of implementing an dinate positions, and adult educational approach to treating anxiety disorders. J Psychiatr • a collaborative way, where the structure is more horizontal and there Ment Health Nurs 2005; 12: 95-99. is no significant difference in the power between subjects, or is establi-6. Hughton S; Saxon D. An evaluation of large group CBT psycho-educa-shed in individual situations based on the knowledge and experience. tion for anxiety disorders delivered in routine practice. Patient educ. Collaborative relationships are a result of conscious decisions and pur-couns 2007; 68: 107-110. poseful actions. Healthcare was and to a certain extent still is characterised 7. http://www.sentprima.com/content/izobrazevanje/duševno-zdravje-by a predominately hierarchic work organization. The latter works as long v-skupnosti as everyone involved accepts such organisation of work and as long as the 8. Švab V. Pacient kot učitelj v procesu izobraževanja [Patient as a teacher social context, culture and socialisation support it as well. Another char-in educational process]. ISIS 2013:59-60. acterisation of modern times is a growing need for collaboration since 9. Bensa MP. Psihoedukacija nevrotskih in stresnih motenj (tritedenski the leaders can no longer be familiar with and control all aspects of work program)[Psychoeducation in neurotic and stress disorders]. Diplom-performed by other professionals. ska naloga. Ljubljana: Fakulteta za psihoterapevtsko znanost Univerze The most common actual health problems are long-term conditions that Sigmunda Freuda, 2014. call for a different and more complex treatment than acute states. At the 10. Dernovšek MZ, Tavčar R, editors. Prepoznajmo in premagajmo same time, the needs and demands of patients are higher and increase the depresijo: priročnik za osebe z depresijo in njihove svojce. Ljubljana pressure encountered by healthcare and social care. 2005. Public Health Institute Slovenia. Acquired on 18.4.2015: http:// cindi-slovenija.net/images/stories/cindi/dusevno_zdravje/prepozna- 5 This work is extracted from the chapter: Pahor M. Alliance for Health : collaboration in healthcare teams. Faculty of Health Sciences. Ljubljana 2014. 215 pp.ISBN jmo_in_premagajmo_depresijo.pdf 978-961-6808-56-9. ilustr. 88 89 What is collaboration? There are various types of teams that differ according to their organization A group of researchers (3) identified the following elements of collabora- (for example, teams can be formed with members belonging to a single tion: profession or several professions, differences between members can be small or big, and there are also several possible levels of formalisation of • bonding or sharing commonalities the relationships), teams can have different levels of interaction (working The commonalities shared by all participating members are respon-simultaneously to solve a problem together or for example engaging in dai-sibility, philosophy behind the activities, values, data, planning the ly or weekly meetings in real or virtual space etc.) and teams also differ ac-activities and performing the actions cording to the role of the patient / client / service user. There are different • partnership types of teams, depending on their duration or location: work teams (e.g. members of the same ward) or task-focused teams (usually temporary). Collaboration happens when at least two actors are engaged in a com- mon activity with shared goals. Relationships between the partici- Team leadership can be authoritative (the leaders having an exposed po-pants are characterized by fellowship and a constructive relationship, sition and good reputation with their leadership focused on the achieve-open and honest communication, mutual trust and respect. Partner- ment of goals, while the tasks of members have a clear structure) or self-ship also entails the recognition of individual contribution and views directed (autonomous, democratic and teams formed on a voluntary basis of each and every member. with team members having an equal role and the leader acting as coordinator). Another style of leadership is a mixed or combined style. • co-dependence Co-dependence needs to be clearly stated and brought to awareness. There are three general types of teams, based on how connected the activi-It is only this awareness that enables a synergy of individual effects. ties of different team members are: • Multidisciplinary team (members with a different professional back- • distribution of power ground have different roles and do not take decisions together, work In collaborative relationships, power distribution is based on knowl- independently of each-other) edge and experience more than on functions or status in the organi- • Interdisciplinary team (more untiy between members with a differ- zation. A typical trait of collaboration is empowering of all of the participants. ent professional background, members know each-other better, dis- cuss actions and take decisions together) • process • Trandisciplinary team (a high level of connection in a team, the abili-Collaboration is a transformative process bringing change to all of the ty to approach the task in a comprehensive manner by every member) participants both on a personal and a professional level. It is characterized by negotiations and compromises in the process of decision- Healthcare teams can consist of different healthcare professionals of regu-making, planning as a team and intervention. lated and un-regulated professions as well as psychologists, social workers, economists, IT professionals, managers, vets, urban planners etc., depending on the healthcare problems at hand as well as the tasks (4). Team as a form of cooperative work A team is a group of individuals with different levels of education, different perspectives, skills and qualifications that work together in order to achieve common goals. Members are familiar with and appreciate contributions of all members. 