The blind spots of psychiatric reform in Greece.

Q3 Medicine
Psychiatrike = Psychiatriki Pub Date : 2024-06-19 Epub Date: 2024-05-29 DOI:10.22365/jpsych.2024.009
Stelios Stylianidis
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(d) Ensuring necessary resources over time, so that resources from the transition of the asylum model to a model of sectorial community mental health services \"follow\" the patient. (e) Strengthening the participation of service recipients and their families in decision-making processes and evaluation of care quality. (f) Practices based on ethical principles (value-based practice) and not only on the always necessary documentation (evidence-based practice).1- 4 Convergent evidence from the \"ex post\" evaluation of the implementation of the national plan Psychargos 2000-20095 and from the recent rapid assessment of the psychiatric reform by the Ministry of Health and the WHO Athens office (SWOT analysis)6 indicates \"serious fragmentation of services, an uncoordinated system that often results in inappropriate service provision, a lack of epidemiological studies and studies concerning the local needs of specific populations, uneven development of services between different regions of the country, a large number of specialized professionals with significant deficits in community psychiatry expertise, a lack of personnel in supportive roles, significant gaps in specialized services (for individuals with autism spectrum disorders, intellectual disabilities, eating disorders, old and new addictions, and community forensic psychiatry services)\". We would also like to highlight lack of coordination and collaboration among different mental health service systems (public primary and secondary service providers, NGOs, municipal services, mental health services of the armed forces, private sector), complete absence of systematic evaluation and monitoring (lack of quality of care indicators, clinical outcomes, epidemiological profile of each service), lack of quality assurance mechanisms and clinical management systems, insufficient number of beds mainly for acute cases, unclear protocols for discharge issuance and ensuring continuity of care, deficient budget for Mental Health in relation to the overall healthcare expenditure (currently 3.3%), and finally, one of the highest rates of involuntary hospitalizations in Europe, which is linked to serious issues concerning the protection of the rights of service users. After the pandemic and the emergence of the silent but expected mental health pandemic, WHO, EU, and the Greek Ministry of Health emphasized the need to adopt a public mental health agenda with an emphasis on community psychiatry in order to address both the old structural dysfunctions and inadequacies of psychiatric reform (regulation 815/1984, Leros I-Leros II plan, Psychargos A & B, incomplete implementation of laws 2071/1992 & 2716/1999, incomplete deinstitutionalization of the remaining psychiatric hospitals). However, it is time to reflect that it is not possible to talk today about the need to update and implement a new national plan to upgrade mental health in the country without answering basic questions, both old and new, about the wider context of its implementation. The transformation of the deficient psychiatric care in the country cannot be completed without the urgent restructuring of the National Health System7 and the reform of the Greek welfare state itself, which is also characterized by irrationality, inequalities, bureaucratic inefficiency, and fragmentation.8 As we should have learned from the bankruptcy and the prolonged economic, social, and cultural crisis in our country, reforms usually pay off in the long term, while the time horizon of the applied policies is narrow and usually reaching the next election. The fact is that in any reform effort, including psychiatry, the political system does not demonstrate the ability to promote transparency, evaluation, stable rules of regulation, reference to a universally applicable legal and institutional framework, the limitation of clientelism and guild resistances. From this point of view, it is necessary to give meaning in the context of Greek psychiatric reform to the professional burnout of the National Health System workers, the lack of motivation and vision, the intrusion into the NGO space by new entities without any connection to the culture of psychiatry reform, the guild resistances of all relevant specialties, the selective use of psychotherapeutic techniques, as trends of discrediting the relief of social and psychological suffering in the field of public mental health. There is an urgent need to understand new pathologies (narcissistic disorders, new forms of addiction, eating disorders, \"pathology of emptiness\", adolescent delinquency and suicide, psychosomatic manifestations due to high stress, pathology of fluid social ties, deficient socialization of young people \"outside of their algorithms\") through a solid and coherent analysis of the toxic postmodernity culture. In addition to the social determinants of mental health,9 it is necessary in clinical work to also assess the psychological factors, such as uncertainty, conflict, loss of control, and incomplete information, that burden human health.10 In order to reduce the gap between declarations and real life, there is an urgent need to overcome the blind spots of psychiatric reform in the country by establishing internal and external evaluation processes, training young professionals in holistic care and community networking and communication skills, retraining leaders for organizational change, and strengthening the participation of service users in the context of deepening democracy in mental health. As mental health professionals, the object of our work in the community should be the reconstruction of meaning and the fragile or non-existent social bond in subjects who have been cut off from any possible production of meaning and participation in their history. Why should our therapeutic responses be stereotypically repetitive in the face of these complex, radical changes in the meta-context and the new demands of our patients? After all, as the philosopher Ernst Bloch puts it, utopia is \"that which does not exist yet.\".</p>","PeriodicalId":20741,"journal":{"name":"Psychiatrike = Psychiatriki","volume":null,"pages":null},"PeriodicalIF":0.0000,"publicationDate":"2024-06-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Psychiatrike = Psychiatriki","FirstCategoryId":"1085","ListUrlMain":"https://doi.org/10.22365/jpsych.2024.009","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"2024/5/29 0:00:00","PubModel":"Epub","JCR":"Q3","JCRName":"Medicine","Score":null,"Total":0}
