By Pino Pini
1. Introduction and background
There exists a vast gray area between mental distress and mental illness. Today, particularly under the influence of clinical practices shaped by the Diagnostic and Statistical Manual of Mental Disorders (DSM)1 and the International Classification of Diseases (ICD)2 diagnostic systems, additionally a neoliberal culture tends to place the burden of responsibility for people’s ailments largely on the individual; this area is increasingly being occupied by new disorders and therapeutic remedies generated by the global knowledge3of major multinational technology corporations. Conversely, there is growing neglect of the local knowledge 3 held by the communities to which an individual belongs, knowledge rooted in native traditions and languages that is considered fundamental to each person’s emotional and cognitive development.
The Shared Experience and Local Mental health Systems (SE&LMHS) project assumes that mental health is not only a matter for special services but should include the whole local community. Several activities beneficial for mental health can be created by working together in the community in peer-to-peer contexts through direct relationships between professionals, people who use the services, carers, the third sector and representatives of the local community. These activities can be very different from each other and can vary according to the local contexts. These activities have nothing to do with structured clinical interventions neither are they an extension of them.
The roots of the project are based in Florence and Prato (Italy), in a context where psychiatric hospitals were being closed (Law 180/1978)4 and the local community was becoming one of the main players in mental health.
The closure of the psychiatric hospital, viewed as institutions that comprehensively suppressed personal rights, also called into question the very nature of the clinical relationship between practitioner and patient. Furthermore, there was no desire to transplant hospital-based practices into the community, as they were ill-suited to the new context. Undoubtedly, this represented a far-from simple transition for all the stakeholders involved.
The hospital’s closure did not happen overnight; for some time, significant international developments in the psychological, sociological, and political spheres had been driving a push for radical reform in both psychiatric care and society at large.
2. Moving beyond the “Us” vs. “Them” relationship
During the early 1970s, both inside and outside Florence’s old psychiatric hospital, as well as in other institutions, alternative approaches emerged that challenged the established clinical relationship between staff and patients. Alongside routine clinical procedures, spaces were created for informal interactions through simple activities such as working with clay, drawing, painting, discussion groups, and setting up meeting areas. These were non-hierarchical group settings designed to foster shared connections among individuals, transcending their personal differences. In such contexts, the person—with their unique characteristics—could re-emerge, while the illness was, to some extent, relegated to the background. Staff members discovered new facets of their patients and themselves and were encouraged to embark on personal journeys of self-discovery through training of an analytical and/or systemic nature available at the time.
However, these experiences largely remained confined to the services themselves (whether within the hospital or at external facilities), while the patients’ home communities—despite frequently being invoked—remained relatively distant.
In the years prior, the need for innovative work extending beyond the clinical setting—and transcending institutional hierarchies—had been amply demonstrated through various experiences across different countries.
The powerful impetus provided by Law 180/1978 strongly stimulated the search for new psychosocial spaces within the very local communities where individuals originated, and fostered reflection on the limitations, if not the harmfulness, of certain clinical practices.
3. Florence Casa della Cultura: initial contacts with mental health associations and self-help groups
In 1980, a group comprising mental health professionals, service users, family members, and volunteers—who had been meeting for years in both psychiatric hospital and community-based settings while developing alternatives to clinical approaches (see the previous section)—proposed, at the urging of some service users, moving their activities to the Casa della Cultura in Florence. This was a cultural and recreational center run by a local voluntary association (ARCI—Italian Recreational and Cultural Association). Through agreements involving the mental health services, the local Borough Council (of which some group participants were also members), the Casa della Cultura, and the University (Psychology Department), a pilot project was launched to monitor the group’s evolution, focusing on both its internal dynamics and its relationship with the surrounding community.
Throughout the 1980s, the group engaged in various practical and theoretical activities. Written and audiovisual documentation 5facilitated exchanges with similar initiatives in Italy and abroad. Relationships were established with mental health associations (such as Mind6 in England and Mental Health Europe—MHE7) and psychiatric self-help groups in Northern Europe and North America. This further fostered increasingly active user participation, leading to the development of collaborative projects focused on psychosocial approaches and self-help.
