1. MENTAL WELL-BEING IS A RIGHT, NOT A PRIVILEGE

We specifically use the word well-being – as opposed to health – both within the overcoming of a biomedical paradigm, and in accordance with emerging terminology and with the indicators used by the United Nations and national bodies (for example Istat).

The right to health is one of the fundamental rights in people’s lives, regardless of age, gender or socio-economic background. The World Health Organization (WHO) states that health is an overall state of physical, mental and social well-being and not merely the absence of disease or infirmity. In this sense, it also refers to mental health, as the United Nations has repeatedly stated.

According to the definition of the United Nations High Commissioner for Human Rights  (Special Rapporteur), in The right to mental health^[1], mental health is described as:

[…] a state of good emotional and social well-being and healthy and non-violent relationships between individuals and groups, characterized by mutual trust, tolerance and respect for the dignity of each person.

The right to health requires that mental health support be brought more closely to primary care and general medicine. In the report on the right to health in early childhood (A/70/213), Special Rapporteur Dainius Puras addresses the need to bring effective psychosocial interventions. In the reports on the right to health of adolescents (A/HRC/32/32) and about corruption and the right to health (A/72/137), specific chapters are dedicated to mental health, as well as devoting space to the right to mental health in each of his country reports.

According to ISTAT (Italy) the “subjective well-being”^[2] is one of the “12 dimensions of equitable and sustainable well-being”.^[3]

Furthermore, according to the WHO, the determinants of mental health and mental disorders do not derive only from endogenous factors of the individual – such as the personal ability to manage one’s own thoughts and emotions – but also from exogenous factors, such as the cultural, social and political context. For this reason, the role of states is essential to ensure the highest attainable standard of health. The Special Rapporteur for the Right to Health underlines the need to ensure that people with mental disorders and psychosocial disabilities have the authority to influence the planning and implementation of mental health policies, laws and services, as confirmed by the WHO Mental Health Action Plan 2013-2020[4]. This clarifies that the right to mental health does not establish a mere obligation of the State to treat the patient, but aims, instead, to facilitate the participation of the individual in his health and thus allow him to exercise his autonomy and, in a certain sense, his right to self-determination.

Furthermore, since the right to mental health is fully part of the right to health, States have the obligation to allocate as many resources as possible to ensure its effective protection. Today, however, less than 7% of the health budget is earmarked for such purpose, with per capita expenditure of less than $2 per year and $0.25 in low-income countries.

Some countries have made great strides in including psychotherapy in the health system, particularly in the UK and Australia. A significant reference in this regard is the IAPT programme (Improving Access to Psychological Therapies)^[5] distributed at national level by the NHS in the UK: it is a completely free mental health support program to help people (especially people with mild to moderate anxiety or depression) manage life’s “challenges” and access to psychological support.

As we see in this first analysis, the term ‘mental well-being’ appears only intermittently and incorporated into that of Health. An important step forward to be made

——————————————————————————————————

[1] https://www.ohchr.org/en/special-procedures/sr-health/right-mental-health

[1] https://www4.istat.it/it/benessere-e-sostenibilit%C3%A0/misure-del-benessere/le-12-dimensioni-del-benessere/benessere-soggettivo

[1] https://www4.istat.it/it/benessere-e-sostenibilit%C3%A0/misure-del-benessere/le-12-dimensioni-del-benessere

[1] https://www.salute.gov.it/portale/documentazione/p6_2_2_1.jsp?id=2448&lingua=italiano   e  pdf

[1] Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. https://www.england.nhs.uk/mental-health/adults/iapt/

2. MENTAL WELL-BEING: NOT ONLY THE ABSENCE OF SERIOUS AND MANIFEST PATHOLOGY, BUT ALSO THE RIGHT TO GROW AND STRENGTHEN, FULLY DEVELOP YOUR OWN LIFE’S POTENTIAL ACCORDING TO AMARTYA SEN’S CAPABILITY APPROACH

According to the United Nations, a good mental health means much more than the absence of a mental disability, and there is no health without mental health.

Attention: talking about human well-being and the right to happiness and growth and considering psychotherapy a vector of growth and social change, leads inevitably to the overcoming of that biomedical paradigm considered a serious problem also by the United Nations.