引用次数: 0

Abstract

According to international experience, the conditions for the successful outcome of a psychiatric reform are the following: (a) Existence of political will (supporting a national plan with assessment, monitoring, and corrective intervention procedures for structural dysfunctions, etc.). (b) Strong mental health leadership (executive expertise and skills that advance the public health agenda). (c) Challenging the dominance of the biomedical model in therapeutic practice through the promotion of holistic care practices, evidence-based innovative actions, collaborative care, the promotion of recovery culture, and the and the use of innovative digital tools. (d) Ensuring necessary resources over time, so that resources from the transition of the asylum model to a model of sectorial community mental health services "follow" the patient. (e) Strengthening the participation of service recipients and their families in decision-making processes and evaluation of care quality. (f) Practices based on ethical principles (value-based practice) and not only on the always necessary documentation (evidence-based practice).1- 4 Convergent evidence from the "ex post" evaluation of the implementation of the national plan Psychargos 2000-20095 and from the recent rapid assessment of the psychiatric reform by the Ministry of Health and the WHO Athens office (SWOT analysis)6 indicates "serious fragmentation of services, an uncoordinated system that often results in inappropriate service provision, a lack of epidemiological studies and studies concerning the local needs of specific populations, uneven development of services between different regions of the country, a large number of specialized professionals with significant deficits in community psychiatry expertise, a lack of personnel in supportive roles, significant gaps in specialized services (for individuals with autism spectrum disorders, intellectual disabilities, eating disorders, old and new addictions, and community forensic psychiatry services)". We would also like to highlight lack of coordination and collaboration among different mental health service systems (public primary and secondary service providers, NGOs, municipal services, mental health services of the armed forces, private sector), complete absence of systematic evaluation and monitoring (lack of quality of care indicators, clinical outcomes, epidemiological profile of each service), lack of quality assurance mechanisms and clinical management systems, insufficient number of beds mainly for acute cases, unclear protocols for discharge issuance and ensuring continuity of care, deficient budget for Mental Health in relation to the overall healthcare expenditure (currently 3.3%), and finally, one of the highest rates of involuntary hospitalizations in Europe, which is linked to serious issues concerning the protection of the rights of service users. After the pandemic and the emergence of the silent but expected mental health pandemic, WHO, EU, and the Greek Ministry of Health emphasized the need to adopt a public mental health agenda with an emphasis on community psychiatry in order to address both the old structural dysfunctions and inadequacies of psychiatric reform (regulation 815/1984, Leros I-Leros II plan, Psychargos A & B, incomplete implementation of laws 2071/1992 & 2716/1999, incomplete deinstitutionalization of the remaining psychiatric hospitals). However, it is time to reflect that it is not possible to talk today about the need to update and implement a new national plan to upgrade mental health in the country without answering basic questions, both old and new, about the wider context of its implementation. The transformation of the deficient psychiatric care in the country cannot be completed without the urgent restructuring of the National Health System7 and the reform of the Greek welfare state itself, which is also characterized by irrationality, inequalities, bureaucratic inefficiency, and fragmentation.8 As we should have learned from the bankruptcy and the prolonged economic, social, and cultural crisis in our country, reforms usually pay off in the long term, while the time horizon of the applied policies is narrow and usually reaching the next election. The fact is that in any reform effort, including psychiatry, the political system does not demonstrate the ability to promote transparency, evaluation, stable rules of regulation, reference to a universally applicable legal and institutional framework, the limitation of clientelism and guild resistances. From this point of view, it is necessary to give meaning in the context of Greek psychiatric reform to the professional burnout of the National Health System workers, the lack of motivation and vision, the intrusion into the NGO space by new entities without any connection to the culture of psychiatry reform, the guild resistances of all relevant specialties, the selective use of psychotherapeutic techniques, as trends of discrediting the relief of social and psychological suffering in the field of public mental health. There is an urgent need to understand new pathologies (narcissistic disorders, new forms of addiction, eating disorders, "pathology of emptiness", adolescent delinquency and suicide, psychosomatic manifestations due to high stress, pathology of fluid social ties, deficient socialization of young people "outside of their algorithms") through a solid and coherent analysis of the toxic postmodernity culture. In addition to the social determinants of mental health,9 it is necessary in clinical work to also assess the psychological factors, such as uncertainty, conflict, loss of control, and incomplete information, that burden human health.10 In order to reduce the gap between declarations and real life, there is an urgent need to overcome the blind spots of psychiatric reform in the country by establishing internal and external evaluation processes, training young professionals in holistic care and community networking and communication skills, retraining leaders for organizational change, and strengthening the participation of service users in the context of deepening democracy in mental health. As mental health professionals, the object of our work in the community should be the reconstruction of meaning and the fragile or non-existent social bond in subjects who have been cut off from any possible production of meaning and participation in their history. Why should our therapeutic responses be stereotypically repetitive in the face of these complex, radical changes in the meta-context and the new demands of our patients? After all, as the philosopher Ernst Bloch puts it, utopia is "that which does not exist yet.".

