Resilient and compliant? The contemporary government of vulnerability

Keywords: vulnerability, resilience, humanitarian government, biopolitics, empowerment, managerial rationality

The treatment of poor people seen as vulnerable and dependant on the help of other citizens or of the State because of their race, class, age or gender status changed completely in the last twenty years worldwide as the Welfare-State regressed. Indeed the pattern of western democratic Nation States has been severely tested both by ethnic divides in a post-imperial world and by the widening gap between the rich and the poor due to the international crisis of financial and industrial capitalism. The central role of the State either in the task of fighting inequalities and social injustice or producing solidarity and recognition for every citizen of his/her rights both to dignity and to wellbeing or to happiness weakened. The forms and the goal of the global/local government of poor people scales and the democratic protection schemes of underprivileged classes changed completely in a four-fold manner. First new discourses are promoting rhetoric schemes of vulnerability and resilience. At the same time the leaders of the Welfare State have implemented new agencies to include the excluded people by controlling their way of life and containing them outside of the public sphere. They are promoting innovating operational instruments applying the managerial capitalistic forms of rationality. Second following these models poverty and mental illness poverty and mental illness are considered either as a personal bad fate or due to a casualty occurring to frail individuals. The linked assumption is that poor and ill people have to take a special part into their moral and social rehabilitation and to be involved in the social actions developed to empower themselves by activating their capabilities. These biopolitical agencies are now used in Europe for managing the social, racial and age issues and the mental problems too. Third these new policies have been built on a system of different protection of individuals promoting an unequal recognition of human rights in a global world where the displacements of populations have increased and are both based on and creating an emergent democratic ‘social contract'. Fourth these new form of humanitarian governmentality promoted in the Western Welfare State especially has awkward consequences on the political and psychical subjectivity of the social and political minorities. In my communication I’ll consider the effects of this new kind of biopolicies and biopolitics on the resilience and resistance of minorities to hazards and risk when there psychical security and safety is threatened on one hand. I’ll examine how the psychiatric diagnosis describes this new human condition of the vulnerables on the other hand.

Helene Thomas is doctor in sociology of the School of High Studies in Social Sciences, Full Professor of Political science at Sciences Po-Aix (university of Aix-Marseille) and psychoanalyst. Her most recent book published at the Editions du Croquant in 2010 is entitled The Vulnerable: Democracies against the Poor.

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Résilients et dociles ? Le gouvernement contemporain de la vulnérabilité.

Mots clés: vulnérabilité, résilience, gouvernement humanitaire, biopolitique, empowerment, rationalité manageuriale.

Le traitement des populations vulnérables et dépendantes en raison de leur situation sociale ou géographique, de leur sexe ou de leur âge s’est modifié avec la régression des Etats-Providence européens depuis les années 1990. Les modèles stato-nationaux européens ont été mis à l’épreuve par des clivages hérités des empires coloniaux et par l’accroissement du fossé entre les riches et les pauvres consécutif à la crise du capitalisme industriel et financier. Leur rôle dans la lutte contre les inégalités et l’injustice sociale, dans la production de la solidarité et la reconnaissance des droits à la dignité et au bien-être de tous les citoyens s’est amoindri.

Les formes contemporaines du gouvernement global et local de la pauvreté se sont transformées d’une quadruple façon. Premièrement les régimes de protection ont promu de nouveaux instruments discursifs ceux de vulnérabilité et de résilience. Les dirigeants européens du Welfare ont mis en œuvre de nouveaux dispositifs d’inclusion qui se basent sur ces schémas explicatifs et visent à contrôler les pauvres et à les contenir hors de l’espace public. Ils promeuvent dans l’action sociale des instruments inédits inspirés des techniques du capitalisme néomanagerial. Ces outils opérationnels d’appréhension des questions sociale, raciale, psychiatrique et du vieillissement se sont récemment imposés partout en Europe. Deuxièmement ces politiques à l’œuvre dans la gestion des pauvres et de la santé mentale considèrent les pauvres et les malades mentaux comme des citoyens frappés individuellement par des aléas et des malheurs que la collectivité prend en charge au nom de la raison humanitaire. Ceux-ci sont sommés de prendre part à leur réhabilitation morale et sociale et de s’investir dans les actions menées pour les y aider en activant leurs ressources. Troisièmement ces formes de gouvernementalité sont basées sur un régime de protection différenciée des individus et de reconnaissance inégale des droits humains dans un cadre global où les déplacements de populations se sont accrus. Elles concrétisent un nouveau contrat social démocratique. Quatrièmement ces formes de gouvernementalité humanitaire des publics de l’Etat social en Occident ont des conséquences négatives sur la subjectivité psychique et politique des minoritaires.

Dans ma communication j’analyse d’une part les formes et les effets de ces nouvelles biopolitiques publiques sur la résistance des minorités aux risques et aux aléas quand leur sécurité physique et leur intégrité psychique sont menacées. J’envisage d’autre part comment le discours psychiatrique et politique  caractérise cette nouvelle condition des vulnérables en démocratie.