ISTAT: Subjective well-being

The concept of personal or subjective well-being in public policies is now present in several states, including Italy. ISTAT summarizes the notion of subjective well-being and provides some indicators.

Perceptions and assessments inevitably influence how people approach life and take advantage of opportunities. The “subjective well-being” (BES) has a transversal character, as it can be referred both to specific areas of life, and to life as a whole. The proposed “subjective well-being” domain, in fact, concerns the assessments and perceptions expressed directly by individuals about their life in general, but also those referring to more specific areas, which may refer to the different domains of the BES. In this sense, some of the indicators identified will complete the framework of these domains, among which, for example, the one on satisfaction with family relationships, included in the domain social relations.

Dimensions considered for the representation of the domain

The concept of “subjective well-being” is identified by the following two dimensions:

1. Cognitive dimension. It represents the process through which each individual evaluates (in terms of “satisfaction”) retrospectively his own life, viewed as a whole; this subjective evaluation is made by referring to certain personal standards (expectations, desires, ideals, past experiences, etc.). This awareness allows you to express a level of satisfaction according to the achievement of your goals, the realization of your aspirations, the comparison with your ideals, with your past experiences or with the results achieved by other significant figures. In other words, life satisfaction is the result of an individual’s cognitive process that evaluates his situation with respect to standards (Nuvolati, 2002) defined in relation to several aspects.

2. Affective dimension. It indicates the emotions experienced during daily life. Such emotions can be positive (pleasant affects) or negative (unpleasant affects) and are conceptually treated in a distinct way, because they are determined by different variables (Bradburn, 1969; Diener/Emmons, 1984; Argyle, 1987). As opposed to the cognitive component, which implies a later reflection on one’s own life up to a certain moment, the affective component is linked to the present, to the current situation.

The research to measure the affective component is in progress; therefore, in this phase the definition of the indicators proposed to the BES will refer only to the cognitive component.

In the Capability Approach of the Nobel Prize for Economics, Amartya Sen, man is considered a complex individuality with the right to be able to fully develop his life’s potential. Sen’s paradigmatic reversal is linked to the need to enjoy collective and individual conditions that allow the individual to choose who he wants to be and express the best of himself. This concept makes clear, in addition to the conditions of objective well-being, the fundamental role of psychotherapy not only to “cure” disabilities and mental “problems”, but to enable people and help them to grow in freedom and well-being, on the basis of indicators already partly developed (vd. ISTAT), and partly to be agreed in the psychotherapeutic field.

3. ABANDONING THE MEDICAL PARADIGM: CHANGING WORDS AND NARRATION.

In 2017, the United Nations Special Rapporteur issued a ground-breaking report addressing the “global burden of obstacles” in mental health settings and in the field of psychiatry, pointing to the dominance of the biomedical paradigm as the first “obstacle”.[1]

Tale atteggiamento allontana ampissime fasce di popolazione, soprattutto gli uomini e le fasce di reddito e istruzione più basse. If psychotherapy really wants to get out of the biomedical paradigm, it must renew words, narration and, sometimes, purpose: to speak of a “person in therapy“, rather than a “patient“, of “growth“, as well as of “cure“, of “well-being“, before than “health“. It is precisely the language used to strengthen the cultural access barriers to psychotherapy (those who go “to treatment” by the psychotherapist will certainly be “sick“: in fact we are the ones who define it that way). This attitude turns away very large groups of the population, especially men and the lowest income and education groups.

[1] https://documents-dds-ny.un.org/doc/UNDOC/GEN/G17/076/04/PDF/G1707604.pdf?OpenElement

4. PSYCHOTHERAPY VIEWED “FROM THE PATIENT’S PERSPECTIVE” AND HIS ACCESS NEEDS.

In a world that is increasingly evolving towards smart working and remote use, in which neighboring areas such as training have reached extraordinary maturity and effectiveness, it is impossible to think of a purely present setting. We aim to structure a truly effective remote or hybrid setting. A basic scepticism seems to prevail among many colleagues (already experienced in the late 1990s – 1998 – when I introduced remote learning in the non-profit sector in Europe with ASVI – Agency for the Development of Non-Profit[1]). Both on the basis of that experience and of that as a psychotherapist, we propose a hybrid mode, on which we are focusing research, collecting and updating data.