90 91 Types of teams based on the relationship between members and Health problem-focused team the role of the patient The patient becomes a member of the team that is based on the health problem. This type of a team is not appropriate for all health problems, but Hierarchical ‘team’ is becoming more and more frequent because of the growing prevalence of chronic disease where an active role of the patient is of key importance for doctor outcomes. medical nurses occupational therapists medical nurses sicoal workers psychologists occupational psychologists therapists patients Problem The expression ‘team’ is in quotes due to the hierarchy in the sense of predominance of relationships of subordination and superordination doctors patient based on the members’ position rather than competence or the problem at hand as opposed to the basic idea of an organisation characterised by social collaboration. workers Patient-focused team Stages in team development Studies (5) have shown decades ago that teams typically develop through medical stages that can be identified and expected, which makes them easier to nurses understand and control. doctors Stage 1: Formation service pychologists Due to the individuals’ need to be accepted by others and avoid confron-user tation and conflicts, the formation stage is usually a time when serious problems are avoided and members deal with routine questions, such as organisation of work, definition of roles, place and time of meetings etc. occupational social therapiststs workers Individuals are still gathering their impressions at this stage. The team does not yet perform its function at this stage, instead still testing its abilities and challenges, forming goals and embarking on tasks. Members still act in an independent manner, while their level of inclusion and connection is Increased knowledge base of those professions in healthcare that had a not yet high. They are polite with each-other, but focused mainly on them-subordinate role in the past has led to more egalitarian relationships with-selves. More experienced members act as role-models while other members in a team. model them. It is very useful for a team at this stage to familiarise itself 92 93 with the stages of team development in order to avoid surprises in the fu-however, sometimes fall back to one of the lower stages, such as for exam-ture. It is important for members to get to know each-other and exchanges ple when new members join the team or work tasks change. Consequently, some personal information and build friendships. The stage reveals more teams usually go through all of the stages of team building several times. about how members act as individuals and how they respond to tasks. Values and ethics of collaboration between professions Stage 2: Confrontation The focus is on the patient and includes working with the community or At this stage, members discuss what the problem is, how to address it, what population, based on the decision to support the common good in health-tasks they are supposed to perform independently and which decisions care. Values reflect a shared commitment towards creating a safer, more will need to be discussed and coordinated. Members become more open effective and successful help system. Values stem from specific competenc-towards each-other and compare different ideas and aspects. This stage es and value system of individual professions, including the patients and can conclude rather fast in some cases and form decisions that are accept-their families as equal members of teams. Their understanding of profes-able for all members, depending on the level of the maturity of members. sionalism emphasizes the meaning of collaboration between professions The stage of confrontation is a necessary stage in team development. It can based on ‘common values’ of different professionals (6), including altru-be time-consuming, unpleasant or even painful for the members who do ism, excellence, care, ethics, respect, communication and responsibility. not like conflicts. It is necessary to highlight the importance of tolerance They come from the assumption that health is a human right. Mutual re-and patience between colleagues at this point, otherwise the team may fail. spect and trust form the basis for work relationships between healthcare That is precisely what happens in some cases since an environment that is professions with each profession making its unique contribution. full of conflicts is counter-productive in terms of maintaining motivation. Knowing other team members Stage 3: Accepting the rules Each team member needs to be clear on their professional role. They should The team forms a clear goal at this stage as well as the plan how to achieve be able to present it to other members of the team in a clear way and at it. Some team members give up their ideas and support ideas of others and the same time understand the roles of others as well as how they comple-solutions are formed, either based on individual suggestions or combined ment each other. Being familiar with other members’ professional roles is a to form a new solution. The feeling of belonging to a team is increased at prescondition for successful collaboration (7, 4, 8, 9, 10). Diversity of team this stage, all members accept responsibility for their outcomes and start members can be an advantage as well as a problem hindering cooperation working towards attaining a common goal. (11) as the number of perspectives a team includes thus grows. A problem that may be encountered are stereotypes, both positive and negative, that Stage 4: Action members hold about the characteristics of others (12). Collaboration calls The stage of action is not achieved by all teams. At this stage, team mem-for constant training and familiarisation with others. Generally speaking, bers act in a coordinated way and perform their tasks in a smooth and ef-those teams that have worked together for longer, function better. fective manner. There are no more unnecessary conflicts, nor the need for control or seeking support outside of the team. All team members are mo-Collaboration within a team tivated and familiar with the work and the roles of other members. They Team work includes coordinated collaboration without any overlapping are competent, autonomous and able to make decisions without control. actions, cessations or mistakes, problem-solving within a team and tak-Disagreements are allowed and resolved in a manner agreed upon beforeing decisions together, especially in situations of uncertainty. A team is a hand, e.g. at team meetings. Team supervisors are practically not needed small and complex system with every member influencing the outcomes. since it is the team that takes all the necessary decisions. The team can, Consequently, it is crucial to be aware of team processes. 94 95 Conflicts may arise due to differences in professional areas and leadership 4. 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The processes required for effective interprofessi-problems and taking decisions as a team are the preconditions typical onal working. In: Barret G, Sellman D, Thomas J, eds. Interprofessional for team work characterised by collaboration. Team processes can be im-working in health and social care. Professional perspectives. 2005. Ba-proved by using tools that improve the quality of work. There are many singstoke: Palgrave Macmillan. sources available addressing team work and discussing the ways it can be 8. Zwarenstein M, Goldman J, Reeves S. Interprofessional collaboration: improved (for example 16). effects of practice-based interventions on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2009 (3) Art. No.: Conclusion CD000072. 