The exchange of personal experiences among all participants—free from hierarchical structures and outside the clinical service environment—proved feasible and served as a vital way to address various forms of personal mental distress, also represented a significant departure from the traditional clinician-patient relationship.
A key component was the weekly discussion group. Staff members adopted a listening stance and facilitated interaction among participants but refrained from passing judgment, issuing prescriptions, or assuming a therapeutic role. The underlying premise was that the group interaction itself—through the sharing of experiences—benefited everyone, allowing individuals to express themselves while considering the contributions of others. The presence of community volunteers necessitated the use of everyday language, ensuring that problems could be understood by all, beyond the confines of codified, objectifying technical jargon. The group approached individual suffering primarily as a lived experience, rather than through the lens of illness. Most group members came from mental health services but were free to decide whether to continue attending them. Sessions lasted an hour and a half, took place at the same time each week, and had no predetermined limit on the number of meetings. Participation was voluntary and open to people from the local neighborhood and the *Casa della Cultura. The group gave rise to further initiatives, ranging from social gatherings to university-led research, academic conferences, and meetings with the mental health services themselves. Coordination was handled by a steering group representing the various stakeholders. However, overall responsibility rested with the mental health service.
It was proposed to define the group as an “Intermediate group” between the services and the community 8; psychotherapeutic/psychosocial-like elements were present at the same time.
4. Prato: proliferation of mental health associations and self-help groups; connections with national and international entities
In the early 1990s, the “Casa della Cultura” model was replicated and further developed in nearby Prato, involving both the city and the province. A formal agreement9 was reached between the Municipality of Prato, the National Health Service, and the ARCI volunteer organization (the same group involved in Florence’s Casa della Cultura) to collaboratively develop a self-help-oriented group.
The following years saw an exemplary flourishing of various self-help groups across the Prato area. These groups drew primarily on the psychosocially oriented self-help and self-advocacy model of the British movement “Survivors Speak Out,” -10- which defined itself as “non-separatist” (meaning professionals were admitted to user groups, but solely in a supportive capacity).
This type of psychosocially oriented self-help stood in stark contrast to the diagnosis-based self-help that was emerging concurrently and competitively during those same years (using the same terminology but attributing a different, if not opposite, meaning to it). Diagnosis-based self-help, by contrast, was clearly centered on the concept of illness and accepted sponsorship from the pharmaceutical industry.
Those who support self-help and self-advocacy groups—and who are critical of interpreting mental suffering solely as an illness—seek explanations and solutions within the psychosocial realm. Conversely, those convinced that their mental distress stems exclusively from an illness will look to services for the most appropriate individual treatments and, should the condition become chronic—as often happens—will seek the opportunity for rehabilitation and optimal integration into the community.
On MHE’s advice, and to support the psychosocially oriented self-help groups that were spreading nationwide, the Italian Association for Mental Health (AISMe)-11– was founded. One of its key initiatives was the European project on user-led service evaluation—an early example of co-creation between “experts by profession” and “experts by experience” 11a
During those same years, the collaboration with Marius Romme and the Hearing Voices Movement12,12a further reinforced the method of exchanging experiences and the equal standing of experts by experience and experts by profession. Hearing voices is not necessarily viewed as a symptom of illness, but rather as a way the mind functions in various situations.
The International Mental Health Network (now renamed IMHCN13) will be part of this process, fostering further international exchanges that culminated in the international conference on recovery, Prato 2000.
At the same time as the aforementioned self-help-oriented groups were emerging—both in Prato and elsewhere in Italy—mixed groups comprising service users, mental health professionals, and family members were also being formed with similar psychosocial objectives. However, these latter groups—which enjoyed strong support from family members—tended to be quite skeptical of self-help groups and doubtful about the ability of service users to collaborate on an equal footing in managing various activities; nor were they interested in exploring broader issues, such as the debate surrounding suffering versus illness, the professional-user relationship, or compulsory interventions.
