Inspired by the values of the WHO, the Piedmont Region's Mental Health Action Plan aims to reorganize and improve the quality of service and the results of care and support for people with mental suffering.
Problems and purpose
The general purpose of the Mental Health Action Plan, devised by the World Health Organization in 2013, "is to promote mental well-being, prevent mental disorders, offer treatment, increase recovery opportunities, promote human rights and reduce mortality, morbidity and disability in people with mental disorders "(WHO, 2013, p. 50).
The health sector, as the World Health Organization points out, alone cannot meet all the needs for the promotion of mental health and the prevention of mental disorders, but can act as a promoter of appropriate actions:
- strengthen leadership and governance in mental health
- provide comprehensive, integrated and responsive mental health and social support services
- design and implement mental health prevention and promotion strategies
- strengthen information systems, scientific evidence and research.
These actions are based on 6 pillars, universally valid, which represent the guiding principles of mental health policies in all Member States:
- access to universal health coverage
- human rights
- evidence-based interventions
- approach oriented to all stages of life
- multisectoral approach
- empowerment of people with mental disorders and psycho-social disabilities.
In particular, for the European Region, WHO emphasizes three relevant aspects of the six Pillars: equity, patient empowerment and the effectiveness of all actions.
“The Piedmont Region fully adheres to this model, underlining the universal, inclusive and proportional character to the needs of mental health promotion interventions and the need to pay particular attention to the relationship in the care pathways. With regard to human rights, the Piedmont Region aims to overcome the use of mechanical restraint techniques and the participation of users and their families in the construction of the treatment project "(IRES, 2018, p. 2).
History and background context
Following the action plan drawn up by the WHO and the invitation to implement it addressed to all member states, in January 2013, the Italian state adopts it through an agreement with all local authorities. In particular, the regions, the bodies with the widest competences in the field of health organization, will be responsible for its implementation.
The Piedmont Region launched a process of elaboration for an action plan on mental health in October 2017, entrusting the task to the Piedmont Institute for Economic and Social Research (IRES), as part of a broader multi-year research and evaluation of health policies and services . The Board of Directors (BoD) of the institute is made up of 5 members elected by the Regional Council and its duration coincides with that of the legislature, until it is renewed.
With the regional elections of May 2019, the center-right candidate Alberto Cirio wins, turning from the center-left political orientation of Sergio Chiamparino who led the region in the previous 5 years. The regional government of Piedmont, since its inception, is characterized by a constant alternation between left and right. In the Chiamparino program of 2014 there was a reference to citizen participation and to the example of the regional law on the participation of Tuscany and the French public debat. Even in the latest electoral program, calls for public participation were recurrent on all points, in particular in the health sector for involvement in the reorganization of strategies, services and hospital structures . While in Cirio's program the term “participate” or “participation” referred exclusively to the investee companies of the Region or to the promotion of the entry of private subjects in public interventions .
Organization, support and financing of entities
Piedmont Region finances the process entirely with health funds, also assigned to cover the three-year research plan drawn up by IRES and approved by the Regional Council in 2017 (see IRES). The specific figure is not given.
Piedmont Region, Health Department: Vittorio Demicheli, Regional Deputy Director of Health (from 1/12/2015 to 31/12/2017) "with an important role in the health reform: the reorganization of the territorial network [...] and of the psychiatry ". For the Mental Health Action Plan, she supervises the research group made up of 5 IRES researchers and 4 researchers from Ecletica Snc.
IRES Piemonte is a research institute, established in 1958 on the initiative of the Province and the Municipality of Turin with the participation of public and private entities. In 1991 it became an instrumental body, “configured as a public body endowed with functional autonomy governed by regional law no. 43 of 3/9/1991 ", of the Piedmont Region. Its Board of Directors is elected by the Regional Council. It is engaged in research on the economy and work, the protection and development of the territory, in training programs, in the evaluation of regional policies. Since 2013, with regional law n. 8, IRES is entrusted with the performance of functions in health matters, such as analysis, evaluation and planning. In 2017, the Regional Council approved the multi-year research program of IRES from whose report it is possible to frame the tasks and commitments of recent years, including those in the health sector, for which the region allocates a total of 1,100,000 euros, while the figure relating to the case in question  is not given. Another 3,300,000 euros are assigned to the other projects. For the Mental Health Action Plan, the research team was made up of the director of the institute Marco Sisti and 5 other researchers.