9. Tuckman BW. Developmental sequence in small groups. 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Med Educ 2005; 39: 456-464. köpings universitet. http://www.hu.liu.se/pedagogisktcentrum/pro- gramintegration. <25.1.2013> 13. Thistlethwaite J, Moran M. Learning outcomes for interprofessional education: Literature review and synthesis. J Interprof Care 2010; 24: 2. D'Amour D, Ferrada-Videla M, San Martin Rodriguez L, Beaulieu MD. 503-13. The conceptual basis for interprofessional collaboration: Core concepts and theoretical frameworks. J Interprof Care 2005; 19 (Suppl 1): 116-14. CIHC - Canadian Interprofessional Health Collaborative. A National 31. Interprofessional Competency Framework. Vancouver 2010: College of Health Disciplines, University 3. WHO. Framework for Action on Interprofessional Education & Collaborative Practice 2010 (WHO/HRH/HPN/10.3). Dosegljivo na: 15. Cronenwett L, Sherwood G, Barnsteiner et al.. Quality and safety edu-http://whqlibdoc.who.int/hq/2010/WHO_HRH_HPN_10.3_eng.pdf. cation for nurses. Nurs Outlook 2007; 55 (3): 122-31. 24.01.2013 16. University of Toronto, 2008. Advancing the interprofessional education curriculum 2009. Curriculum overview. Competence Framework. 96 97 Toronto: University of Toronto. Office for Interprofessional Education. Urška Weber, Nataša Potočnik Dajčman Dosegljivo na: http://ipe.utoronto.ca/initiatives/ipe/iheif/competen- cies.html. 25.1.2013 Preventing mental health disorders in children and 17. Hean S, Clark JM, Adams K, Humphris D, Lathlean J. Being seen by young adults others as we see ourselves: the congruence between the ingroup and outgroup perceptions of health and social care students. Learning in Preventing mental health disorders in children and young adults is ex-Health and Social Care 2006; 5 (1): 10-22. tremely important for a variety of reasons. Mental disorders represent a 18. Lambe M, Boylan O. Developing teamwork in primary care. Educ Prim significant burden on society, as their effects bear a significant influence Care 2008; 19 (5): 530–4(5). on the health, social, educational, employment and legal areas. (1). Most 19. Baggs J, Schmitt MH. Nurses‘ and resident physicians‘ perceptions of chronic mental disorders appear at a young age – 50% until age 14.and 75% the process of collaboration in the MICU. Res Nurs Health 1997; 20 until age 25 (2). Studies show the treatment of the disorders in question to (1): 71-80. be relatively ineffective; making preventive measures even more important 20. NHS Institute for Innovation and Improvement (). Quality and Service (3-5). Some studies show that a 25-50% of mental disorders could be pre-Improvement Tools. SBAR – Situation – Background – Assessment – vented with the appropriate, professional measures (6). The burden on both Recommendation. 2008. Dosegljivo 20.9.2015 na: http://www.insti-children and society is further increased by stigma, which makes destigma-tute.nhs.uk/quality_and_service_improvement_tools/quality_and_ tization a significant aspect of this promotion and, more widely, a preven-service_improvement_tools/sbar_-_situation_-_background_-_asses- tive measure in the populations of children and young adults (7). sment_-_recommendation.html. 21. Zaccaro SJ, Heinen B, Shuffler M. Team leadership and team effective- 1. Mental disorders are frequent among children and young adults ness. In: Salas E, Goodwin GF, Burke CS (eds.) Team effectiveness in complex organizations. New York: Psychology Press, 2009, 183-208. The prevalence of mental disorders among children and young adults is 22. Salas E, Goodwin GF, Burke CS (eds). Team effectiveness in complex considered to be around 20% in Europe (3). In Slovenia, most children organizations). New York 2009. Psychology Press: 183-208. and young adults seek professional help because of mental development disorders, reactions to severe stress, adaptive disorders, eating disorders, ADHD (Attention Deficit Hyperactive Disorder) and other behavioral and emotional disorders that usually appear in childhood. The reasons for seeking professional help in individuals over 15 years of age aresimilar to the reasons in the adult population – behavioral and mental disorders, depression, anxiety, severe reactions to stress, adaptive disorders and eating disorders. Individuals in this age bracket also experience a significant increase in behavioral and mental disorders due to alcohol abuse, the use of cannabi-noids, solvents and various combinations of illegal substances. In recent years, an increase in the number of mental and behavioral disorders among children and young adults has been noted. A significant number of them already exhibit symptoms and will, in their adulthood, develop a personality disorder. The lower age limit continues to descend into childhood in some mental disorders (First episodes of depression or schizophrenia) (8). 98 99 2. Risk and protective factors in the development of mental disor- • Primary health care (education for prospective parents, pregnancy- ders among children and young adults specific health care, counseling offices, periodical systematic health checks of children and young adults, developmental out-patient clin-The probability of mental disorders among children and young adults is ics, health education), higher due to various risk factors, both biological and psychosocial. Individuals who areoften and chronically ill, individuals with a central nervous • Educational institutions (school counseling services, kindergarten and system disorder, individuals growing up in an unfavorable environment, school programmes), individuals subject to constant stress, individuals with a lower socio-eco- • Social care institutions (children, young adult and family programs nomic standard, individualswith fewer friends, individuals with educa-within social work centers, NGOs and family centres). tional issues as well as those attending a less demanding high school are considered especially at risk and demand a higher level of care. Among pro-3. Multi-level, secondary and tertiary prevention within: spective parents, those that are in an unfavorable socio-economic situa- • Specialist out-patient clinic health services, tion and victims of violence are especially at risk (3, 8, 9). • Specialist hospital health services, The effects of risk factors on the mental health of children and young adults • Counseling centres for children, young adults and parents, can be significantly reduced by several protective factors. Protective fac- • Institutional care (youth welfare and youth educational institutions, tors can be divided into biological and psychosocial factors. An appropriate training centres, work and protection centres, youth centres, commu-level of care for the mother’s health before and after birth, appropriate panity housing groups and recovery