5. Prato: the SE&LMHS project for a structured relationship between services and the community
In the early 2000s, Prato was home to 30 psychosocially oriented groups, all operating outside the formal service system and based at various locations within the community. Seven of these groups were clearly inspired by self-help principles, while the others were primarily defined by their specific activities (such as sports, art, or work). The former—broadly categorized as “self-help” groups—focused on debating issues like the concept of mental illness, the relationship between professionals and service users, and the mandatory nature of interventions. The latter—referred to as “bridge experiences” to highlight their particularly close ties to the community—received greater support from family associations; while they showed little interest in the topics typical of self-help groups, they shared the commitment to maintaining close contact with the community. Regardless of their differing perspectives, a fundamental characteristic shared by all these groups was the valuable role they played in bridging the gap between the community and the services.
The SE&LMHS project was also conceived as a means of communication between services, associations, and civil society. Both so-called “self-help” initiatives (which were more critical of the illness model) and “bridge” initiatives (which did not challenge that model) required a close relationship with the community. It was therefore necessary to clarify the various groups’ demands while respecting each party’s position. Individuals were free to view their own mental distress as linked to a wide range of factors and had the right to engage in open dialogue should they wish to do so.
The four annual conferences held in Prato from 2001 to 2004 on “Self-Help and Bridge Experiences” (later renamed SE&LMHS Shared Experiences and Local Mental Health Systems) involved, in addition to services, associations, and local authorities in Prato, various Italian and international organizations, including MHE and the European Network of Users and Survivors of Psychiatry14. Numerous interesting exchanges took place among the participants, and the concepts of Shared Experience, Local Mental Health System, and Intermediate Area were discussed and refined in relation to different cultural and environmental contexts.
The concept and practice of Shared Experience, Intermediate Area (between the service and the community), and the Local Mental Health System have been presented and discussed on several occasions and in contexts in more recent years, both at the national and international levels.
n 2005, a survey conducted by the Tuscany Region15 across its ten Mental Health Departments revealed that the Prato Mental Health Department achieved positive results equal to or better than the other departments, yet at a significantly lower cost. The reduced reliance on traditional therapeutic and rehabilitative facilities appeared to be the reason for these lower costs. It was hypothesized that this outcome could be attributed to the presence of the aforementioned 30 groups in the Prato area—representing collaborative initiatives—as well as their role in bridging the gap between services and the community and their creation of new spaces for understanding mental health issues.
6. The clinical model becomes increasingly dominant
Meanwhile, the pervasive effects of the clinical approach—driven by the widespread global adoption of the DSM (starting with the third edition in 1980)—intensified throughout the Western world, increasingly overshadowing subjective, relational, and environmental aspects, which were consequently neglected. Problems were now sought within the individual rather than in their social context. The ever-growing number of disorders identified through statistical-descriptive methods (yet lacking reliable biomarkers) were expected to be treated using new technologies. Psychological sciences themselves drifted away from the humanities and were absorbed into biomedical sciences. The term “psychoeducation” came to signify one-way information directed at the patient, their family, and various caregivers regarding the illness and its progression.
The individual was increasingly viewed as a passive consumer of clinical interventions to be implemented as soon as possible. Subjective factors, as well as relational and environmental contexts, were overlooked. The motto “from patient to citizen”—common in the psychosocial approach—was deemed outdated and unrealistic.
The three medical schools in Tuscany (Florence, Pisa, and Siena) had clearly adopted a biomedical orientation, and the Tuscany Region entrusted the universities with the task of coordinating the development of the region’s mental health services. While the consolidation of small geographical areas into larger ones led to a rationalization of financial and structural resources, it hindered the development of human resources focused on the more personal aspects that could only emerge within small, local settings.
As a result of this trend Prato NHS Trust declined to contribute to the advanced training course on self-help promoted by the Faculty of Psychology and AISMe.
7. Associations take the lead on the project, further national and international connections
In 2005, services in Prato announced they could no longer host the SE&LMHS project conferences. Consequently, AISMe assumed full management of the project, collaborating with other associations linked to the *Casa della Cultura* in Florence. This center would once again become a key hub for promoting self-help initiatives and hearing-voices groups.
The 2009–2011 edition of the SE&LMHS project linked organizations in Florence and Prato with counterparts in North Lanarkshire (Scotland) through an intensive program of theoretical and practical work16
Efforts were made to facilitate the creation of a national network of self-help groups. AISMe and other associations collaborated with the Tuscany Region’s Regional Health Agency to map participatory initiatives.