Hélène Thomas   -   Professeur Un. Sciences Po   -   France   -     helene.thomas@sciencespo-aix.fr

  
Profile : est docteur  en sociologie de l’Ecole des Hautes études en sciences sociales, professeur de science politique à Sciences Po Aix (université Aix-Marseille 3, France) et psychanalyste. Son dernier ouvrage paru sur le sujet aux éditions du Croquant en 2010 s’intitule Les vulnérables. La démocratie contre les pauvres

Deinstitutionalization and poverty, between rhetoric, politics, rationality and reality

Keywords: deinstitutionalization, poverty, social policy, rationality

Mental patient deinstitutionalization began as a humanist movement, aiming at the respect for human dignity, to which prolonged institutionalization of the psychotic patients appeared as degrading and alienating. It was supported by the Democratic politicians and was based on rigorous scientific research that indicates reduced social skills by psychosocial under-stimulation, as well as the reactivation of psychosis through overstimulation, while lacking good social support.

The various programs applied internationally have shown that deinstitutionalization has value only in the presence of alternative structures of community support, both informal, as well as by community mental health services. This requires financial and human resource allocation.

Deinstitutionalization, in the absence of alternative solutions to ensure, is not a rational process.

Rationality entails the radiography of a society, both in terms of distribution of resources and community services that are accessible to the poor.

Rationality also implies mental health risk assessment. This is important especially for the economically disadvantaged population. It is not just about the vulnerability and resilience of people, but the characteristics of the favorable environment in which they develop and the access to medical services and assistance.

In a country with a lower level and standard of living, compared to the European average, as is Romania, events happen that should not be neglected, for example:

• In poor families, both parents go abroad to work for many years, while the children's education is neglected, a fact that is clearly felt in the child psychiatric consultations.

• The offer of education, of health, social and community mental health care is much lower in remote rural areas, compared with some urban centers. Such differences are added to the social layering.

• The directing of the central and local financial resources towards the support of the mental health of disadvantaged people has no clear plans and objectives, which is why it is ignored.

The conclusion is that the pursuit in the direction of the relationship between poverty and mental health should not only be viewed in global terms or from the point of view of the analysis of social anomic groups. It is a topic that permanently deserves to be a subject in the multifaceted debate of the community.

MIRCEA LAZARESCU    -   Timisoara   -   Romania   -   mlazarescu39@yahoo.com

Poverty and Social Justice in Romania - a reality and a dream in 2011, after 20 years of democracy!

Since 1990 Romania started a new cycle of life, dreaming to democracy, free movements, better life and dignity.

In 2004 Romania became a NATO member after 11 years of work and progress on military bases.

When Romania started the process of accession to European Union everyone start dreaming that once we will achieve this goal we can start living the real democracy and our dreams can become realities.

In 2007 Romania became a EU Member State but we still continue to dream even today on how democracy really work. How can people with disabilities have a normal and decent life if still in 2011 they have inadequate opportunities on labor market, on education or on sanitary treatments according to their illness (eg. autism, polimicrogirie right front temporal parietal etc.). We can have a look how can people have equal access to travel with public transport, to see how they can have access into the public institutions and how they are treated if they cannot be helped or assisted by their own family.

We assist now to a new way of counting the persons which need to be assisted by the Romanian state, to see if they are really or not disabled or if they are not able to work. The access to work is not thinking in this case as an applying of the principle of social justice but a consequence that they must work and not to be anymore a recipient of guaranteed minimum income.

Today we need more to have a clear voice toward society claiming our rights and to dare more in asking the authorities to respect our human dignity.

We need now to share best practices, to make alliances and to be more active in asking that social justice become true even in Romania.

Cristina Loghin   -   Bucharest  -  Romania   -   office@progenies.org

Social Determinants of Health and  Promotion of Mental Health in Old Age

Since the World Health Organization has defined health as a state of complete physical, mental, and social well-being, not merely the absence of disease and mental health as a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively, and is able to make a contribution to his or her community that the well-being dimension became central in policies and strategies of Health and Mental Health.

Mental well-being is an asset of individuals, communities and populations whose value can change throughout the life course. Someones mental health is affected by a range of determinants throughout life, such the genetic heritage, personal experiences, and the environment in which the person lives.

Social determinants of health are the conditions in which people are born, grow, live, work and age and which are shaped by the distribution of money, power and resources at global, national and local levels (4). These social determinants are associated with mental disorders by contributing to its onset or course.

Social determinants may play a role as risk factors for mental health (unemployment, poverty, inequalities, stigma and discrimination, poor housing, poor early years experience, violence, abuse, drug and alcohol abuse, poor general health, caring duties), while others may be protective factors (employment, social protection, resilience, social networks, positive community engagement, positive spiritual life, hope, optimism, good general health, good quality parenting, positive relationships in childhood).

By acting on social determinants of health, it is possible to contribute to a better subjective mental health and well-being of people, to build the capacity of communities to manage adversity, and to reduce the burden and consequences of mental health problems. Disadvantages because of mental health problems damage the social cohesion of communities and societies by decreasing interpersonal trust, social participation and civic engagement.

The goal of this presentation is to describe how the interaction between social determinants and mental health and well-being of older persons were considered on recent selected statements, policies, declarations or other public health documents with the aim to promote a better mental health.

Carlos Augusto de Mendona Lima   -   Guimares   -   Portugal   -   climasj@yahoo.com

Passerelle de l'inclusion vers l'exclusion

L'Association Solidarit 66, au service des personnes en grande exclusion, rencontre depuis juin 2008 dans les rues de Perpignan, une soixantaine de Roms de Roumanie, mendiant,  importunant  les passants et  drangeant  les Pouvoirs publics. Ils sont gnralement sans ressources et sans qualification.

En 2007 la Roumanie devient un nouveau pays membre de lUnion europenne. Face  des conditions de vie trs prcaires et  la prsence denfants en bas ge, les autorits locales acceptent au cas par cas de rgulariser leur situation administrative. Elles leur permettent ainsi daccder aux droits fondamentaux tels que le logement, les soins, la scolarisation, lemploi et la formation.