centre). rental care (including upbringing, attachment patterns and other familial relationships), an appropriate social circle and social support (including the There is a large variety of available preventive services at all afore-men-development of necessary social skills and a favorable educational and wid-tioned levels of care. It must be noted, however, that they are not stand-er social environment), a reasonable socio-economic status (within a family ardized on a national level and only a few are evidence-based and available enjoying such a status or one taking advantage of financial, employment at all times (8). and other forms of aid meant for families lower on the socio-economic scale) and a favorable genetic makeup and personality structure of the child Assessment studies revealed that the key characteristics of proven-success-are considered the most important protective factors (3, 9). ful primary prevention programmes are (14-16): • Limiting risk factors and strengthening protective factors in mental disorder development 3. Mental health preventive programmes among children and • young adults Learning cognitive-behavioral skills and social skills, • Employing age appropriate and exciting approaches, In Slovenia, prevention of mental disorders among children and young adults is organized in stages (8): • Implementation in the immediate environment – family, school, so- cial work centers, youth centres... 1. Informal community assistance (community counseling offices, pre- • A sufficiently long and continuous implementation of the pro- ventive drives and programmes, web-based, professional and lay sup- gramme, port) • The inclusion of a number of significant individuals in the child’s im-2. Primary prevention within: mediate environment – family, teachers, health care, social workers, police, youth institutions and others. 100 101 Within the universal primary prevention field, the most successful pro-Neverjetna leta (Incredible Years) (13) is an early treatment and prevention grammes are directed towards expectant mothers and the parents of very programme aimed at children below 12 years of age. It is a primary preven-young children, along with violence prevention programmes and tolerance tion programme that includes subprogrammes for parents, teachers and programmes in educational institutions (7, 10-13). Selective or indicated children. It is based on a developmental theory that focuses on explaining primary prevention programmes are even more effective. They are aimed significant risk and protective factors in behavioral disorder development specifically at children and young adults with known mental disorder risk among children. The purpose of the programme is to strengthen parents’ factors or those suffering from developed less severe forms of disorders (14). and teachers’ skills and their roles in a child’s education. This improves their ability to deal with a child’s educational, social and emotional issues Within secondary and tertiary prevention, comprehensive programmes and consequently, benefits prevention and early treatment of any behav-are proven extremely successful due to(14): ioral issues. In a modified form, the program has been implemented for • Appropriate drug treatments when indicated, parents of children with developed behavioral disorders, attention deficit • Appropriate forms of psychotherapy, hyperactivity disorder, disorders on the autistic spectrum or speech development disorders. • Limiting risk factors and strengthening protective factors in mental disorder development, • Involvement and cooperation of the child’s family and other impor- Sources tant members of his social circle, 1. Wittchen HU, Jacobi F, Rehm J, Gustavsson A, Svensson M, Jönsson • Inter-sector cooperation (health, educational and social sectors) in B et al. The size and burden of mental disorders and other disorders the form of community preventative and inclusion activities of the brain in Europe 2010. Eur Neuropsychopharmacol 2011; 21: • Ensuring formal community mental health services, i.e. “case man- 655-79. agement”, where each child and his/her family are assigned a coordi- 2. Kessler RC, Amminger GP, Aguilar-Gaxiola S, Alonso J, Lee S, Ustün nator. The coordinator then ensures that the appropriate institutions TB. Age of onset of mental disorders: a review of recent literature. Curr perform diagnostics and other measures, including community reha-Opin Psychiatry 2007; 20(Suppl 4): 359-64. bilitative and inclusion activities. 3. World Health Organization. Child and adolescent mental health poli-Below, two programmes that exhibit all previously enumerated charactercies and plans. Mental health policy and service guidance package. Ge-istics of preventative programmes are listed (17-23). neva: World Health Organization, 2005. Krog varnosti (Circle of security ) (11) is an early intervention programme, 4. McDaid D, Park A, Knapp M, Losert C, Kilian R. Making the case for aimed at children below 5 years of age. It is based on attachment theory. investing in child and adolescent mental health: how can economics The purpose of the programme is to teach both parents and children to help? Int J Ment Health Promot2010; 12: 37-44. establish a mutually supportive emotional relationship. The programme 5. Knapp M, McDaid D, Parsonage M, editors. Mental health promotion also exists in several modified versions aimed at older children and young and prevention: the economic case. London: Department of Health, adults. These modified versions are intended for parents who have chil-London, 2011. dren at high risk of developing a mental disorder (e.g.: parents who are not yet of age, parents with a poor socio-economic status, parents serving 6. Kim-Cohen J, Caspi A, Moffitt TE, Harrington H, Milne BJ, Poulton R. a prison sentence, adoptive parents and foster parents, parents suffering Prior juvenile diagnoses in adults with mental disorder: developmental from personality or mental disorders…) and for parents of children who follow-back of a prospective longitudinal cohort. Arch Gen Psychiatry were already diagnosed with a mental disorder. 2003; 60: 709-17. 102 103 7. Patel V, Flisher AJ, Hetrick S, McGorry P. Mental health of young peo-17. Cassidy J, Ziv Y, Supica B, Sherman LJ, Butler H, Karfgin A et al. En-ple: a global public-health challenge. Lancet 2007; 369 (Suppl 9569): hancing attachment security in the infants of women in a jail-diversion 1302-13. program. Attach Hum Dev2010; 12: 333-53. 