Following a proposal by AISMe, MHE established the Beyond the Biomedical Paradigm Task Force in 2012 to understand the development process of the DSM system, its implications for the ICD system, and its overall societal impact17.
Relationships were developed with the Critical Psychiatry Network (CPN)18,18a to address the issues of over-diagnosis and over-medicalization, as well as to oppose the increasing reliance on compulsory interventions and the associated national and international legislation.
English services showed interest in the SE&LMHS project, leading to further connections with AISMe and MHE.
Watford SE&LMHS
The SE&LMHS project has been established in Watford since 2018, with the aim of exploring whether the Prato and Florence project could be developed in the Hertfordshire area.
A transitory Steering/Development Group (DevG) composed of people who use services, carers, professionals, local government representatives and third sector organizations was established and meetings between various stakeholders were held monthly first at Colne house (Community Mental Health Team of the Hertfordshire Partnership Foundation Trust – HPFT-), at Watford Central Library and finally at Watford Town Hall. The DevG group aimed to disseminate the SE&LMHS project in the Watford area by supporting the Shared Experiences activities in the community19.
It was acknowledged, by the DevG group, that the mental health situation in the Watford area had several issues including:
- the fragmentation of Services under stress and rising demand
- repeated brief presentations without any resolution of people’s presenting problems
- preponderance of the therapeutic model and symptoms containment interventions rather than a focus on personal recovery
- forced treatments – which are 8 times more likely in England than in Italy 20.
- The continuation of a “them and us” culture which creates systems that discriminate and stigmatise and have the potential to traumatise.
It was decided to develop first a shared experience group to be named Common Sense Group (CSG) composed of the same key subjects of the DevG. In the CSG, outside the clinical environment of services and outside diagnostic and therapeutic settings, participants have been invited to share their personal experiences by using everyday language to understand human experiences in a free way within a community context. By doing this it has been possible to develop a better interaction between people, the services and the community, with mutual benefit. Users and professionals could learn the language of the community and the community could learn more about shared experiences.
Leaflets were prepared explaining the scope of the group, practical information and the confidentiality policy. The CSG started in July 2019 at the Watford library. The new environment was very promising and was attended by several people, but unfortunately the COVID pandemic occurred a few months later. The DevG continued online, and it was possible to develop new ideas and documents about how to continue to work in the extraordinary situation. For the CSG there were some difficulties for people to meet online especially if they were new to the group. In the summer of 2021, the CSG was able to regularly restart as a face-to-face group.
The issue of confidentiality was raised several times, though concerns focused more on those outside the group than on the members themselves. Those who are part of—or choose to join—the group understand that it is an open environment where individuals are free to decide whether to reveal personal details, and to what extent. Participants are aware that one of the group’s goals is to find a language that fosters mutual understanding; furthermore, operating within a community setting—outside of clinical environments- using non-specialized communication and taking responsibility for one’s own choices and behavior.
Two referral forms were developed: one for individuals coming from the service and another for those coming from the community. Referrals for the former group had to include up-to-date risk assessment data, and the presence of a key worker was required, at least for the initial session. In any case, all referrals had to be discussed by the steering group. Individuals were not to be automatically discharged from the service, to avoid “dumping” particularly complex cases into the group.
An application was prepared for the HPFT Innovation Fund20a and was successful in 2023-2024. This contributed to further develop and consolidate the project by establishing new relationships between the HPFT service, and the Watford community. For the last few years, it has been decided to hold the CSG every other Monday, in the Watford library and to meet online on the subsequent Monday to reflect (Reflective Group -RF-) on the previous CSG. All participants to the previous CSG were invited to the RF. The combination of the CSG, the RG and the DevG allows a better articulation between personal, collective and organizational issues so it is possible to develop a process tailored on the needs of each participant.
In the project a significant number of people, of different backgrounds, have been involved, including service professionals, people who use services, carers, the third sector, Watford Borough councillors and Hertfordshire University. The potentiality of the project to involve further people and to be beneficial at an individual and collective level has been very promising. Transition from the clinical to the community environment and a better reciprocal communication between the services and the community, remains the most important aim of the project.