Avec leur soutien, Solidarit 66, en adquation avec ses valeurs thiques et ses principes, a labor un projet de service,  passerelle de lexclusion vers linclusion  afin de rpondre aux besoins de cette minorit europenne rom.

Elle propose les moyens de favoriser leur intgration pour quils deviennent pleinement des citoyens europens.

Beatrice HERNANDEZ   -   Perpignan   -   France   -  

The Transition from Institutional to Community-based Care Across the European Union

Many people spend long years in institutional care. Some of them have physical or intellectual disabilities, others suffer from mental health problems, and yet others are elderly and frail. There are also many children in institutions, both with disabilities and without. For decades, the existence of such institutional care was seen as proof that society cares, that it does not leave vulnerable persons without assistance and that it provides the needy with food, shelter, clothing and treatment. But is this indeed the best possible model which advanced European societies can offer to these people in the 21st century? I am convinced that in an age when non-material aspects such as human dignity, autonomy and inclusion in the community are increasingly recognised as being of paramount importance, European societies should aim for more humane, person-centred, individualised models of care. The users themselves and, where applicable, also their families should become partners and take part in all decision-making. Everyone should be enabled to reach their full potential.  ( Vladimír Špidla – ex Commissioner for Employment, Social Affairs and Equal Opportunities)

Summary

Many people of all ages and different conditions (elderly, children, persons with disabilities – including persons with mental health problems) live in residential institutions which tend to segregate them from the community.
These institutions are not defined primarily by their size but above all by features of “institutional culture” : depersonalisation, rigidity of routine, block treatment, social distance, paternalism…
In general, the process of desinstitutionalisation must respect users' rights, and users have to be involved in all decision-making processes. There has to be a holistic system of prevention of placement into institutions. Community-based services must be created in parallel with the closure of the institutions.

The process requires sufficient and well-trained staff with skills appropriate for community-based care as well as adequate support to families.

Typical characteristics of "institutional culture" have been described and analysed by pioneering researchers some four decades ago. It has long been argued that institutional care segregates users and tends to be characterised by depersonalisation (removal of personal possessions, signs and symbols of individuality and humanity), rigidity of routine (fixed timetables for waking, eating and activity irrespective of personal preferences or needs), block treatment (processing people in groups without privacy or individuality) and social distance (symbolising the different status of staff and residents). 

Key challenges in transition from institutional to community-based care and suggestions on how to address them

1. Over-investment in current institutional arrangements
2. Risk of maintaining parallel services
3. Too "institutional" alternatives

4. Closure without adequate alternatives

Common Basic Principles for transition from institutional to community-based care

1. Respecting users' rights and involving them, and their families, in decision-making
2. Prevention of institutionalisation
3. Creation of community-based services
4. Closure of institutions: This process should, if possible, start from pilot projects.
5. Restriction on investment in existing institutions
6. Development of human resources
7. Efficient use of resources
8. Control of quality
9. Holistic approach
10. Continuous awareness-raising

Comment of Ian PFEIFFER , chairman of High Level  Expert Group preparing 
Report of the Transition from Institutional to Community-based Care

The need for community mental health services
(where we stand in the reform of the mental health system)

In a period when political forces (including the Romanian government) declare that the welfare state has to come to an end, it is important that professionals in the area of social protection and mental health raise again basic questions about the chances and the rights of people with mental health issues to have access to adequate services. The paper will look to some of the Romanian social policy measures adopted in the area of mental health that have marked the EU integration process, and point to their effects on the quality of life of people with mental health problems. It will discuss the Romanian regulations on assisted living, and its positive effects in deinstitutionalization. It will also raise issues related to the lack of community mental health services and its negative consequences on the outcomes of deinstitutionalization and the quality of life of beneficiaries.  Outreach by community mental health services to people with mental health problems will be presented as a necessary multi-professional comprehensive action, which can provide shelter, monitored medication, rehabilitation activities, legal representation, psychological and social support for people with mental health problems. We shall argue that investment in community mental health services is a necessary condition to the rehabilitation   of mental health patients, a necessary step in the improvement of both psychiatry services and social services for social cases.

Maria Roth   -   Cluj-Napoca   -   Romania   -   roth.mari@ymail.com

Présentation réforme SSM 2010 en Belgique

Historique   -  En région de Bruxelles-Capitale

-           Années 60 : recours privilégiés aux soins en ambulatoire et création de centres conventionnées INAMI

-           Années 90 : fermeture d’un nombre conséquent de lits psychiatriques (lits T) sans création équivalente de places résidentielles (IHP & MSP)

La région bruxelloise se différencie des autres régions par une offre psychiatrique moindre, des soins à domicile moindre, une médecine hospitalière générale avec beaucoup d’actes techniques (voir la présence de 3 hôpitaux universitaires), un nombre important de centres conventionnés INAMI et une offre ambulatoire et associative importante, variée et pointue.
 

-         2007 : lancement des projets thérapeutiques (fin en avril 2011)

Les projets thérapeutiques ont permis (toutes les nuances sont de mises):

• de jeter des ponts entre les secteurs hospitaliers, ambulatoires et intermédiaires.

• de formaliser le travail en réseau.

