“The past is not dead, and neither tomorrow -nor yesterday- is written” (Antonio Machado)
We, the undersigned authors of these opinions and proposals, are citizens who are aware of individuals’ rightsand the obligations of the public authorities, we have qualified knowledge about what is occurring in the setting where we perform our healthcare activity, we know that we are responsible for our healthcare actions and omissions, we are mental health professionals who have experienced and, along with many others, led changes that have involved advances based on the principles that inspired the Psychiatric Reform Report from the latest initiation of the democratic construction and against the resistance of some contemporaries. These changes have brought much higher levels of respect to mental health care and disorders than those found in the past, which many of us clearly remember.
We have reached an historical moment where improvements, deficiencies and risks coexist.
We find ourselves at a critical point where we can no longer engage in a merely passive analysis or fruitless complaining without taking action; nor can we strive for theoretical “perfection” and find comfort in what is familiar.
Basic advances in our lives and our co-existence are seriously at risk, as well as our professional and civic identity.
For this reason, accepting the responsibility that corresponds to us, today on April 26th in Madrid, we join other voices and call on everyone who wants to participate, particularly those working in the mental health field: other psychiatrists and clinical psychologists, and, of course, colleagues making essential contributions, such as mental health nursing, social work, occupational therapy, social educators and others.
We will address organizations working in Public Health, and sensitive and concernedentities and sectors, trying to converge, contribute to, join and plan a path that will surely be long and important.
Collectively and democratically, with tolerance and appreciating the rich diversity of analyses and proposals, we put out a call to urgently create the means to organize sustained lines of action designed to modify the severe current situation, which has been damaging the previous achievements, endangering the essential levels of quality in mental health treatment, and, accordingly, confront the dangers and harm to the population produced by the progressive deterioration in mental health conceptions, benefits and services.
We are working on it.
SERIOUS DAMAGE IS BEING DONE
The health care policy currently being implemented has already caused serious damage and continues to do so.
The information about the evolution of mental health in the population is quite worrisome. Predictions and warnings by organisms with knowledge and authority (WHO, 2010), given far enough in advance to adopt preventive measures, are being confirmed, after having been ignored by those responsible for protecting the population’s health.
The damage is increasing. The Government is familiar with these data and the fact that they validate what was considered as just a perception until recently. Now, unfortunately, this is not just an opinion. Now these data provide evidence of an irresponsible healthcare policy that does not consider the most vulnerable members of the population.
Suffering, disease, the worsening of the lives of many people, unemployment, a shorter future, compromising the development of children and youth, poverty… This is the trail left by a premeditated response to the crisis that shows the harshness of the marked increase in unjust social inequality, condemning broad sectors of the population to chronic poverty. This would be a sign of our leaders’ incompetence, if it were not intentional, but it is.
In public health, the crisis has been the justification for the attempts of the Government and the economic oligarchies with interests in the sector to execute a plan begun long ago: the transformation of health and disease into merchandise and citizens’ health care into a business.
The aggression unleashed against the public health services with the proclamation of the RD Law 16/2012 had a precedent (the Law 15/97), and justified ideas that progressively took hold over the years as reasons, when they were only evaluations of interested parties (the supposed good that comes from establishing the market as the only authority, the apparently neutral separation between providers and financial backers, the unproven lack of sustainability of the public system…).
The most important effects of this offensive are already the deterioration of health care and the damage to equity, as well as the change in the healthcare model due to the move from universal health care to the restoration of the mutualist model. The instigators of this situation have opened the dikes that prevented privatization and the sale of the public health service. This has all been done with apparent urgency, justified by the supposedly threatened sustainability, while the main measure adopted had nothing to do with the reasons given, without participation or debate, violating the democracy that must be respected by the executive branch above all.
For these objectives, these methods are used: the fair distribution of common assets is the subject of dialogue, and they try to persuade us about the regulation that must control it; however, the appropriation of public property is carried out hurriedly and secretly, without allowing any discussion about the reasons…: It represents a form of expropriation.
In this context, the mental health care system has suffered additional harm, both because of its limited resources and its fragile situation among the priorities of health care leaders and planners, and due to the deficiencies and contradictions of their disciplines, healthcare organization, management, knowledge and practices. The attack against the public health system found the mental health sector in the midst of a prolonged crisis, precisely when the needs of those for whom the professionals are responsible, the citizens, was about to increase as a result of the economic crisis and its correlates.
Meanwhile, those directly affected, already overwhelmed by their healthcare needs, the difficulties often created by the care offered to them, and the frustration of their neglected rights, are situated as observers by those who manage their health, who try to dupe them with offers of treatment and future care which, however, are currently being reduced even though they are acknowledged rights.
WE WERE WARNED
We were warned that the economic crisis involved a certain risk of worsening the population’s mental health, along with the measures to control or mitigate this risk (OMS, 2010). However, none of them has been adopted following the recommendations.
On the contrary, the Government has maintained a response to the crisis, presented as the only feasible possibility when it was just one of many, that has aggravated the situation. This response, mainly consisting of the reduction in public services and benefits and the privatization of the attention to healthcare needs, has created a situation where:
- There is a violation of citizens’ rights to participate in making decisions that concern them, to have knowledge about relevant health care information for their lives, to fair access to public services and health protection.