An official agreement between the involved stakeholders is going to be presented HPFT and Watford Council and will surely allow further positive developments of the project and development in other areas of Hertfordshire and the establishment of an Intermediate area between the service and the community. This will better balance the service knowledge with the community knowledge allowing better mental health at both an individual and collective level.
The question of evaluation remains to be addressed; evaluation must be determined and developed collaboratively, involving all stakeholders and an organization with expertise in the field of evaluation.
If, as hoped, the CSG model can be replicated in other areas, we could envision a proliferation of groups with a strong psychosocial focus—similar to the Prato initiative—and consider establishing a new steering group to coordinate these various participatory efforts, thereby creating a genuine intermediary area between services and community.
Enfield SE&LMHS project, hearing voices group and deprescription group
The SE&LMHS project was presented to Enfield services and received a positive response; while meetings were held with the Borough Council, it has not yet been possible to implement the project.
However, a “Hearing Voices” group was established in 2025 at the Edmonton Green Library (Enfield Borough). Based on the peer exchange of experiences among all participants, the group features service staff acting as co-facilitators. This group combines the Romme’ work with voice hearers (by promoting a joint work between experts by profession and experts by experience) with the principles of the SE&LMHS project, focusing on the exchange of experiences among diverse participants in a community setting outside of the service facilities. The organization Mind—which has a long history of working with voice-hearers using the Romme method—was involved in training the group’s facilitators.
Service staff members have also formed a group focused on deprescribing, in collaboration with members of the CPN.
Once the SE&LMHS project launches, these “Hearing Voices” and Deprescription groups will benefit from greater community engagement—a development that will prove highly valuable for the groups themselves, the service, and the wider community.
Feedback from participants
When I was invited to attend the Common-Sense group, I could not have imagined the impact it would have on my mental health. I have been attending regularly for several years, and listening to the experiences of the other people in the group has encouraged me to be more open. I regularly engage with the discussions, which previously, I found difficult. As a result, my confidence has grown and I am able to mix with people more easily. Community support is at the heart of this project, and I have learned to value being part of a team and a project whose principal is to empower, collaborate and co-create better and stronger communities.
A component of the Watford SE&LMHS project.
‘ Being involved in the SE&LMHS project has been fundamental to my personal and professional growth. As someone with lived experience of trauma from being in a hierarchical mental health system for over 10 years, the Common Sense Group with its values and principles of equality, mutuality and reciprocity helped me heal. I was able to see psychiatrists and other mental health professionals as people and not an enemy that was out to hurt me. Professionally being part of the steering/ developmental group helped me understand the true value of co-production, of moving away from the ‘them’ and ‘us’ culture, sharing experiences outside the clinical domain and learning from each other.’
Alex Hunter, Peer Support Trainer and Consultant and member of the SE&LMHS project
The SE&LMHS project is significant because it views mental health beyond the clinical aspect of services, instead engaging communities that are open to understanding and welcoming individuals with mental health issues. The project targets not only those who utilize existing services but also individuals who avoid seeking psychiatric care due to long waiting times or stigma. In Italy, regions have been granted autonomy, allowing them to adopt mental health systems that can relatively differ from those of other regions, provided they adhere to the fundamental principles of Law 180/1978. The Tuscany Region promotes a mental health approach involving three key stakeholders: services, municipalities, and associations. These associations—which must remain independent of the services—are called upon to collaborate on community-based mental health projects that actively involve service users, their families, and health and social care services. Individuals must be supported in integrating into their local communities.
A component of the Tuscany SE&LMHS project.
As an Expert by Profession facilitator, my involvement in the Hearing Voices Group has been one of the most rewarding aspects of my work. The group offers a different way of relating where lived experience is valued equally alongside professional knowledge, creating a space in which traditional power imbalances are softened and genuine collaboration can emerge. Working alongside Expert by Experience co-facilitators is particularly enriching; their insight, authenticity, and ability to connect through shared experience are central to the group’s success. I often find myself looking to them for guidance in maintaining the ethos of the group and helping conversations remain grounded in what matters most to participants. This trauma-informed, relational approach shifts the focus from diagnosis and intervention to meaning, connection, and mutual learning, reminding us that recovery is often nurtured not through expertise alone, but through community, human connection and shared humanity. There is the recognition of each person’s expertise in their own life, that everyone has something important to teach and something important to learn.