• d’identifier une multitude de modèles de coordination

• d’associer des institutions non directement dispensatrices de soins dans les processus de concertation

• d’associer le patient aux décisions concernant son plan de soin

Les projets thérapeutiques c’est aussi :

• des modalités de fonctionnement rigide imposé par l’INAMI

• une temporalité inexistante pour démarrer les projets dans de bonnes conditions

• une inadéquation entre le temps clinique et le temps organisationnel

• l’absence de la première ligne (médecins généralistes)

• un monitoring quantitatif du patient totalement inadapté

• une mise à mal de la protection de la vie privée

• une communication défaillante entre les instances décisionnelles et la base

Une bonne partie de la réforme proposée s’inspire du modèle de Birmingham qui privilégie les équipes mobiles d’intervention dans l’organisation des soins. Les anglais ont fait le pari qu’il était possible de soigner les gens dans leur milieu de vie plutôt qu’à l’hôpital.

• Investissement financier énorme

• Equipes mobiles constitués de staff conséquent dont plusieurs membres travaillent conjointement soit à l’hôpital, soit dans un « community mental health team » (sorte de SSM)

• C’est la mixité des équipes qui permet une bonne coordination entre les différentes équipes ainsi que la continuité des soins

• Intervention des équipes dans l’heure (24h/24h) et dans n’importe quel lieu de la ville.

• Les liens avec la 1^ère ligne sont encore insuffisants malgré la création d’une porte d’entrée (pas la seule possible) dans le système que sont les « primary care »

• Le secteur résidentiel est géré soit par des grosses organisations sociales (250 personnes), soit par des charity (associations de patients et de proches) en lien avec les pouvoirs locaux.

 Points d’attention (pas exhaustif)

Ø  C’est l’hospitalier qui a la main vu que c’est sur base des moyens humains et financiers liés à leurs lits psychiatriques (art.107) que les fonctions 2,3 et 4 seront réalisées. La promotion des projets passe par eux.

Ø  Le choix des partenaires ambulatoires semble également être l’apanage du secteur hospitalier. Cela, ils sont « obligés » de collaborer avec des structures ambulatoires s’ils veulent obtenir une chance de voir leur projet retenu.

Ø  Les SSM semblent être invités à s’inscrire dans la fonction 1. Personnellement, je pense qu’il est indispensable que la culture ambulatoire infiltre également les fonctions 2 et 3 afin que l’expertise, le travail de proximité et l’ensemble des outils et méthodes « faisant soin » développés depuis de nombreuses années par le secteur ambulatoire soient pris en compte  au niveau des contenus de ces différentes fonctions.

Ø  C’est la mixité des équipes qui vont permettre de créer du lien entre les différents dispensateurs de soins et ainsi permettre la continuité des soins
 

Youri Caels   -   Coordinateur  Plate-forme concertation santé mentale en Région de Bruxelles-Capitale
 

Deinstitutionalisation as a resource and a therapeutic practice

As is well known, after Philippe Pinel, the man who cast off the shackles of the insane, the French law of 1838 was officially sanctioning the asylum model.

The director of the mental hospital was a sort of Louis XIV within the Institution. Just in the same way as the Berlin wall represents an extraordinary metaphor of the uselessness of containing subjective personalities within one wall. When in the year 1961 the first director of a psychiatric Asylum [1] simply refused to sign the restraint register, an epoch of dialectic, rather than tyranny, began towards mental patients.

Transcultural psychiatry can explain to us today that what we once believed to be unreason is actually just a “different” form of Reason.

International experiences demonstrate the fact that it is possible to substitute ever larger sectors of a traditional service aimed at providing care and reparation for the damage done, with prevention-centred services.

The truth is that rehabilitation is directly connected to deinstitutionalisation. Rehabilitation is closely linked to emancipation. In this process, the organisation of resources for work becomes central.

In the end, to cure is to change. Thus, this concept of emancipation goes beyond the closure of lunatic asylums and extends further.

During the “great deinstitutionalisation” of the 70s everyone, both users and professionals, played their part in freeing themselves from the burdens and fetters of Total Psychiatric Institutions. Today residential facilities, as part of an organised network of services, are a cornerstone of deinstitutionalisation and rehabilitation.

In the 80s there was a widespread debate throughout Europe concerning deinstitutionalisation. In those places where the historical budget which used to belong to the Total Institution was not dismantled and dispersed, but reconverted into new reformed community services, it was largely possible to preserve resources. Deinstitutionalisation costs less than asylums. It is neither necessary nor advisable to allow budgets to fall drastically, which would greatly reduce action in the spheres of rehabilitation, therapy, social healthcare. Reconverting resources, i.e. staff, implies changing attitudes within the service. Only if reconversion is TOTAL will it be possible to leave authoritative, control-based psychiatry behind and make way for a different future. As long as one single person is still tied up or isolated, this kind of response will continue to be considered ultimately indispensable. This can create an ideological-practical-ideological short circuit which reinforces and feeds itself.

Human resources are by far the most important, as staff is capable and experienced in relating to such special clients as psychiatric service users are. Traditional psychiatric staff should be reconverted and become carers who work in people’s homes. Their previous role which aimed at control must be largely forgotten, and instead a new practice based essentially on the idea of service must be developed.

by Lorenzo Toresini

Beyond the principle of love and hate”, „Dincolo de principiul iubire-ură.”

The title of this paper represents a metaphor for what we have considered to be the relational quintessence of these teenagers acting-outs, abuse, suicide attempts, rapes, quick and brutal transitions from idealization to devaluation.