Eclectica Snc is a private company based in Turin. Composed of sociologists, psychologists, trainers, it deals with social research, training and methodological accompaniment. In the project on the mental health action plan she collaborated, commissioned by IRES, with a group of 4 researchers, including the head of the research sector Franca Beccaria. The expense or the method of assigning the assignment is not indicated.
Recruitment and selection of participants
Working group - "At the beginning of 2017, the Working Group was set up consisting of 12 experts on the subject, coming from Health Authorities, Social Service Organizations, Service Providers, Universities which supported the IRES Piemonte-Eclectica research group in the coordination of the Plan preparation process "(IRES, 2018, p. 3). The methods of recruitment, the place, the number of meetings are not given.
Territorial workshops - On weekdays, in the "period between the beginning of May and the end of June 2017, 5 workshops [lasting one day] were held, each relating to a Piedmontese territorial quadrant" (Eclectica, 2017, p. 4). For each workshop, a list of guests has been drawn up divided into 8 categories: professionals of social and health services, members of voluntary associations, operators of social cooperatives providing services to users and family members, local administrators, representatives of productive realities sensitive to the issue, figures from the scholastic world, officials from employment centers (Ib.). “415 letters of invitation were sent by e-mail; the response rate was around 85%, thus demonstrating a high level of interest in the initiative and a good ability to intercept the communication methods adopted ”(Ib., p. 5). There were 230 participants with an adhesion rate of over 55% (Ib.) With an average of 46 attendances per meeting. The composition of the group of participants reveals a slight over-representation of health sector operators that correspond to almost 50% of the participants in the initiative, offset by a consistent presence of members of the associations, equal to more than 20% of the participants, and of social cooperatives (17%). Less numerous are the members of the social services that cover about 10% of the sample, followed by only 2 local administrators, 2 operators of employment centers, 2 university professors, 2 lawyers / support administrators and 1 trade unionist of the CGIL (Ib. , p. 5-6). During each meeting the participants were asked for their willingness to participate in the accompanying tables for the construction of the Mental Health Action Plan and at the time of drafting the closing report of the workshops there were 77 (Ib.).
Thematic tables - "In the summer of 2017, collecting the applications from interested parties - 124 people, 74 in the workshops and 50 following a second call - three thematic working groups were set up" (IRES, 2018, p. 3). Each table, on different topics, made up of 14 members, gave voice to the different worlds that deal with mental health: ASL (Departments of mental health and other services), User and family associations, Bodies managing social assistance services, Local authorities or other public bodies, cooperatives, foundations or other service providers. Between October and December 2017, 4 meetings were held for each table - led by facilitators, with the participation of an IRES Piedmont researcher - aimed at elaborating the Plan proposal (Ib.). For each table there is a list of participants by category, with names and role references. The composition of each single table responds to the following categories of components: 4 Asl DSM (Mental Health District); 1 Asl other services; 4 associations (eg Caritas, Più Rights, Usacli); 2 service providers (eg cooperatives or associations); 1 managing body (eg Municipality of Turin); 1 local authorities or other public bodies (eg University of Turin); 1 regional group (eg Asl TO1).
Methods and tools used
Working group - Multi-actor or multi-authority group or table in which a process expert discusses how to design and plan, in whole or in part, a participatory process. In this case it is a table made up of experts and operators of the sector supporting the research group for the coordination of the process. No further information is given on the meetings, methods of conduct, or minutes.