8. Ministrstvo za zdravje RS. [Ministy for Health Slovenia]. Resolucija 18. Cassidy J, Woodhouse S, Sherman L, Stupica B, Lejuez CW. Enhancing o Nacionalnem programu duševnega zdravja 2014 – 2018. [National infant attachment security: an examination of treatment efficacy and Resolution on Mental Health].Acquired on: 26.3.2015 from: http:// differential susceptibility. Dev Psychopathol 2011; 23: 131-48. www.http://www.sent.si/fck_files/file/NOVICE/NPDZ_3_J.pdf. 19. Hutchings J, Bywater T, Daley D, Gardner F, Whitaker CJ, Jones K et 9. Campion J, Bhui K, Bhugra D. European psychiatric association (EPA) al. Parenting intervention in Sure Start services for children at risk of guidance on prevention of mental disorders. Eur Psychiatry 2012; 27: developing conduct disorder: pragmatic randomized controlled trial. 68-80. Br Med J 2007; 334(Suppl 7595): 678-85. 10. McDaid D, Park A. Investing in mental health and well-being: find-20. Gardner F, Hutchings J, Bywater T, Whitaker CJ. Who benefits and how ings from the DataPrev project. Health Promot Int 2011; 26(Suppl does it work? Moderators and mediators of outcome in a randomized 1): 108-39. trial of parenting interventions in multiple »Sure Start« services. J Clin 11. Marvin R, Cooper G, Hoffman K, Powell B. The Circle of security pro-Child Adolesc Psychol 2010; 39(Suppl 4): 568-80. ject: attachment-based intervention with caregiver-preschool child dy-21. Jones K, Daley D, Hutchings J, Bywater T, Eames C. Efficacy of the ads. Attach Hum Dev2002; 4(Suppl 1): 107-24. Incredible Years basic parent training programme as an early interven-12. Khan RJ, Bedfort K, Williams M. Evaluation of the MindMatters bud-tion for children with conduct disorder and ADHD: long-term follow- dy support scheme in southwest Sydney: strategies, achievements and up. Child Care Health Dev2008; 34(Suppl 3): 380-90. challenges. Health Educ J 2012; 71: 320-6. 22. Bywater T, Hutchings J, Daley D, Whitaker CJ, Jones K, Eames C. 13. Webster-Stratton C, Mihalic S, Fagan A, Arnold D, Taylor T, Tingley C. Long-term effectiveness of the Incredible Years parenting programme Blueprints for violence prevention, book eleven: The Increadible Years in Sure Start services in Wales with children at risk of developing con- – parent, teacher, and child training series. Boulder, CO: Center for the duct disorder. Br J Psychiatry2009; 195: 1-7. study and prevention of violence, 2001. 23. Bywater T, Hutchings J, Whitaker CJ, Evans C, Parry L. Research pro-14. Tennant R, Goens C, Barlow J, Day C, Steward-Brown S. A systemat- tocol: building social and emotional competence in young high-risk ic review of reviews of interventions to promote mental health and school children: a pragmatic randomized controlled trial of the Incred-prevent mental health problems in children and young people. J Pub ible Years therapeutic (small group) Dinosaur curriculum in Gwynedd Ment Health 2007; 6(Suppl 1): 25-32. primary schools, Wales. Trials 2011; 12(Suppl 1): 39-46. 15. Nation M, Crusto C, Wandersman A, Kumpfer KL, Seybolt D, Morris- sey-Kane E et al. What works in prevention: Principles of effective prevention programs. Am Psychol 2003; 58: 449-56. 16. Doughty C. The effectiveness of mental health promotion, prevention and early intervention in children, adolescents and adults. A critical appraisal of the literature. Christchurch: New Zealand Health Technol-ogy Assessment (NZHTA) Report 2005, 8. 104 105 Vesna Švab strengthening user cooperation in mental health services also more important. In effect this means that usersshould evaluate the services they Promotion and prevention in mental health use by being involved in decisions, planning and implementation. Prevention is, in essence, the message that people’s dignity needs to be preserved Mental health promotion and mental disorder prevention are becoming and that the quality and accessibility of services need to be improved. As-more and more important to countries and societies. Data shows that a sistance and treatment needs to be organized in close vicinity of home, large number of people suffer from mental disorders, that mental disorin the community also because of organization of preventive and promoder can have severe effects in the form of reduced capabilities along with tion activities is much easier and achievable at the primary level of care . corresponding economic consequences, which can be immense (1). Most Moreover, community organization shows significantly fewer violations of mental disorders appear in childhood or adolescence and persist through human rights than community one (6). adulthood (albeit in a different form), affecting quality of life. They reduce Prevention and promotion programs can be divided according to where a person’s capabilities and increase the stress on social aid systems, the they are implemented, who implements them and what groups of people judicial system and others (2). Concrete proof exists that mental disorders they are aimed at. can be prevented before they form. In the event that they do, they can be The first group of measures consists of political and economic measures both treated extensively or controlled (3). aimed at improving nutrition, housing, education, reducing financial un-The purpose of this chapter is to introduce groups of proven preventative certainty and enable employment and adapted employment to vulnerable and promotional services in the mental health area. An overview of pro-groups. This preventative measure can only be used by the state, which fessional literature shows that many methods of improving one’s mental is obligated to contribute to the mental health of the general population. condition exist, along with educational materials intended to assist par-Recommendations on reducing exclusion are written down in the Euro- ents in raising their children and educating them. Other methods include pean Mental Health Plan and were emphasized years ago, when the eco-programs aimed at strengthening employers, professionals working in the nomic crisis was about to descend on Europe, in the well-known Helsinki field of mental health, the educational field and the social services. There is Declaration (7). also a strong and continuous trend in the media intended to improve the Since a person’s personality undergoes the fastest and the most dynamic mental health of the general public. The European Psychiatric Association’s development during his childhood, mental health prevention and promo-guidelines summarize all this by pointing out that 70% of the burden mention programs aimed at children and young adults are a priority. Resist-tal illness places on our society cannot be reduced by treatment. This vast ance to mental disorders among children and young adults can be achieved percentage can, however, be influenced by prevention and promotion (4, 5). by promoting appropriate parenting techniques and implementing early Mental health and its status in the world are tightly interwoven with hu-interventions where children that are considered at risk for mental dis-man rights. Stigma, discrimination and disrespecting basic human rights orders are concerned. An overview of existing research in