- Information is concealed about the evolution of public health, about the Government’s plans for mental health care, the functioning of the healthcare services, adverse incidents and harm produced by the restriction of resources, and the mismanagement of the healthcare network.
- There is a lack of direction, management capability and a mental health strategy that defines a plan to deal with the evolution of the situation. The Government’s action has weakened and paralyzed the Mental Health Strategy of the National Health System being developed since 2006, which represents a severe lack of responsibility in the present health and social situation. The lack of means, incompetent leadership, and management oriented toward presenting false productivity results are producing devastating effects on the quality of the services and harming professional motivation and initiative.
- Participation in health care functioning and leadership is impeded, both in the community and among professionals. Institutional authoritarianism in the daily functioning of mental health services has increased, dismantling the scarce collective instruments of participation still available, and fostering a form of management that does not consider the professional capacity to advise, assess and make decisions.
- The health care response is deteriorating and becoming more limited, with very negative effects both on citizens’ rights to effective benefits and on the therapeutic efficacy of treatments. The professionals’ capabilities would allow levels of health quality and security that are much higher than those presently achieved, but the necessary range of diverse therapeutic options is severely limited in favour of the biological ones, closing the networks of diversified relationships among services in the territory, destroying the consideration and richness of teams, erasing the users’ right to talk and the professionals’ right to listen in a clinical practice that must consider the nature and conditions of the clinical and psychotherapeutic commitment, and extinguishing the few steps taken toward the empowerment of professionals, users and families.
- The follow-up instruments for training in Mental Health specialties in the certified Mental Health services (Educational Accredited Units, EAUs) are being disregarded. Adequate conditions for this important responsibility of training the new generations of Mental Health specialists must be guaranteed and promoted, sufficiently regulating the functions and protected time for tutoring, establishing the Mental Health Resident Handbook as an indispensable tool, promoting audits that are partially dependent on the National Committees of each specialty, fostering an education of excellence that is protected from other parallel programs that might be developed in these EAUs to the detriment of the training of Mental Health specialists (Masters, postgraduate courses and others).
- The stigmatization and marginalization of the most seriously affected people are being fomented, and there is no prevention plan to keep those who are not in this situation from evolving toward severity. Recent evaluations of people in high positions in the ministerial setting for mental health planning linking mental health problems with a public health risk, and thus justifying coercion measures of control and vigilance, are a very worrisome sign of the prejudiced attitude and lack of capacity of relevant public leaders in this field and of the ongoing threats. These suffer the worst damage: the most fragile ones, those with the greatest needs, those in the worst material, relational and psychic conditions are the first and most severely affected by the present deterioration in mental health care.
- In dealing with the subjects of the demands for Mental Health Care, diagnostic and therapeutic discriminations are established that it is important to modify paying attention to clinical knowledge and valuing this aspect based on clinical management that recognizes the value of the intervention in community mental health at the three levels of Prevention: Primary, Secondary and Tertiary.
• The reinforcement of coercive measures is announced while actions oriented toward social reinsertion are reduced. The dreadful Penal Code reform project promoted by the Ministry of Justice, representing the reversal of the stigmatizing assessments mentioned above, recreates the prejudice about the dangerousness of mental patients and once again provokes a lack of protection and intolerable violation of their rights because it differentiates them from the rest of the citizens due to their disease. Where there should be therapy and social integration, only more coercion is foreseen.
• People with severe mental disorder are suffering the worst damage. The most fragile, those with the greatest needs, those in the worst material, relational and psychic conditions, are the first and most severely affected by the current deterioration in mental health care. The maintenance of psychiatric hospitals based on the asylum model in the State is unbearable.
• The foundations of social co-existence are being actively destroyed by these policies. The model of society we decided to bet on (democratic, tolerant, oriented toward a distribution of common goods based on equity) is being changed without debate or consultation. Once again, an asphyxiating situation is being created, where the weakest members of society cannot expect the support that the public institutions owe them.
The worrisome current mental health policy, consisting of lack of foresight, lack of direction, management incompetence, disorganization, lack of social sensitivity, prejudice, authoritarianism, deficient management of the scarce resources, and ignorance, leads us toward a health care and social horizon with unbearable levels of personal and collective suffering, disease, lack of solidarity, devaluation of individuals, injustice and fear.
THE COUNTER-REFORM CURRENTLY IN PROGRESS MUST BE STOPPED
The regression occurring in mental health care must be stopped and, at the same time, the insufficiencies that facilitated the current deterioration must be corrected.
In the framework of defending public health care and free and universal access to its benefits joining everyone who promotes the improvement of the National Health System so that, with its activity oriented toward the search for equity and the protection of the population’s health, it contributes to society’s advance towards higher levels of social justice, we the undersigned of this document estimate that, to deal with the situation analysed above, the following lines of action must be developed:
- The public nature of all the health care goods and services, their ownership and their management, must be reinforced, without exceptions, without ambiguities, without nuances. Health is a collective good, and its protection must be a right available to everyone, the expression and the basis for the equal value of individuals, and a condition for economic and social development. If people cannot be privatized, their health must not become a business.