[1] Now Social Change School www.socialchangeschool.org

5. ON LINE AND HYBRID PSYCHOTHERAPY, AS WELL AS FOR TRAINING, CAN BE A STRONG ENGINE FOR SOCIALIZATION TO BREAK DOWN THE BARRIERS OF LOGISTICAL, ECONOMIC AND CULTURAL ACCESS AND REACH WIDER BANDS OF THE POPULATION.

As for training, there cannot be a naive expectation that the ‘online’ or hybrid could be the appropriate mode for all types of intervention (it is certainly not ideal for therapeutic groups or family therapy) and for all types of people in therapy (eg in case of major depression). However, we are sure that a greater ‘social’ presence and a controlled and quality expansion of the therapeutic setting can make the difference in terms of social impact, helping to spread psychotherapy in new contexts and ‘reach’ a large audience very little, badly or not at all covered to date. Taking back very relevant spaces of meaning, impact and market. It is within this “horizon of meaning” – and not just of mere “delivery” – that this Manifesto seems to us a useful contribution to a shared reflection.

The ‘Position Paper on Online and Hybrid Therapy’ of a Social Psychotherapist is expected to be published shortly.

6. THE PSYCHOTHERAPIST MUST FEEL MORE AND WITH GREATER PRIDE AS A SOCIAL ACTOR, MORE THAN A LONELY PROFESSIONAL.

We believe that psychotherapy both as ‘cure‘ and ‘growth‘ should ‘socialize‘, be easily accessible, be considered a precious ‘common good’ not to be segregated in private studies. Take back a ‘social space’, semi- abandoned to hosts of ‘life-coach’ willing but not always with the proper preparation for the complexity’ at stake. We think that hybrid and on-line psychotherapy can support this process. And, as it was for training, reach wider population groups easier.

Taking up a bit of that revolutionary spirit of social psychiatry that had characterized the 70s and gave rise to the phenomenon – now structural, with 700,000 employees and xx billion in turnover – of social cooperation.

The subject seems to be treated more from the point of view of the ‘psychotherapist in the social’ rather than from the professional identity. However, several colleagues have somehow focused on the need for a paradigm shift, eg. D’Elia, L. (2020), The social function of the psychotherapist, Alpes, Rome[1], where Social psychotherapy is an “umbrella term within which are enclosed a varied series of practices, often isolated and fragmented, united by the need to lower the barriers, including economic ones, which separate a part of the population from some mental health services, such as psychotherapies[2]“.

Concerning psychotherapy and social change, we have Spaner, F. E. (1970)[3] who argues that psychotherapy intended as a vehicle for individual change is not distinguished from psychotherapy as a vehicle for social change.

F. Korten e S. W. Cook[4], believe that the psychotherapist has a duty to influence and promote the process of change in society and discuss the cultural context of psychotherapy, as well as the issues that need to be studied[5].

___________________

[1] The book’s stated goal: to fill a training gap relating to the path of every psychotherapist who faces clinical problems in a social medium in constant and very rapid change. This gap concerns, for the author, both the theoretical-conceptual level (there is no social psychotherapy, at least in Italy, despite the multiplication of initiatives with this intention), and the clinical level (it is not at all clear how and where an awareness of social function should be translated into clinical practice).

[2] From https://sportellotiascolto.it/2021/01/07/psicoterapia-sociale-e-capacitazione-accessibilita/

[3] Spaner, F. E. (1970), “The psychotherapist as an activist in social change: A proponent”. In F. F. Korten, S. W. Cook, & J. I. Lacey (Eds.), Psychology and the problems of society (pp. 58–62).

[4] In F. F. Korten, S. W. Cook, & J. I. Lacey (Eds.), Psychology and the problems of society (pp. 58–62). American Psychological Association. – https://psycnet.apa.org/record/2004-15424-004

Marco Crescenzi – credits

Experimental Social Psychologist and Cognitive-Behavioral Psychotherapist at the II Center for Behavioral and Cognitive Psychotherapy in Via degli Scipioni, Rome.