this area shows are a big burden on those suffering from mental illness, additionally, se-that programs aimed at mothers-to-be and mothers with very young verely damaging their mental health. Besides this, societies around the children are extremely effective because they allow for early recognition world still consider mental disorders to be untreatable. This false assump-of mental issues in mothers after birth. All mothers are involved in the tion occasionally surfaces even among professionals and future profes-program which makes the program non-discriminatory. The program also sionals-sometimes even in educational materials. Effective prevention is uses a holistic approach to evaluating the health of mothers and children, aimed at stopping prejudice and is formed in accordance with the princi-meaning that the mental health aspect is evaluated alongside the mother ples of social equality, equal opportunity and accessibility to the most mar-and child’s physical health. The high value of prenatal house calls is fur-ginalized societal groups. Injustice does happen, however, which makes ther confirmed by research done abroad (4, 5). Identifying developmental 106 107 issues in the early childhood period through periodical examinations per-Union. In Slovenia, suicide prevention programs have been underway for formed by highly qualified professionals in mental health centers (com-decades, mostly in the professional education field, public education and, munity nurses) are the other part of the prevention program, though not in some areas, aid accessibility. Prevention and promotion activities are a well evaluated one, in my opinion. mostly headed by the National Public Health Institute. Other institutions Research further shows that school aid and support programs that include are also actively involved to a lesser extent, including NGOs, the Slovenian teachers and parents are very effective as well. Proven bullying prevention Research Centre in Koper, individual out-patient clinics, media, hospitals programs and tolerance education programs, as well as supportive envi-and clinics through research. ronment programs are being implemented to great effect. The Australian We now know what the most important suicide risk factors are, yet it is Mind Matters program (8) includes the whole school environment and is a still extremely hard to identify individuals who are especially at risk. Con-good example of such a program. In Slovenia, the Incredible Years program sequently, prevention is focused on high-risk individuals, specifically those is to be initiated (9). who were recently discharged from various institutions. These individu-The third group of measures that has achieved success in prevention and als are to be carefully followed and educated about their disorders. Among promotion are workplace mental health programs, aimed either at mental other forms of assistance, behavioral-cognitive methods are proven suc-health protection or support programs for those already suffering from cessful (10). mental disorders and so need additional support or aid in their work. Most Protective factors ensuring good mental health in every population are promotional programs focus on stress control and a holistic healthy life-beneficial parenting, favorable childhood environment, significant social style promotion. It seems that such programs are economically success-support networks, low levels of inequality, employment, goal-oriented and ful, while also reducing the amount of sickleaves and increasing employee meaningful work, social capital, confidence, autonomy, altruism, emotion-productivity. Protection programs for those already suffering from mental al and social knowledge and, of course, physical health. disorders are also very successful, especially in social enterprises. It turns out that employment is one of the best means of rehabilitation from men-Wellbeing has therefore been one of the most important areas of political tal disorders (4,5,9). interest and research over the previous decade. Wellbeing is a subjective term, defined as how content with various areas of life a person is or, alter-In the senior age group, understanding the connection between physical natively, how good a person judges their life to be. The current emotional and mental health is extremely important. This can be proven by observing state of a person making such a judgment, needs to bet taken into account the correlation between mortality and good mental health, as well as the (11). The importance of this area of study is reflected in the fact that the good physical health of those seniors who are emotionally balanced. 25% of World Health Organization has organized a number of events with wellbe-seniors in the community (e.g.: Great Britain) exhibit symptoms of depres-ing as the main theme. During the ROAMER (Roadmap for Mental Health sion severe enough to require assistance. Dementia affects 5% of seniors in Europe) project, data was collected on the already implemented wellbe-over 65 years of age. Those that are physically ill are even more re at risk. ing projects in Europe. The number of publications in this area has doubled Successful prevention of mental disorders in old ager are psychosocial in-since 2007, with most publications coming from Scandinavian countries, terventions, a high level of social support when enduring illness, social the Netherlands and Ireland (12,13). isolation prevention, physical activity, learning, appropriate housing, psychoeducation and reducing poverty. Mental health promotion and prevention in seniors is mostly implemented through house calls, physical exercise, psychosocial groups and work therapy. The worst consequence of mental disorders is suicide. Preventing suicide is one the basic preventative and promotional activities in the European 108 109 Mental disorder prevention among children and young adults children are often exposed to neglect and abuse, humiliation and careless- with reduced capabilities ness. The consequences of such upbringing can appear in the social, behavioral and mental areas (14). Comfort, equipment, colorfulness and even The most fundamental children’s right is the right to the removal of obsta-the staff’s commitment in such institutions has comparatively little effect. cles preventing inclusion in society. Children’s fundamental rights include Children and young adults develop best at home, next to their families, es-the right to identity, the right to live with parents, the right to education, pecially when they and their families are offered assistance sufficient to en-right to be free from abuse and torture, right to live in the community and sure a comparatively comfortable life for the child. the right to health. Children from the lowest socio-economic classes are three times as likely to develop a mental disorder. Children that do not live with their families are five times more likely to develop a mental disorder, Sources children with learning disorders six and a half times, while male children 1. Wittchen et al. The size and burden of mental disorders and other from 15 to 17 years of age who live in institutions are 18 times more likely disorders of the brain in Europe 2010. Eur Neuropsychoph. 