A component of the Edmonton (Enfield) library Hearing Voices Group
11. Conclusion
In its current form, the SE&LMHS project is the result of various contributions made over a considerable period. The project aims to co-create 21 together with all involved stakeholders—new psychosocial perspectives within the local community, outside the clinical setting. This approach seeks to foster new opportunities for development for both individuals and the collective of which they are a part, including the services themselves.
The initiative has evolved from the experimental introduction of activities within psychiatric hospitals that offered alternatives to clinical-biomedical interventions (during the second half of the last century) to efforts aimed at engaging civil society at the local community level. Subsequently, the contributions of mental health associations and psychiatric self-help groups helped to further shape the project.
While the battle for deinstitutionalization was once waged against a psychiatric system centered on the old asylum, the concept of illness, and the equation of care with control, things unfortunately do not seem to have changed much today. Across most of the Western world, psychiatric hospitals still exist—albeit updated in terms of infrastructure and technology—and remain a cornerstone of care for people with mental health issues. Although various countries now offer far more community-based services than in the past, these are typically clinically oriented, heavily bureaucratic, and focused more on illness than the person. Countless new diagnostic categories and treatments have become available, yet—paradoxically—mental suffering appears to be rising rather than falling (the “epidemic” phenomenon)22. Compulsory treatments are also on the rise, and we may well have become trapped in a vicious cycle that is difficult to break.
Local communities, on the other hand are losing their original identity and become increasingly dependent on global models through new technologies. Relationships between people within their local communities are becoming increasingly rare. People are less interested in participation, social cohesion, and community development as means to a better life and to the construction of their own identities through direct interaction with others. Relationships are increasingly formed with virtual reality rather than directly with people. We are becoming ever more passive in our engagement with global knowledge and associated technologies; if something goes wrong on a personal level, we search online for the most convincing solution—and perhaps even seek to be assigned a specific diagnostic category that guarantees a measure of social recognition and a means of survival.
As previously mentioned, the project involves four key parties: in addition to the professional, the service user, and the family member or caregiver, the fourth party—representing the community—is equally essential. This figure brings the perspective of the community context in which the person with mental health issues lives (it is crucial that meetings take place at a community venue, outside of formal care services). Communication among these four core parties fosters the development of a new “local language,” enriching the discourse and opening up horizons beyond the standard clinical approach (whether medical or psychotherapeutic). This non-specialized local language allows for the simultaneous interconnection of personal, interpersonal, and social-contextual aspects. It serves as a kind of intermediate language—understandable to all participants—capable of capturing intimate, relational, and social dimensions alike. While this may reflect psychotherapeutic influences, it has been augmented by elements of socialization (facilitated by holding the group in a community setting outside of clinical services) and by the experience of self-help, which has empowered service users and lent dignity to their voices.
In the 1990s, P. de Maré defined the “Intermediate Group” as an enlarged group that placed particular emphasis on free interactions among participants -23-. The distinction he made between the small psychoanalytic group and the intermediate group can prove useful in defining the experience-sharing groups within the SE&LMHS project. These latter groups cannot be defined as psychotherapeutic in the strict sense, as all participants regard themselves as equals, regardless of social or professional status, and no one assumes the role of therapist to the others. It could be said that SE&LMHS groups are characterized by a participatory psychosocial approach-24-.
However, a distinction must be made between two types of psychosocial approaches: one sees the clinical approach extending into the community through specialized rehabilitative or psychoeducational tools; the other—which we might term a participatory psychosocial approach—does not employ the clinical model but instead seeks to redefine individuals’ mental distress using local, non-specialized language and common sense.
The psychosocial approach of the SE&LMHS project, which falls into this latter category, is not merely an extension of the medical model into the community; consequently, it does not utilize the clinical tools typically employed by services. It relies on self-help and self-advocacy rather than diagnosis-based self-help.
Nowadays, in most cases, the term “psychosocial approach” refers simply to extending the clinical model (psychoeducation, rehabilitation) into the community. Services focus primarily on whether individuals adhere to prescribed clinical treatments, which may be accompanied by certain psychosocial activities aimed at rehabilitation.