Keywords: institutions, communication, teenagers, dependency, autonomy

Authors: Simona Trifu MD, psychiatrist, Hospital Al Obregia

Elena Dicu psychologist, Complex for Communitarian Services Găieşti

Promoting empowerment and belonging through education: a pioneer project with people with psychiatric disorders in Portugal

This communication  presents the main results of a pioneer project in the field of educational inclusion, developed with (not for) people with psychiatric disorders, admitted to the unimputable ward of a Public Hospital. This project aimed at enhancing academic qualifications of a group of individuals with psychiatric disorders by offering them the possibility to engage in the process of recognition, validation and certification of competences (RVCC) achieving basic compulsory education (9 years). This process enabled them to identify knowledge and competencies acquired previously in their professional and social trajectory.

Besides the description of this project (concerning its goals, methodologies, activities) we present the outcomes of the evaluation developed. Documents and materials produced by the participants during the process were taken in consideration. We also developed two Focus Groups [groups of adults (n=10) and professionals (n=8)] during which the following themes were explored: importance of including people with psychiatric disorder in the RVCC process, gains from RVCC to the rehabilitation program, introduced adjustments (e.g., methodologies), individuals and technicians perspectives about the main gains of the process (e.g., for autonomy, welfare) and perceived difficulties and strategies for their resolution.

               Results indicate that both technicians and patients perceive(d) this educational process as extremely significant in promoting the well-being and renewed perception of (social) belonging of the participants. They were able to improve different dimensions of their performance, train autonomy skills and experience opportunities for social participation.

               Looking critically at these results, accordingly to the Human Rights framework, it becomes evident that governments and institutions must join efforts on planning and developing quality educational policies and practices effectively having in consideration the specific needs of people with psychiatric disorders. To accomplish this challenge is essential to involve and listen to their perspectives when creating positive environments that contribute to their empowerment and social belonging.

Dora Redruello   -   Cerebral Palsy Association of Coimbra   -   Snia Mairos Nogueira

Faculty of Psychology and Educational Sciences, University of Coimbra     dora.redruello@apc-coimbra.org.pt

Community Based Rehabilitation and Clubhouses as Good Practice

The CBR principles and best practices of Clubhouses are the topics of the presentation.

Key words: CBR, Clubhouse model, psychosocial rehabilitation, empowerment, social inclusion.

According to growing evidence the community-based rehabilitation opportunities for people with psychosocial problems or mental disorders are underdeveloped in majority of European countries. This is a very real challenge in many EU member states, as well as, in the rest of WHO European region outside the EU.

Community-based rehabilitation (CBR) methodology is built on the multi-science, multi-professional and multi-sectorial approach. CBR covers the whole person with psychosocial problems or other disability and all aspects of everyday life in the process of recovery, empowerment and social inclusion. In these respects the prevailing medical approaches are not efficient enough or cost-effective and the involvement of service-users in their care is unsatisfactory. For successful recovery and social inclusion all areas of personal development are important. This wider approach has been jointly formulated and recommended by the WHO, ILO and UNESCO since 1980s (WHO 1994, 2004 and 2010). However, the good quality CBR-based psychosocial rehabilitation like Clubhouse model is taken into use only in minority of European countries.

World Health Organization (WHO 2003 and 2007) has also published recommendations how to organise optimal mix of mental health services (e.g. pyramid model) which is based on human rights and equal opportunities of people with mental disorders. Community-based psychosocial rehabilitation is the cornerstone of the optimal mix of services. The Clubhouse model is mentioned as a useful model in this context. 

In Europe we need effective implementation of the CBR recommendations and dissemination of the evidence-based Clubhouse model. Today Europe is divided into three: (1) Best practice countries like Finland, Sweden, Denmark, Norway and Scotland where the clubhouse model is integrated part of national mental health policy, (2) 13 other countries where one or two Clubhouses are available but the model is not promoted actively, and (3) about 30 countries where Clubhouses and other CBR services are not yet available. The transfer of CBR knowledge from the best practice countries to the less developed countries is needed urgently.

Esko Hanninen   -   Helsinki   -   Finland   -   hanninen.esko@gmail.com
 

“The psychiatric nurse in multidisciplinary mobile team”

In the last 17 years, in Romania is opened “The Trainig Center Fracaritatis Bucharest” as a part of “Psychiatric Clinic Hospital “Prof.dr.Al.Obregia”, with the supervision of “Brothers of Charity” Organisation from Belgium, having as president Br.Dr.René Stockman.

We are a team of teachers leaded by Conf.dr.Oancea Constantin, including psychiatrist, psychologist and seven nurses with a big professional experience, with scoolarship abroad. We prepare nurses for specialization in psychiatry in one academic year programme (1500 hours), recognized officially by The Ministry of Health.

We have the role of teachers for the nurses who work in psychiatric hospitals or in community (over 450 for now). We offer knowledge and abilities for nuses, in order to work with patients and families, for difficult cases. It’s necessary to have a new perspective and attitude toward them, to view them in a holistic way.

The tendency for desinstitutionalisation and care in the community, created the necessity of development of (MHCC) Mental Health Community Centers and the mobile teams to work in crisis situations, where the person live, in her own environment.

The “mobile team” concept is new in Romania and could have: psychiatrist, psychologist, social workers and psychiatric nurses at least.

The place of specialized psychiatric nurse is important in mobile team, because there are seen the human qualities of nurses: kindness, patience, understanding, tolerance,so they can make a good contact with human in great suffering, extreme poverty, mentally ill persons, humiliated and neglected by the society.

Also, the psychiatric nurse can stay much more time with the patient and families in need and they can made psychoeducation.