World Café - WOCA is an interactive conversation method that has been adopted by large corporations, governments and communities around the world to animate collaborative dialogue networks. WOCAs are built on the principle that people already have the wisdom and creativity needed to tackle the toughest challenges and can learn a lot from spontaneous conversations with people outside their organization or groups they are used to. Therefore, in the discussion mode, tables of 4-8 people are formed. After the first discussion on a question posed by the organizer of the event, a witness (or table-host or "host") of the table remains stationary while the others go to different tables. The witness records the ideas expressed and communicates them to new guests or the plenary facilitator before the next discussion begins. And so on until all the questions are exhausted. The WOCA was used in the 5 one-day territorial workshops. In this case, the tables consisted of 8-10 people. In each workshop, 5 thematic tables have been set up relating to three paths of reflection on mental health. “Each table had the mandate to discuss the elements of effectiveness and transferability of 3-5 practices, selected by the project group as they were considered particularly innovative and representative of the reference area. Starting from the experiences identified as a stimulus, highlighting their strengths and criticalities, the members of the group were invited to reflect more generally on the themes proposed (work, home, care, socializing, health promotion) "(Eclectica, p. 7)
Nominal Group - The Nominal Group is a structured process for reaching group consensus on the priority to be assigned to a list of problems or solutions produced by the participants themselves; the leader formulates a question or produces a solicitation on a specific theme, to which each member of the group responds individually, noting their observations on a sheet of paper. Subsequently, the conductor invites each one to expose their proposals to the others, which he collects and systematizes in a common list, grouping the same or similar ideas. Finally, each participant is invited to vote on the concepts of the list drawn up by the group that they consider most important, in order to obtain a ranking of the most voted ideas. Used in this case in the territorial workshops, “the Nominal Group was designed as a moment of abstraction of principles and founding elements, on the basis of the reflection matured within the World Cafés, elaborated by the hosts and presented to the public during the plenary session. Therefore, for the Nominal Group, the same thematic tables of the World Café were restored and members were asked to identify priorities and key concepts to be included in the Mental Health Action Plan ”(Ib., P. 7).
Thematic tables - These are multi-actor meetings, in which, with the guidance of a facilitator, we discuss and try to reach a consensus, an agreement, one or more shared positions on a single theme / aspect of a program, a plan, a 'action. In this case they were led by a facilitator, with the participation of an IRES researcher. In the 4 meetings for each table, objectives were addressed gradually more operational in order to define the actions shared and considered feasible.
What happened: process, interaction and participation
The project "Participatory activities in the field of Mental Health", activated by IRES Piemonte on a mandate from the Department of Health, consisted of an initial collection of practices in the Piedmont area [with the establishment of the working group ] and in the organization 5 territorial workshops , aimed at involving as many stakeholders as possible in the elaboration of the Piedmont Region's Mental Health Action Plan (Ecletica, p. 4). No further information is given on the meetings of the working group.
“The priority objective of the workshops was to define principles and key elements to be included in the Plan, starting from the discussion of the practices selected from the material that emerged from the initial survey and used as a stimulus. In order to encourage as much as possible the expression and the comparison between the different points of view, we opted for the use of participatory methods, which provide for the centrality and active involvement of the participants and the use of interactive techniques and tools. "(Ib.).
Between May and June 2017 the one-day workshops were held in: Omegna (for the Biella-Novara-Vercelli quadrant); Ivrea (Province of Turin); Turin (City of Turin); Alessandria (Alessandria and Asti); Cuneo (Cuneo and Alba). "In each one In each of the five workshops, five thematic tables have been prepared [with the WOCA method], relating to three different areas of mental health:
- the paths of treatment (two tables),
- the paths of qualification and emancipation (two tables);
- the paths of prevention and health promotion.
The first area concerns therapeutic rehabilitation projects in a broad sense, including home services and self-help experiences; the second area includes initiatives transversal to the areas of sociality, living and job placement; the third area concerns the promotion of mental well-being, the prevention of discomfort and the sensitization of citizens to the issue of mental health.
Each table had the mandate to discuss the elements of effectiveness and transferability of 3-5 practices, selected by the working group as they were considered particularly innovative and representative of the reference area. Starting from the experiences identified as a stimulus, highlighting their strengths and criticalities, the members of the group were invited to reflect more generally on the themes proposed: work, home, care, socializing, health promotion "(Ib., P. 7).