2011; 21: to commit suicide than others of the same age. 655-79. Committing children to institutions is a violation of their basic human 2. McDaid D & Park A. Investing in mental health and well-being: find-rights and the consequence of severe ignorance of a child’s needs, especial-ings from the DataPrev project. Health Promotion International 2011; ly where children with reduced capabilities are concerned. What children 26 (S1), i108-i139. need, first and foremost, is growing up in a family. All families cannot en-3. WHO Prevention of mental disorders : effective interventions and pol-sure that all conditions for a healthy upbringing are met. These families ob-icy options : summary report / a report of the World Health Organi- viously need assistance in caring for their children. This assistance is vastly zation Dept. of Mental Health and Substance Abuse; in collaboration preferable to children being institutionalized, as being in an institution has with the Prevention Research Centre of the Universities of Nijmegen been proven to cause regression in a child’s development and a significant and Maastricht. Geneva 2004. http://www.who.int/mental_health/ increase in likelihood of illness, injury and suicide. This is due to the lack of evidence/en/prevention_of_mental_disorders_sr.pdf. quality care, lack of interpersonal communication and lack of stimulation. Children in institutions also have a generally lower lifespan. A variety of evi-4. Campion J, Bhui K & Bhugra D. EPA guidance on prevention of mental dence exists that proves institutional care is the cause of psychological and disorders. European Psychiatry 2012; 27: 68-80. physical damage and that children in institutions are exposed to violence 5. Saxena S, Jané-Llopis E, Hosman C. Prevention of mental and behav-much more than their non-institutionalized counterparts. ioral disorders: implications for policy and practice. World Psychiatry The most common institutionalization prevention strategy is developing 2006; 5(1):5-14. community services. Programs that can accelerate a child’s inclusion into 6. WHO. The European Mental Health Action Plan. Çeşme Izmir 2013. http:// the community include early interventions, community mental health www.euro.who.int/__data/assets/pdf_file/0004/194107/63wd11e_ services, educational and other high quality upbringing an care programs MentalHealth-3.pdf aimed at parents, informal support for children and families, inclusive edu-7. WHO European Ministerial Conference on Mental Health: Facing The cation, financial aid for families that need it to survive, ensuring free time Challenges, Building Solutions, Helsinki 2005: 14. for parents, developing fostering programs, developing work groups and monitoring child and young adult services. 8. Wyn J, Cahill H, Holdsworth R, Rowling L & Carson S. MindMatters, a whole-school approach promoting mental health and wellbeing. Aus-The most common reasons for institutionalizing children are poverty, tralian and New Zealand Journal of Psychiatry 2000; 34: 594–601. stigma, discrimination and the lack of community services. In institutions, 110 111 9. Samele C, Frew S, Urquía N. A European profile of prevention and Renata Ažman promotion of mental health (EuroPoPP-MH), EU report 2013. http:// ec.europa.eu/health/mental_health/docs/europopp_full_en.pdf Recovery from a user’s perspective 10. McDaid D, Bonin E, Park A, et al. Making the Case for Investing in Suicide Prevention Interventions: Estimating the Economic Impact of Introduction Suicide and Non-Fatal Self Harm Events. Injury Prevention 2010; 16: 257-8. One of the main characteristics of recovering from a mental illness is the-fight for survival. While this sounds dramatic, it can be summed up as an 11. Diener E, Suh EM, Lucas RE, & Smith HL. Subjective well-being: Three attempt to achieve health both spiritually and physically by ways of prop-decades of progress. Psychological Bulletin1999, 125, 276-302. er nutrition, exercise, therapy, psychotherapy, reading and writing. One 12. Haro JM, Ayuso-Mateos JL, Bitter I, Demotes-Mainard J, Leboyer M, should also make regular visits to the psychiatrist, go for walk and always Lewis SW, Linszen D, Maj M, McDaid D, Meyer-Lindenberg A, Robbins take one’s medicine. TW, Schumann G, Thornicroft G, Van Der Feltz-Cornelis C, Van Os J, The above paragraph describes how world sees our recovery sometimes, Wahlbeck K, Wittchen HU, Wykes T, Arango C, Bickenbach J, Brunn yet the elememts at hand are but the first step on the path to recovery M, Cammarata P, Chevreul K, Evans-Lacko S, Finocchiaro C, Fiorillo which winds ever onwards – through pain, relief, burden and acceptance A, Forsman AK, Hazo JB, Knappe S, Kuepper R, Luciano M, Miret M, and finally ends at our own feet. Obradors-Tarragó C, Pagano G, Papp S & Walker-Tilley T. ROAMER: roadmap for mental health research in Europe. International Journal of Methods in Psychiatric Research 2014; 23(S1): 1-14. My story 13. Miret M et al. The state of the art on European well-being research It all began with my first experience of depression in the fall of 1992 fol-within the area of mental health. International Journal of Clinical lowed by severe mania in the following spring. In March of 1993, I was and Health Psychology 2015. Acquired 10.9.2015on http://dx.doi. hospitalized for the first time and stayed at the Polje Psychiatric Hospital. Upon discharge, I continued to visit a private practice managed byDr. Bo-org/10.1016/j.ijchp.2015.02.001. rislava Lovšin. I rejected the treatment because I thought I could overcome 14. WHO. Glubenkian Mental Health Platform Promoting Rights and symptoms without the use of medication. Community Living for Children with Psychosocial Disabilities. Lisbon It took me a decade and two hospitalizations before I finally took the re-2014. Draft sponsibility for my own life. I was able to overcome my illness and live with my symptoms eventually by taking the prescribed medications, finding my own spirituality and expressing myself in writing is. I realized that the things that helped me, definitely worked for me – regardless of how they may have beenseen. I found my answers in nature, healing crystals and people around me, which definitely shows that the path to recovery is an individual one. What all those suffering from mental disorders share is the fact that our path to recovery is a matter of survival. We fight to survive the system, to get through