- Mental health care must follow the principles of universality, equity, efficiency, solidarity and integration. No one who needs it can be excluded from it, nobody can be prevented from receiving necessary the care and attention, in an integral way.
- In mental health care,there must be a revitalization of the multidimensional approach, the multi-professional response, the community care orientation, the continuity of care, attention and support in the home setting, and social work of prevention (redefining what is needed after having analysed the accumulated experience). The difficulty in developing these orientations does not justify their abandonment; instead, they must be better defined, keeping in mind that the therapeutic impoverishment and the dominion and abuse of the pharmacological response as the main healthcare instrument are also due to the abandonment of those proposals.
- The organization and functioning of the mental health care services at all levels must be participative and transparent, enhancing the participation of professionals, users and families. This requires organisms for democratic management, and the professionalization and political independence of this management.
- The core of the healthcare care effort must be focused on those who need it the most, clarifying and arranging the demand directed to the mental health services, giving priority to the development and implementation of resources to meet the needs of people with severe mental disorders.
- It is necessary to correct the insufficient supply of material and professional health care resources, and to urgently verify the existence of conditions for good practices, paying attention to the specificities of the practice of each professional degree.
- To revitalize the Mental Health care, the Mental Health Centres must be maintained as the main axis of the functional orientation of healthcare; therefore, the Inpatient Mental Health Units in the General Hospitals must not hold a nodal hierarchical position in the health care network. Their progressive role in the current direction of the healthcare response, too often blurring the severe lack of an authentic planned and satisfactory network of alternative resources to hospitalization, makes it necessary to review their functioning, the ends that have been progressively imposed on their practice, their supplies, healthcare modes, assessment criteria to evaluate their activity, and their relationship to the whole network of diversified and territorialized healthcare services that must be promoted. The closure of psychiatric hospitals with the asylum model was an achievement of the Reform. But the false debate about the recommended number of long stay beds in the general hospital resurges with increasingly more strength in the State territories, masking an implicit reversal that sometimes makes it difficult or impossible to treat and maintain citizens with severe psychopathological disorders in their environment.
- A regression in the equality of the legal treatment of individuals must not be allowed. Citizen opposition to the modification of the Penal Code is a democratic necessity. The prejudice toward people with mental disorders produced by defining them as dangerous can only cause harm and suffering. It is necessary to be especially alert to any extension or presence of coercive practices in the mental health services, which, due to their nature, reduce people’s autonomy, thus obstructing progress toward their healthcare and social objectives. The defence of the political, social and health rights of people with mental disease must be a priority among the professional concerns. In this sense, the asylum model of care in the different State psychiatric hospitals that still exist is both obsolete and unbearable.
- Professional development policies must be implemented in order to recover professionals’ motivation, enable them to perform their capabilities, foster their training coherently according to explicit health objectives, freeing them from the pressure and training bias promoted by the pharmaceutical industry, and value them based on their effective contribution to the National Health System activity.
- As mental health care professionals, we all have to completely accept our responsibility, defending our autonomy in performing the health care activity (of diagnosis, care, treatment or rehabilitation) in accordance with what is established in the law, which protects and holds us responsible, as well as the ethical demands orienting our activity, recognized as having special social and human value. Our commitment to the defence of citizens’ health rights acquires particular importance in the present situation, as it prevents professionals from being used to deprive citizens of the attention they need or to establish and extend diagnoses and treatments basically determined by the commercial interests of the pharmaceutical industry.
- Specialized training must be fomented through the Intern-Resident Model in the disciplines that make up mental health teams, appropriate for the health care needs and the processes of the interdisciplinary team, facilitating the consolidation, diversification, growth and quality of their training programs and activities. In the training process, from the Degree level, attention must be paid to training in ethics and the rights of individuals, which represents the most basic substratum of the identity of the healthcare professional as a citizen in the process of progressively accepting responsibility in the special social function of providing health care to others. Access to specialized Intern-Resident training must take place after acquiring the professional status of general healthcare practitioner, a situation that today is still, incomprehensibly, pending resolution in the case of clinical psychology.
- Research must be fomented: optimizing resources through integration actions with the main centres and institutions where it is developed (Universities in particular), forming and facilitating the involvement of professionals and users, broadening and linking the research objects of interest to the needs of clinical practice and community health care, and reducing dependence on the pharmaceutical industry.
- It is necessary to reinforce and support the empowerment of associations of users and their families, promoting their participation in the elaboration, follow-up, evaluation and management of mental healthcare plans, programs and research, as well as in the framework of clinical intervention.
- Immediately repeal Law 15/1997 on the authorization of new forms of management of the National Health System, and Royal Decree-Law (already ratified as Law) 16/2012 on urgent measures to guarantee the sustainability of the National Health System and improve the quality and security of its benefits.
In defence of these approaches and proposals, we must remember that progress is never guaranteed, and that it takes the same effort to move forward and to remain firm.
Signed in Madrid, April 26th 2014