On the first line - the paths of care - the discussion focused on: the accessibility of services understood not only on a greater availability of opening times but on a continuous, global, no longer fragmented taking charge; the personalization of interventions through a home service and the involvement of the family and users in the treatment process (Ib. 8). For example, two experiments were discussed on this topic: the nursing service of continuity of assistance with availability even at night and on holidays dedicated to particularly fragile users or those who are going through critical phases; the Mental Health Center open, with longer opening hours (12 hours for CSMs and 8 for day centers) with a wider activity and therapeutic-rehabilitation programs that also involve external collaborators. These pilot experiences were positively received by the participants because "they would have an important preventive effect, avoiding the worsening of a critical moment and the consequent hospitalization, with a reduction in costs for the health system and less use of restraint, considered by many to be a therapeutic failure. The overcoming of contentive practices has in fact been the subject of discussion, as it is considered a desirable goal, linked to a more humanizing psychiatric approach, which reduces the risks of a negative impact on the user's self-perception. The reflection on the different forms of restraint (physical, mechanical, pharmacological) was prompted by the discussion of a specific experience, activated within the SPDC of Borgomanero, in the province of Novara. On this issue, the need was again expressed to create a monitoring system on physical restraint and to pay more attention to the administration of drugs, putting forward the proposal to have at the regional level an informed consent to be presented to patients, with the list of possible side effects (Ib., p. 9). The consequent requests for greater involvement and integration between sectors, departments and professions, however, clash with conflicts and communication problems, organizational constraints (including contractual ones as in the case of the nursing service for continuity of care) and in general with the lack of human and economic resources ( Ib.). One way to overcome the glimpsed obstacles is to personalize care by resorting to home intervention and involving the social network of which the user is a part. Two experimental cases are considered valid and replicable: the open dialogue conceived in Finland and adopted by various DSMs in Italy including Turin. It is a timely intervention by two specially trained operators that leaves drug treatment in the background and involves the whole family unit; UFE (expert family users) are users and family members who have acquired an “experiential knowledge” that enables them to provide recognized services in different areas of DSM activity. Other positive examples follow such as self-help groups and the intercultural interdepartmental group to respond more effectively to the needs of the immigrant population.
The second line relating to de-institutionalization and empowerment dealt with the issue of psychiatric structures which, as an alternative to housing communities or nursing homes (nursing homes), hetero-family foster care or light residential initiatives were proposed with the aim of the housing autonomy of users. Other proposals already tested aimed at the socio-economic integration of patients, concern the autonomization and global taking in charge, training, opening up to voluntary associations, social cooperatives, sports associations. Finally, the third strand is dedicated to prevention and health promotion. Various aspects are addressed such as the dissemination of prevention education in schools and support for parenting. On the forms of awareness raising, for example, 3 stimulating experiences were submitted to the tables of the WOCA: "the Orfeo urban poetic circle" (Turin and Grenoble day centers) with the aim of activating the community to promote action to resist crises, such as rallies of "poetic liberation", in public places, to promote awareness of mental illness in the whole population; the week of mental health (DSM of Turin) which includes a series of artistic, cultural and scientific events on the subject and is entitled “Roba da Matti”; “Urban Laboratory of Local Mind” is a research and support group for mental illness (DSM Turin) which promotes weekly self-help meetings and social communication projects to foster help relationships between peers (Ib. P. 23).
Following the reflection gained in the WOCA, with the Nominal Group each table has identified the principles and key elements to be included in the Mental Health Action Plan.
Actions / needs for each branch were thus ordered in order of priority and sharing. On the first line relating to care pathways, for example, we need more human and economic resources and adequate spaces within the Mental Health Centers (CSM). Integrated inclusive paths with the territory, the health budget as a tool to offer flexible and personalized services with a view to socio-health integration of resources, and many others.
Less shared and therefore positioned in the last places are: the implementation of actions aimed at reducing the use of restraint, the promotion of peer support, the cross-cultural attention to care pathways, the support of care paths to those of insertion work, privileging family and social relationships over the use of pharmacological therapies (Ib., p. 25). It is interesting to note how it completely disappears from the list of actions even by the less shared ones: the proposal for the creation of a "physical restraint monitoring system" and the proposal to submit to patients a declaration of "informed consent" that included the possible side effects (Ib., p. 9).
In conclusion, the hope of the participants is that "the workshops represent the first appointment of a season of bottom-up regional planning, effective in avoiding that the services are focused on helping the user in the acute phase, but then do not accompany him in the next phase, or rather, they raise those who have fallen but do not have space to walk. Mental health is in fact understood as a broader concept of psychiatry, which should be configured as a problem that the whole community takes on, proposing effective social inclusion paths that do not aim only at creating permanent parking lots (Ib. , p. 27).