A key factor in the success of the SE&LMHS project is a proactive attitude among service providers and their willingness to collaborate with the community to address significant instances of mental distress, particularly where clinical interventions alone prove inadequate.
All mental health professionals, including those with the highest level of clinical expertise, are called upon to contribute to this project by engaging with the community alongside local government officials and associations. Engagement with the community cannot be fully delegated to voluntary organizations; instead, it must be a collaborative effort involving them and all other relevant stakeholders. This work is, therefore, simultaneously technical and political in nature. Such an approach has the potential to transform current services and shift the prevailing culture away from its excessive focus on the clinical aspect.
Mental health services should not only follow the clinical approach currently dominated by the biomedical model and DSM/ICD nosographic categories. This approach, useful in specific and limited circumstances, risks instead damaging/colonizing and traumatizing the communities themselves by stripping them of their natural resilience mechanisms, when extended inappropriately out of context. Services in the meantime should also be open to the social and cultural perspectives of the communities in which they operate by playing an important role in promoting collaborative activities with all key stakeholders present in those same communities.
All service staff—starting with those holding the greatest clinical responsibilities—should dedicate a portion of their working hours to participatory (shared experiences) psychosocial projects, rather than delegating them to underpaid voluntary organizations that remain subordinate to the professionals themselves.
Moving away from the current, excessive reliance on the clinical realm requires firm yet gradual steps through projects aimed at rebalancing the clinical and psychosocial approaches. This can be achieved by according greater dignity and autonomy to the psychosocial sector—viewing it not merely as an extension of the clinical sector, but as something unique and valuable that emerges from collaboration with diverse local communities (drawing on local knowledge).
Basaglia’s famous motto—“Illness must be bracketed”—which addressed the difficulty of defining mental suffering simply as an illness, should still hold true today. Yet now, it seems the medical model of illness is no longer being called into question.
There is a lack of epistemological clarity regarding the vast majority of diagnostic categories used in the mental health sector; the impression is given that these categories correspond to diseases, whereas—apart from organic, genetic, and toxic disorders—they are merely syndromes. While diseases have a definitive causal explanation, no such definitive explanation exists for syndromes, or it remains merely hypothetical. In the realm of mental health, syndromes are social constructs devised by DSM committees that subsequently find expression in society. The disease model appears simple and appealing because it holds out great promise, yet it is often misleading due to the way it is promoted and perceived. Credence is given to pseudoscientific models, and diagnoses are reified -25-. Common sense and the relationships we have with those around us are no longer valued. Practitioners with both clinical and psychosocial interests can help clarify this epistemological confusion.
The current replication of the project in England appears to confirm its feasibility in diverse contexts. The synergy between the Italian SE&LMH projects and those in Watford and Enfield—facilitated by collaborations with organizations such as MHE and CPN—contributes to advancing key themes: co-creation; the development of legislation supporting a participatory psychosocial approach; the deprescribing of psychiatric medication26; the implementation of “Hearing Voices” groups based on the Romme method; and, regarding the issue of diagnosis, monitoring the development of the sixth edition of the DSM (scheduled for the end of this decade)27.
Nevertheless, the project’s cornerstone remains the involvement of local communities and the transition from clinical settings to community-based environments through the engagement of all stakeholders. Within the project, reclaiming citizenship—understood as civic life, a sense of belonging, and participation in community development—emerges as an essential element for both individual and collective mental health. This is a complex undertaking requiring time and collective commitment from services, local communities, and associations of service users and their families/carers. Yet, this appears to be one of the few ways to rebalance global knowledge with local knowledge and enable responses that better meet people’s needs.
References
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27. Niall McLaren Announcing … DSM-6 – Niall McLaren on Critical Psychiatry
About the author
Pino Pini is an Italian psychiatrist who worked for decades in the public mental health services of Florence and Prato, directly experiencing the deinstitutionalisation process in relation to Law 180 (1978).
For over ten years he has been practising in the NHS North London Mental Health Trust, United Kingdom. He is a board member of Mental Health Europe (MHE) and a long-standing advocate of community-based, psychosocial approaches within the critical psychiatry movement.