our treatment, survive our illness and ourselves. I believe it was my decision to embrace my own wishes that led me to recovery and I am truly grateful for it. 112 113 Following my heart, I managed to take stock of my past and write four treatment is effective, bringing relief with few exceptions – and even those books (Japajade, 2005, Depra, 2007, Itaq, 2011 in Yoyo, 2014), lead more can be used to trim our social circle. than ten workshops on therapeutic writing and was also one of the peoThe final step in communication occurs when we communicate with the ple behind the anthology “Izpišimo bolečino” (Celjska Mohorjeva družba, public. In the moment when anyone is able to read what we wrote, our 2014). I am proud of what I have become and have a feeling that the best secrets cease to be secrets. They become stories bringing with them the is yet to come. Accepting myself lead me to appreciate how blue the sky is power that stories possess. It can inform and show the causes and conse-and that I deserve my own place underneath it. Depression is still a part of quences of mental illness, adding significantly to the process of destigma-me, yet now a part that is understood and accepted. tization. Stories Social circle Every mental health disorder hides a story that needs to be heard, analyzed I believe that recovery depends, to an extent, on our relationship with and accepted. These stories are hard to imagine and even harder to relate. those in our social circle. Our relatives, friends, co-workers and acquaint-Some parts of them are hidden deep beneath what we can perceive and ances form a network capable of helping us through our recovery. The need the help of others to release them. In my opinion, this is a part of what people we surround ourselves with are what we know ourselves by and a psychiatrist or a psychotherapist does and is, a person that can unlock our are thus extremely valuable. The social circle that we establish needs to be memories. A person who is interested and trusted, who knows how to listen tended with sincerity and respect to ensure stability and mutual benefit to and hear. Writing is a part of this process of unlocking and acceptance. everyone in it. Employingthe basic journalists’ tools – asking who, when, what, where and why – I tried my hand at therapeutic writing. This eventually resulted in thepublication of my books and my attempting to write stories that would The profession not be constrained by the therapeutic writing model. I learned that the The relationship patients establish with their psychiatrist or psychothera-true therapeutic writing takes place on three levels of communication, first pist is extremely specific and would bear a significant effect on the way on the level of communicating with myself, secondly, communicating with the treatment proceeds. Trust is of course t keyword in all therapeutic re-others and on the third level, engaging in communication with the public. lationships. When we begin to trust a psychiatrist to know what will help I am fully aware of the fact that therapeutic writing holds greater impor-us and how it will do so, the treatment becomes much easier. Establishing tance for the writer and less so for the public. Authors can thusarticulate a relationship that is honest and empathetic, we give ourselves the chance their thoughts and transform themselves through writing, which makes to recover.Patients need to be encouraged and directed to activities that writing letters, diaries and even stories a very popular mode of treatment. both interest and benefit them, which can be hard as we don’t often get Communication with others may employ letters (sent and unsent) and to see our doctors. Therefore, our survival rests in our hands for the most other forms of writing that we give to others to read. The use of the lat-part and with the exception of times of hospitalization, we are the ones terallows us to communicate with peopleimportant to us at a slow pace, responsible for what we do and how we feel. We can do a lot to redirect our one that is characterized by measured responses. These responses will thoughts when they stray into shadows and we can always adapt to our be positive for the most part, which can significantly help transform our symptoms. The fact remains that we might not be able to control them. own self-image. Any secrets revealed through writing lose their hold over Psychiatrists and other professionals step forward in those cases and en-us, while the risk of shock, disgrace and shame is tempered by the meas-force rules that let us stay a part of society. I believe the shortest path to ured response inherent to writing. There can be no doubt that this form of freedom is following those rules. 114 115 Stigma and destigmatization When I woke up in the hospital for the first time and realized that I am now a mental health patient, I was shocked. I realized that I will always be a patient, a person with a mental disorder,carrying that mark. An experience of that kind would hurt anyone. I consequently tried to hide my illness and became ashamed of myself, starting to hide from my loved ones. I faced isolation and lost most of my social circle, however, when I released my first book Japajade (2005), it put an end to all secrets as well as all bad and good advice. In the book, I dis-closed everything in relation to my experience and the publication resulted in meeting some wonderful people. While it was not as big of a success as my second book Depra (Celjska Mohorjeva družba, 2007; Chipmunkapub-lishing, 2007), which saw three separate editions, it helped me to accept myself. People wrote to me and thanked me for writing the book. Stigma lost its hold on me. Other books followed – Itaq (Miš, 2011) and Yoyom (ALUO, 2014). Mental Ecology I believe that patients who genuinely wish to be resocialized need to relin-quish what is left of their former lives. Attempting to heal old wounds requires clearing the foundations. This is, as I can attest, a long and a painful process that demolishes what we used to believe ourselves to be. I can also attest that it is worth the pain to remove what we must change to be happy again. Body, mind and soul all need to be cleansed and taken care of. Food, hygiene, nature, clothing and the company of kind people is needed. Our mind should be cleansed of questions and doubts, of dark thoughts and destructive impulses. Reading about what affects us, thinking and writing is the best way to do so, I have found. We need to cleanse our soul as well, which can be done with music, art and spirituality. A belief in good overcoming evil and a universal order are balms to a tortured soul. Conclusion No path to recovery can be treaded twice, yet the decision to walk it is the same every time. Always remember that fortune favors the brave. 116 117