Following the workshops, once the applications and responses to a second invitation (via e-mail) to new contacts have been collected, the working group has set up 3 thematic work tables made up of 14 people: category, initials of belonging and names are listed for each table. "Between October and December 2017, 4 meetings were held for each table - led by facilitators, with the participation of an IRES Piedmont researcher - aimed at elaborating the Plan proposal. The first meeting started from the priority themes that emerged from the workshops and identified a list of objectives for the Plan; the second meeting produced a list of useful actions to pursue the objectives; in the third and fourth meeting the actions that met the consensus among the participants and were considered feasible were planned. The objectives to be pursued and the twenty actions to achieve them are contained in the PASM proposal "(IRES, 2018, p. 3).
It is a plan divided into 7 macro-themes and 20 overall actions.
The PASM (Mental Health Action Plan).
As a premise it is stated that "to verify the real effectiveness of a plan it is necessary to monitor its implementation and evaluate the impact of the actions on the health of the population" (Ib.,). “A monitoring and evaluation system for the 20 actions of the plan will therefore be structured” and “particular attention will be paid to the development of participatory evaluation” (Ib.). "The full functioning of the information system for mental health is a prerequisite for the monitoring and evaluation system" (Ib.).
- Improve governance . It should be noted that Piedmont spent 10% less than the national average on mental health services. A priority is investing in monitoring and evaluation for rigorous evidence-based resource planning.
Action 1 - Regional Council for Mental Health - Made up of actors interested in mental health "it has the function of bringing out and reporting problems concerning mental health, making proposals, addressing cognitive and research questions to all competent subjects and has the the right to receive transparent and timely answers on the merits. Once constituted, the Council appoints a representative who will take part in the PASM Monitoring Committee ”(Ib., P. 5).
Action 2 - Monitoring Committee of the PASM. Composed of representatives of the working groups, of the PASM working group and a representative of the Council (Action 1). The function of the Committee is to periodically verify the effective implementation of the PASM actions, highlight the problems that concern it, ask cognitive and research questions to the competent regional Departments and have the right to receive answers on the merits, transparent and timely. "(Ib., P. 5).
Action 3 - Monitoring of care pathways. The information system on care pathways and users in charge is developed in such a way as to collect homogeneous data on the territory and produce periodic monitoring reports, at least annually. Particular attention is paid to verifying compliance with existing standards, also with reference to the professional figures involved. Monitoring reports and related data are made public and easily accessible to all interested parties. On the basis of the monitoring data, service improvement objectives are also defined, in unambiguous and verifiable terms. The information flows are made consistent and comparable at regional level. The action is carried out by the Health Department of the Region through the epidemiological observatory on mental health of Piedmont.
Action 4 - Evaluation of the quality of services and outcomes. The Piedmont Region promotes and carries out specific in-depth analyzes and evaluation of the quality of services and the outcomes of treatments and interventions, also at the request of the Regional Council for Mental Health and the Monitoring Committee of the PASM. Possible topics to be studied and evaluated, also through participatory evaluation, are the use of drugs, the use of compulsory health treatment (TSO), the use of restraint. The results of the in-depth analyzes and evaluation are made public, easily accessible to anyone interested and are used to improve the quality of services.
Other 16 actions follow regarding: awareness campaigns; accompanying parenting services, co-planning tables to enhance life skills in childhood and adolescence, physical activity, service initiatives for care-givers, a project by area dedicated to the prevention and promotion of health, projects to extend and improve accessibility to services and CSMs, a dedicated regional website. In the macro-theme of integration, a multidisciplinary mental health assessment unit (UMVS) is set up - through action 15 - chaired by the district directors and the directors of the service management bodies. With regard to the macro-theme of autonomy paths, actions 17 and 18 are noteworthy, which promote projects aimed at supporting autonomous living and in any case maintaining a home, job placement, support for self-employment initiatives, 'insertion of patients or former patients with the profile of experts in peer support (Ib., p. 18).
Influence, results and effects
The PASM is approved by the Regional Council of Piedmont, as delivered by the IRES - its functional body - on 22 January 2019 with resolution no. 355 - 1817. It is recalled - as acknowledged by the resolution - that the approval of a plan does not it involves charges to be borne by the regional budget and that the Board "will define with subsequent acts the specific methods of implementation of the actions, the resources necessary to carry them out and the competent subjects".