We need such persons with a “big and worm heart” who have the consciousness and to do the effort to change “just a little bit” the life of other human being with an unhappy destiny. Each of us can do one thing in order to give them the human dignity.

 Hrestic Stefania Mihaela

 Coordinator of “The Trainig Center Fracaritatis Bucharest”

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“Asistenta medicală de psihiatrie în echipa multidisciplinară mobilă”

Rezumat

În ultimii 17 ani, în Romania funcţionează “Centrul de Formare Fracaritatis Bucuresti” , în cadrul Spitalului Clinic de Psihiatrie “Prof.dr.Al.Obregia” sub egida organizaţiei belgiene “Fraţii Carităţii”, reprezentată de Br.Dr.René Stockman.

Un colectiv de lectori  în frunte cu Conf.dr.Oancea Constantin, psihiatru, psiholog şi sapte asistente cu mare experienţă şi cu studii în străinătate, pregătesc asistenţi medicali pentru specializare în psihiatrie, într-un program de un an academic (1500 ore), acreditat de Ministerul Sănătăţii.

Noi avem rolul de formatori pentru asistente care lucrează în spitale de psihiatrie sau în comunitate (peste 450 până acum). Noi oferim cunoştinţe şi abilităm asistentele pentru a lucra cu pacienţii şi familiile lor pentru cazuri complexe întâlnite pe teren, pentru a-şi schimba atitudinea şi a privi din perspectivă holistică.

Tendinţa la dezinstituţionlizare şi îngrijiri în comunitate, a creat necesitatea dezvoltării CSMC (Centre de Sănătate Mintală Comunitară) şi formarea de echipe mobile de intervenţie în situaţii de criză, acolo unde se află persoana, în mediul ei obişnuit.

Conceptul de “echipă mobilă” este o noutate în Romania şi ar trebui să cuprindă minim un medic psihiatru, psiholog, asistenţi sociali, asistenţi medicali specializaţi în psihiatrie.

Locul asistentului specializat este important în echipa mobilă pentru că se apelează la calităţile umane ale acestor persoane: blândeţe, răbdare, înţelegere, toleranţă, aşa încât să poată face un bun contact uman cu cei în suferinţă, extrem de săraci, umiliţi de societate, marginalizaţi. De asemenea, asistentul poate petrece mai mult timp cu pacientul si familia în situaţii dificile şi se poate implica în educaţia pentru sănătate mintală.

Avem nevoie de persoane cu “inima mare şi caldă”, care să apeleze la conştiinţa lor, în efortul de a schimba “cât de cât” viaţa unor semeni care nu au avut o soartă fericită. Fiecare din noi poate face ceva care să le redea demnitatea umană.

 Hrestic Stefania Mihaela

 Coordonator “Centrul de Formare Fracaritatis Bucureşti”

"La desinstitutionnalisation en France : l'exemple de Lille-Est"

Le basculement du "tout hospitalier"à la psychiatrie dans la cité avec le développement de

• de l'hospitalisation à domicile ,

• des "appartements thérapeutiques" et

• du travail en liaison avec

  • les services sociaux ,

  • les municipalités et

  • les associations d'usager

- création d'un conseil local de Santé Mentale
- limites (et les eventuels "effets pervers")

Jacques Debieve  -  Lille - France

Outside-In, Inside-Out: A Copernican moment and the Birmingham Model

Outreach services offer two possibilities: Taking people out of the institution and bringing people in to care in the community. For those people already inside the system, whom the hospital doesn’t help or creates more problems than it solves, it is a process of Inside-Out; taking the person out of the Institution, and the Institution out of the person, and relates to the first part of the ‘Tripod of Inclusion’.

And for those outside the system and ill, but for whom the step into services creates more trauma, for whom hospital makes no sense, but at the same time we and society cannot stand by: A process of making Outside-In; not bringing people into the Institution but into society, and relates to the third part of the ‘Tripod of Inclusion’.   

20 years ago in Birmingham England a radical process of change created a system of community based outreach services that offered the same necessary functions of the hospital but instead provided them in people’s homes, working alongside anyone who cared to be involved in their neighbourhoods. It was a Copernican shift from patients revolving around the service in our institutions, to a service that revolved around the patients in their communities. Outreach is a way of organising resources, a means that can be adapted to a chosen end, whether that be reaching the homeless, the refugee, meeting people where they are and not where we are. For sure it also changes the way we think and practice, as we people in a new context and presenting more than just pathology.  The Birmingham Model is one example of how outreach can meet the challenges of moving from exclusion to inclusion.

Professor Mervyn Morris, Birmingham City University, England

Mervyn Morris has held Professorial posts in the UK and Norway, and is currently Director of Community Mental Health in the Centre for Health and Social Care Research at Birmingham City University. He has an academic background in education and social policy, with a focus on workforce development to deinstitutionalise care and develop community based services.  His international work includes service re-design through Government and EU funded projects, and also for the World Health Organisation in the Balkans and Asia.

Mervyn has extensive experience of working in hospital and community mental health services, with a clinical interest in psychosis and in particular voice-hearing, developing service user perspectives of research and recovery. Mervyn has also been a Chief Executive of a mental health NGO and is currently Chairman of Soteria Network.

Outside-In, Inside-Out: A Copernican moment and the Birmingham Model

Outreach services offer two possibilities: Taking people out and bringing people in to care. For those people who are inside the system, whom the hospital doesn’t help or creates more problems than it solves: A process of making Inside-Out; taking the person out of the Institution, and the Institution out of the person, and relates to the first part of the ‘Tripod of Inclusion’.