Member of the Order of Psychologists Section A, n. 4311 (resolution of 20/12/1993).

Member of SITC – Italian Society of Behavioral and Cognitive Psychotherapy.and EABTC- European Association for Behavioural and Cognitive Therapies,

Collaborator of the Department of Social Psychology, University of Rome, period 1988-1992.

Founder and scientific director of the program and of the site “Social Psychotherapist”.

Supervisor of the Platform of the NGO ‘Necessito Terapia’, Madrid, Spain.

Founder and President of the Social Change School, since 1997, a leading institution in the training of non-profit managers, with which he introduced online management training for the Third Sector in Europe.

Author since 1998 of numerous specialized and popular publications, he writes on the blogs of Huffington Post and Il Fatto Quotidiano and is among the referents for the Italian media on the issues of work in the non-profit sector.

Institutional documents and references

This paper, while proposing a paradigm shift, is in continuity with the ongoing institutional framework provided by UN, WHO, Istat. Among the most interesting documents we mention:

• “The world must change the way mental health challenges are addressed, UN expert says,” issued 6 July 2020
• “COVID-19 has exacerbated the historical neglect of dignified mental health care, especially for those in institutions: UN expert,” issued on 23 June 2020
• “Major changes to suicide prevention needed, with rights-based approach to make life ‘more liveable’ — UN expert,” on the World Mental Health Day on 10 October 2019
• “UN expert highlights importance of social relationships for mental health and well-being,” issued on 24 June 2019
• “World needs ‘revolution’ in mental health care – UN rights expert,” issued on 6 June 2017
• UN rights expert urges shift away from drugs in addressing depression – World Health Day – Friday 7 April 2017
• “South Africa: UN experts shocked by death of at least 37 people in flawed relocation process from psychiatric hospitals,” issued on 2 December 2016

• OMS, “Mental Health Legislation & Human Rights”,2003, Nazioni Unite, “Convenzione sui diritti delle persone con disabilità”, 6 dicembre 2006
• United Nations Human Rights Office of the High Commissioner, “Consultation on Human Rights and mental health: Identifying strategies to promote human rights in mental health”,2018
• Lo Spiegone, “Il diritto alla salute come diritto umano”, 2020
• Cameron, “Mental Health Law: International Legal Standards and Human Rights”, Legal Dialogue from Civil Society, 2017

Wide debate with stakeholders: below we supply some exchanges undertaken (Responses from Stakeholders in the UN debate)..

The Special Rapporteur’s 2020 report on a human rights-based global agenda for mental health and human rights triggered a response from the World Psychiatric Association (WPA) and the World Medical Association (WMA). See letter (7 August 2020).

The Special Rapporteur’s 2017 report on mental health triggered various responses from different stakeholders as follows:

• The World Medical Association, WMA (26 Jun 2017)
• A wide variety of organisations including Mental Health Europe and the British Psychological Society, as well as individuals representing people with personal experience of mental health services, professionals and academics (8 August 2017)
• The Word Psychiatric Association, WPA (29 August 2017)
• The German Association for Child and Adolescent Psychiatry (12 Sept 2017)
• The European Psychiatric Association, EPA (26 Sept 2017
• The Society of Biological Psychiatry, SOBP (26 Sept 2017)
• The International College of Neuropsychopharmacology, CINP (27 Sept 2017)
• The European College of Neuropsychopharmacology, ECNP (6 Oct 2017)
• The European Brain Council, EBC (12 Oct 2017)

Other

Position Paper sulla Terapia On line ed Ibrida’ di Psicoterapeuta Sociale, di prossima pubblicazione

Notes.

In Italy there is a Register of Sustainable Psychotherapy Organizations of the Order of Psychologists of the Lazio Region.

In Piedmont there is a social psychotherapy network (Piedmont) created in 2016 https://retepsicoterapiasociale.jimdofree.com/

Beside the Service there are social psychotherapy clinics such as in Turin – https://www.ambulatoriosocialepsicoterapia.com/,
Social Psychotherapy Clinic (Opera Don Calabria) – https://psicoterapia-accessibile.it/.