The Mental Health Committee took office and opened a Facebook page. From what emerges from the last post on 2/3/19, the meetings for the constitution of the Council for mental health have also been started. However, no further progressions can be found, while there is an interrupted / null interaction - from the last post to date (ril. 27/9/19) - in the social tool. Probably with the establishment of the new center-right council, therefore in discontinuity with respect to the previous center-left, we have to wait for the appointments of the new board of directors of IRES (from the site not yet carried out) and the top management of regional health.
Conclusions . From the reports available online, the material is complete as regards the contents and points of arrival of the process but it is not possible to reconstruct the debates and discordant positions. There are discrepancies between the results of the first workshops and the work of the thematic tables which - as the minutes are not available - it is not possible to understand. In any case, it seems that the hottest issue concerns the area of traditional intervention (drugs and restraint) which is still in vogue and needs monitoring. The problem is that monitoring (in the plan calls for extended participation in this activity) is not yet possible because the information system is inadequate; this inadequacy concerns not only the issues mentioned but also the other data of the health system on mental health, both due to the scarcity of resources and the social complexity that this sector requires. On this at least there seems to be the intention to continue swiftly but probably the change of council has slowed down the process. A process that, however, IRES seems to have continued, at least keeping alive the attention and promoting training days (between March and May 2019): 4 days dedicated to "inclusive and participatory mental health" and 3 dedicated to "associations of people with experience of mental suffering and their families ". Finally, a conference is scheduled during the week on mental health, restraint and health in prison (Link 1).
Analysis and lessons learned
It should be remembered that Franco Basaglia himself (1924-1980), a well-known psychiatry reformer of the traditional mental health approach based on asylums, introduced the concept of participation, in the sixties and seventies, in his clinical and organizational method.
This case concerns an innovative plan with good relevance . It touches on fundamental issues relating to the quality of life of people in difficulty, involves many public workers and investments in relevant public resources. Participatory work seems to have produced a consistent, clear and actionable result. The key player in this result of influence and effectiveness is IRES, a public entity and therefore with a strong institutional impact; the plan was developed almost by a third party agent managing the participatory process, a research body rather than a guiding one, with specific expert skills, which however is strongly politically oriented, both for the continuous funding, and for the very presence of the political actor in office on the Board of Directors.
In general, the transparency of the process is not complete, there is a lack of minutes and a wider communication / publicity of the process, not limited to professionals. Furthermore, the financial commitment required for the process is lacking.
The sharing of the path does not seem to have been addressed or in any case there is no detectable path of preparation and negotiation prior to the process.
The representativeness of the subjects present in the workshops and thematic tables does not seem to be sufficiently balanced with respect to patients and their families.
- WHO (2013), Mental health action plan 2013 - 2020, http://www.salute.gov.it/imgs/C_17_pubblicazioni_2448_allegato.pdf (ril. 23/9/19).
- IRES (2018), Mental health action plan. 20 actions for mental health, https://www.ires.piemonte.it/images/Ricerca/Salute_mentale/Report_PASM.pdf (ril. 23/9/19).
- Eclectica, IRES (2017), Mental health in Piedmont. Results of a participatory process,https://www.ires.piemonte.it/images/Ricerca/Salute_mentale/Rpt-Wsp-Sm.pdf (ril. 23/9/19).
1 - IRES, ires.piemonte.it
 Piedmont Region, Resolution of the Regional Council, n. 234-36975 of 10 October 2017.
 Piedmont Region, Regional Council Resolution, n. 87- 6289 of 2 August 2013;
 IRES Piedmont, Mission, ires.piemonte.it
 PD, Chiamparino President, The courage to say Yes, http://www.pdpiemonte.it/programma-per-un-piemonte-europeo/#europa (ril. 23/9/19).
 Alberto Cirio Chairman. Another speed for Piedmont, http://www.albertocirio.it/?p=1603 (ril. 23/9/19).
 Strippoli, S., Piedmont, vaccine controversy: Demicheli, deputy director of regional health, leaves, in: L'Espresso, 4/4/2017, https://torino.repubblica.it/cronaca/2017/ 04/04 / news / piedmont_polemica_sui_vaccini_se_ne_va_demicheli_vicedirettore_della_sanita_regionale-162161541 / (ril. 23/9/19).