And for those outside the system and ill, but for whom the step into services create more trauma, for whom hospital makes no sense, but at the same time we and society cannot stand by: A process of making Outside-In; not bringing people into the Institution but into society, and relates to the third part of the ‘Tripod of Inclusion’.  

20 years ago in Birmingham England a radical process of change created a system of community based outreach services that offered the same necessary functions of the hospital but instead provided them in people’s homes, working alongside anyone who cared to be involved in their neighbourhoods. It was a Copernican shift from patients revolving around The service in our institutions, to a service that revolved around the patients in their communities. Outreach is a way of organised resources, a means that can be adapted to a chosen end, whether that be reaching the homeless, the refugee, meeting people where they are not where we are. For sure it also changes the way we think and practice, as we people in a new context and presenting more than just pathology.  The Birmingham Model is one example of how outreach can meet the challenges of moving from exclusion to inclusion.

Professor Mervyn Morris, Birmingham City University, England

Le  « Samusocial » à Bruxelles entre urgence sociale  et  aller vers ...

Après une rapide présentation de notre dispositif « Samusocial », notre intervention se portera sur deux axes : - la notion d’urgence sociale  et l’Outreach, avec pour illustration, la projection d’un film (3 min max).

Dans notre introduction, nous commencerons par une brève présentation du Samusocial de Bruxelles ; dans quel cadre il intervient, à quelle demande il répond, ses missions, son public cible,  son offre de services (social, psychologique, médical, hébergement, de son travail de nuit via les maraudes, etc).

Nous aborderons ensuite la notion d’urgence sociale. Urgence et précarité ; le paradoxe où l’un se doit de résoudre dans un temps bref une situation de crise et l’autre ne pouvant apporter de réponses qu’au terme d’une approche globaleà moyen voire à long terme. La fonction première de ce dispositif d’urgence sera de repérer et de prendre en charge dès l’accueil de la personne sa détresse sociale et/ou psychique. La qualité de la première accroche s’avérant dès lors fondamentale pour poursuivre et amorcer une prise en charge de qualité, au cas par cas, et pluridisciplinaire.

Plus spécifiquement, l’approche dominante de l’intervention psychosociale urgente au Samusocial se voit centrée sur la personne avec comme objectif in fine l’amélioration de la qualité de vie de la personne et de son sentiment de bien être physique et psychique. Comment articuler et mettre en lien un travail dans l’ « ici et maintenant », apportant une réponse rapide aux besoins de base et dans un même temps garder en vue  la possibilité de réinscrire l’individu désinséré dans une temporalité plus large.  Quelles sont par ailleurs les limites de notre intervention et les obstacles rencontrés ; Comment ne pas maintenir le symptôme et ne pas reproduire les scénarios d’échec.  Soulignons l’importance du maintien du lien avec le réseau existant autour de la personne (famille, amis, service social, médecin référent, etc ) et de la nécessaire collaboration entre ses services.

- Projection d’un film (3 min)–

L’ « Outreach » ou l’ « aller vers »... Et quand l’individu a coupé les ponts avec la société, qu’elle n’exprime plus de demande et ne nourrit plus d’attentes. Comment l’approcher et reprendre le lien ?Présentation de notre approche au Samu, du travail de terrain effectué par notre « Maraude ». Quand l’institution sort de son cadre et rencontre la rue...

- Débat -

BOURGUIGNON Laurence
 

Infirmiers de rue  :  Proposition de présentation pour le colloque du SMES

Quels sont les besoins auxquels nous essayons de répondre ? 

• des patients : il faut encourager les patients à prendre soin de leur hygiène et de leur santé (motivation), les informer des services disponibles, des horaires, etc.(information), et si besoin les accompagner dans les services (accompagnement), parfois reprendre contact avec les personnes qui n’ont plus de contact (relation). 

• des professionnels (professionnels de la santé, travailleurs sociaux, personnel de sécurité ou de nettoyage): il faut les remotiver à entrer en relation avec les personnes précarisées (remotiver) et leur expliquer comment le faire (expliquer) et comment adapter leur pratique professionnelle à ce public particulier (adapter).

• des infrastructures/information : il faut faire un inventaire de ce qui existe, en termes de santé et d’hygiène, et mettre cette information à disposition de tous ceux qui en ont besoin (diffuser l’état des lieux); autour de cet inventaire et des besoins constatés, proposer des actions qui peuvent améliorer la situation (proposer des actions).

Comment y répondons-nous ? 

• nous allons à la rencontre des gens dans la rue, pour les encourager, les informer, les accompagner, parfois aussi pour les soigner, s’il n’y a pas d’autre solution

• nous organisons des formations pour tous les professionnels avec lesquels nous travaillons, nous les sollicitons activement, quotidiennement, pour la prise en charge de nos patients.

• nous imprimons des plans et des listes des infrastructures ou des services existants, et nous les diffusons. Nous proposons des améliorations aux services concernés.

 Comment nous inscrivons-nous dans les trois thèmes ?

• aller-vers : nous allons dans le milieu de vie du patient

• dés-institutionnalisation : nous essayons toujours d’aller vers une remise à domicile, avec des services d’accompagnement autour, et un suivi régulier et proactif.

• autonomisation : nous allons au rythme de la personne tout en la sollicitant beaucoup (dialogue actif), nous encourageons beaucoup et nous accompagnons, nous accordons de l’importance aux ressources de la personne.