希腊精神病学改革的盲点。
根据国际经验,精神病改革取得成功的条件如下:(a) 存在政治意愿(支持一项国家计划,其中包括评估、监测和纠正功能失调的干预程序等)。(b) 强大的精神卫生领导力(推动公共卫生议程的行政专业知识和技能)。(c) 通过推广整体护理实践、循证创新行动、协作护理、促进康复文化以及使用创 新数字工具,挑战生物医学模式在治疗实践中的主导地位。(d) 确保长期提供必要的资源,以便从庇护所模式过渡到部门社区心理健康服务模式的资源能够 "跟随 "病人。(e) 加强服务对象及其家人对决策过程和护理质量评估的参与。(f) 基于伦理原则的实践(以价值为基础的实践),而不仅仅是基于总是必要的文件 (以证据为基础的实践)。1- 4 对 2000-2005 年国家心理健康计划执行情况的 "事后 "评估5 以及卫生部和世卫组织雅典 办事处最近对精神病治疗改革的快速评估(SWOT 分析)6 均表明,"服务严重分散,系统不协调, 往往导致服务提供不当,缺乏流行病学研究和有关特定人群当地需求的研究、全国不同地区之间的服务发展不平衡,大量专业人员在社区精神病学方面的专业知识严重不足,缺乏发挥支持作用的人员,专业服务(针对自闭症谱系障碍、智障、饮食失调、新旧成瘾和社区法医精神病学服务)存在巨大差距"。我们还想强调的是,不同的心理健康服务系统(公共一级和二级服务提供者、非政府组织、市政服务、武装部队心理健康服务、私营部门)之间缺乏协调与合作,完全缺乏系统的评估和监测(缺乏护理质量指标、临床结果、每项服务的流行病学概况),缺乏质量保证机制和临床管理系统,主要用于急性病例的床位数量不足,出院通知书和确保护理连续性的协议不明确,心理健康预算占整体医疗支出的比例不足(目前为 3.3%),以及最后的一个问题:"心理健康服务系统之间缺乏协调与合作,缺乏系统的评估和监测(缺乏护理质量指标、临床结果、每项服务的流行病学概况),缺乏质量保证机制和临床管理系统,主要用于急性病例的床位数量不足,出院通知书和确保护理连续性的协议不明确"。最后,非自愿住院率是欧洲最高的国家之一,这与保护服务使用者权利的严重问题有关。在大流行病和无声但可预见的精神卫生大流行病出现后,世卫组织、欧盟和希腊卫生部强调,有必要通过一项公共精神卫生议程,将重点放在社区精神病学上,以解决旧的结构性功能障碍和精神病学改革的不足之处(第 815/1984 号法规、Leros I-Leros II 计划、Psychargos A 和 B、未完全执行的第 2071/1992 号和第 2716/1999 号法律、未完全实现剩余精神病院的非机构化)。然而,现在是时候反思一下了,如果不回答有关其实施大背景的新老基本问题,就不可能在今天谈论更新和实施新的国家计划以提升国家精神健康水平的必要性。如果不对国家卫生系统进行紧急重组7 ,不对希腊福利国家本身进行改革,就不可能完成对国内欠缺的精神医疗服务的改造,而希腊福利国家本身的特点也是不合理、不平等、官僚低效和支离破碎。8 正如我们应该从我国的破产以及长期的经济、社会和文化危机中学到的那样,改革通常会带来长期的回报,而实施政策的时间跨度很窄,通常要到下一次选举。事实是,在包括精神病学在内的任何改革努力中,政治体制都没有表现出促进透明度、评估、稳定的监管规则、参照普遍适用的法律和制度框架、限制客户主义和行会抵制的能力。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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Psychiatrike = Psychiatriki
Psychiatrike = Psychiatriki Medicine-Medicine (all)
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