En fil rouge dans tout cela : COMMUNICATION et COORDINATION avec les autres acteurs, ce qui semble manquer encore à Bucarest, alors que des actions existent.

Infirmiers de rue   -   Bruxelles    -   Belgique   -   

Quelle réduction des risques auprès des usagers de drogues en rue?

mots-cls : drogues en rue; rôle de l'approche de réduction des risques; contact avec les jeunes consommateurs

Quand la "drogue" croise la question de la pauvret, les intervenants sont instinctivement amènes  penser l'arrêt des drogues ou les drogues comme "cause première".

il est souvent envisageable d'accepter le rythme de la personne en rue, mais lorsqu'il s'agit de dépendance , tous s'accordent pour tenter de contraindre ou stopper la consommation.

Or la place de la consommation s'insère dans une dynamique extrêmement complexe.

c'est pourquoi une approche de la réduction prend une place importante auprès des usagers en grande précarité.

Par ailleurs, il faut sensibiliser l'ensemble des intervenant  la question des "toxicomanies", non plus entendue comme maladie mais bien comme symptôme. ce symptôme est  la fois social et intime, au point d'être un style de vie, une nouvelle norme de la marginalité . 

RAEDEMAEKER   -   DUNE ASBL   -   BRUXELLES   -   BELGIQUE   -   direction@dune-asbl.be

'Legal assistance for children in conflict with the law'
The complex situation of juvenile offenders affected by mental health issues: A European analysis.

The International Juvenile Justice Observatory (IJJO) aims to contribute widely to the promotion and dissemination of information on juvenile justice issues from an inter-disciplinary and international point of view, through research work, trainings, organization of seminars and conferences and diffusion of minimum standards.

The IJJO, in its field of expertise, deals with the treatment of young people in vulnerable situations due to mental disorders or drug abuse who found themselves in the juvenile justice system. In this context, the European Commission has supported the IJJO’s project European Comparative Analysis and Transfer of Knowledge on Mental Health Resources for Young Offenders (MHYO) as part of the Daphne Program. The latter aims to prevent and combat all forms of violence against vulnerable groups and to help them to reach a high level of physical and mental health protection, well-being and social cohesion within the EU.

The IJJO’s project purposes to develop the sharing of knowledge and expertise in the field of young offenders with mental health issues. Minors find themselves in a paradoxical situation: they are at the same time offenders and victims of their own mental disorder. Juvenile offenders are placed in two different systems: the judicial and the health system. The IJJO aims to bring about innovating mechanism for implementing a change and convergence relating to these issues.

The project’s strategy is based on a comparative research. The analysis is focused on national health and judicial systems for young offenders suffering of mental health disorders. The IJJO in this project has identified treatment strategies which constitute the basis for producing and developing practical tools and adequate policy.

Cédric Foussard - Agustina Ramos   -    IJJO   -   aramos@oijj.org    www.oijj.org

Active inclusion for young people with disabilities or health problems

Employment is an integral part of effective participation and  innovative ways are needed for inclusion of this disadvantaged group. The Eurofound study is (i)investigating the main reasons for the increase in the take up of incapacity benefits among young people and(ii)is providing examples of good practice and effective activation measures involving different sectors - health, employment, social protection, education etc. Research has already taken place in 6 Member States with a further 5 MS participating in the 2011 study.

The Eurofound preliminary research shows that there are a number of EU countries with a significant increase of young people with disabilities receiving incapacity/unemployment/social assistance  benefits. The reason for the increase up has been predominantly various mental health problems. The country where there have been the most dramatic changes is the Netherlands. Currently one in 20 of 18 year olds is enrolled in the WAJONG scheme (a specially designed scheme for young people). Inflow into this scheme has tripled compared to ten years ago. There seems to be a similar trend in other European countries, but not only (US and Australia also face similar challenge).

Our research aims to examine active inclusion measures and developments for employment of young people with long-standing health problems or disabilities.

Anna Ludwinek, Eurofound (European foundation for the Improvement of Living and Working Conditions)
                             Dublin  -  Ireland   -   alu@eurofound.europa.eu

An experimental project in a residential therapeutic community for adolescents with mental disorders. The experiense of La casa di Francesco e Chiara, Vinci (Tuscany).

Key words - Children, adolescents, therapeutic community, rehabilitation, mental health disorders.

This work presents the results of an experimental project for the rehabilitation of adolescents with mental disorders in a residential therapeutic community (RTC).

The RTC accomodates nine teenagers from 12 to 18 years old, male and female.

The guests of the structure benefit of an individual therapeutic program, constantly reassessed during their staying.

The equipe is multidisciplinary and it adopts a model of integrated intervention which focus on psycotherapeutical and social educational aspects, through a clinic approch that pay attention to cognitive hermeneutic and affective relational elements.

The poject is an answer to a need emerged from the epidemiologists data that show a considerable increase in the number of children and adolescents with mental and behavioral problems.

Italian health planning has been particularly weak in this area, effectively delegating the function of care to social welfare institutions which do not always allow adequate assessment of the real care needs.

The paper illustrates the different phases of the rehabilitation treatment from the entry to the resignations, the management of the rules in community, the different activities (clinical and eductional), the job with the families, the complex relationships with the different local institutions.

The data so far collected show a clear reversion of symptoms and an evident increase of the social competences in the adolescents who followed or who are following a specific program in the community.

Pietro  Tatti,  G. DArcangelo, M. Francardi, S. Manucci   -   Vinci (Florence)   -   Italy   -   pietro.tatti@libero.it