Dr. Ricardo Guinea – Psychosocial Rehabilitation

World Association for Psychosocial Rehabilitation Image of woman sitting stairs of a marble building
Around the world there are vastly different ways people with mental health issues receive treatment. At worst, they’re removed from their families and institutionalized in psychiatric hospitals, given sub-par treatment and alienated from society. But the World Association for Psychosocial Rehabilitation (WAPR), an international non-governmental agency, is working diligently to educate countries and practitioners around the globe about a more integrative, humane approach.

Psychosocial rehabilitation is a process that facilitates the opportunity for those with long-term mental health issues reach their highest level of functioning within the community. In other words, it’s personalized treatment focusing on helping individuals develop skills and access the resources needed to live meaningful lives. Recently, ABILITY spoke via SKYPE with WAPR’s president, Ricardo Guinea, MD, who is based in Spain, about the organization’s mission, successes and challenges.

Chet Cooper: Can you give us some background on WAPR, when it started and its mission?

Dr. Ricardo Guinea: Yes. It’s a professional organization that was created in the last decade of the last century by a group of psychiatrists, psychologists and other mental health professionals. We are interested in improving the psychosocial rehabilitation of people who are disabled due to a mental illness. The approach is very community-based. I realize the term “mental illness” can be controversial for some groups, but this is, I think, the clearest way to state it.

We’ve been working for the last 30 years trying to improve treatment options. We have a declaration that states what we define as proper attention and care. It is in our founding document, which is on our website, and states that it should be a good treatment with all kinds of social support for the person that includes family and the wider community. To accomplish this in various countries, it requires a lot of intervention in terms of politics, improving facilities and training professionals. Of course, we are advocating a community-based approach as opposed to an institutional approach. We think people should receive the best support possible in an environment with his or her family, and that offers all kinds of social support, access to work, and so on.

We need to change the philosophy of how help is provided for people affected by mental illnesses. When we started, institutionalized treatment was the most common approach. In many parts of the world, it is still the norm—someone receiving treatment will likely be put inside a hospital and might receive good or maybe not-so-good treatment. So the philosophy we try to spread is, “OK, colleagues, we have to change this perspective. We have to provide patients with the best possible treatment in their homes, and we have to think beyond just providing treatment, but helping patients access work and so forth.”

Cooper: How do you promote this approach internationally?

Guinea: We don’t receive a lot of support. We are not a wealthy organization, so our main tool is to offer training wherever needed. Sometimes it involves participating in mental health conferences for professionals. Sometimes we collaborate with organizations to provide training in both developed and developing countries. We try to provide training everywhere. In developed countries our main tool, for instance, is our World Congress. We have a World Congress every three years, but between congresses we have a lot of small, local and regional conferences, where we can explain our philosophy. Slowly, I think, this philosophy is being accepted more and more everywhere.

Cooper: So when you talk about training, do you have best practices? Do you have examples of the differences between the conventional, old-school methods compared to what WAPR advocates?

Guinea: Yes. We have all kinds of things we consider good practices, but what can be considered good practice varies a lot depending upon the country. In a developed country, for instance, good practices a couple of years ago could be, “OK, we should try to reduce the number of long-term beds in psychiatric hospitals. We don’t like psychiatric hospitals. We want to offer different types of treatment.” But in middle-developing countries where mental health is receiving very, very little attention from the states’ health and social ministries, we try to push by saying, “OK, your government needs to offer a network of services for the people.” For example, one big success over the last few years is Peru.

Four years ago we toured Latin America, and in Peru we succeeded in connecting with some key professionals at the right time. They began to push for full psychiatric reform. When we first went there, there were only old-fashioned psychiatric hospitals in the middle of big cities. This was the normal situation in many, many countries in the world. But then, they understood this philosophy, and they said, “OK, you are right. We will begin with psychiatric reform.” They opened a lot of community centers in many different places around the country, not only in the big cities, but also in accessible areas where people could go frequently to receive support, advice and medication when necessary. This is an example of what we do.

Cooper: So the idea is to replace hospitals with community centers that allow people to receive treatment but live on their own or with their families?

Guinea: Yes, but in Peru, for instance, the success involved a very complex strategy. They have trained hundreds of professionals in this new approach. By professionals, I mean psychiatrists, psychologists, social workers, occupational therapists and even teachers. And instead of people going to these old-fashioned mental hospitals in the middle of the cities for treatment, they go to a community center in their neighborhood. Individuals and their families should go there to receive advice about treatment and support. This should be a good practice, for instance.

Cooper: Right, but do you also address human rights? 

Guinea: Yes! In other places, for instance, we talk about the importance of human rights. There are still many broken places in the world where there is no possibility of support or advice if you suffer from a mental illness. So the only possibility is to have very, very, very bad institutional treatment, which is not actually treatment. This is the old-fashioned way. They put patients inside an institution who receive no treatment. So in these kinds of places, we try to educate the policymakers by saying, “OK, you should spend some money to help people with these kinds of problems, and furthermore, the way you are treating people in these very bad places is against the Declaration of Human Rights.”

Cooper: In Peru, were they able to find the funding to support community centers and train staff?

Guinea: Well, yes. In this particular situation, in Peru, for instance, the funding for training came from European foundations.

Cooper: Oh, OK.

Guinea: So European foundations, for instance, paid for some professionals from Peru to come to Europe and see with their own eyes how things are done here in Spain. And also some specialists have gone to Peru to teach hundreds of professionals in the new model. And now the university is becoming more interested in this approach, so some degrees and master’s degrees are beginning to be implemented there for the activity. And of no less importance, the government is beginning to pay for new professionals out of the mental hospitals. So it is a combination of things.

Cooper: Very nice. What is the biggest struggle your organization is facing now?

Guinea: Well, as an organization, one struggle we have to face is our very limited resources. We do not receive any money from the medical industry. And we fund ourselves from our conferences when there is some kind of surplus, from the dues from members. And sometimes we’ve found partners for particular projects. The financial struggle is ongoing.

Another struggle we face is that it’s very slow and difficult to implement this kind of transformation. We’ve been working at it for 30 years. I am the 13th president of our organization. Things are better in some places, slightly better in other places, and we are aware that the task we have ahead is so huge that this will take a lot of time to improve the situation to the extent it needs to be.

Cooper: Is Peru currently the best example of your organization’s success thus far?

Guinea: It is only an example. For instance, Spain, the country where I live and work, could be an important success. We made our psychiatric reform some 25, 30 years ago. Of course, it is not the only agency doing this kind of work. There is a lot of synergy with other organizations and with committed professionals who work on these issues. But maybe Spain could be considered a good example. Another success is that we have now a number of research and training centers in different parts of the world, which has happened during my presidency. We now have a number of places in Egypt, in the United Arab Emirates, in Colombia, in Kenya, in Norway, and we will probably have a number of new centers to disseminate good practices and to conduct research in our field to provide new evidence and new credibility for our strategies.

Cooper: That’s good. You mentioned other organizations doing similar work. What makes your organization unique?

Guinea: Well, I don’t think we are unique. (laughter) We are humble, and I think we are good people, but you have the World Federation for Mental Health working in a similar way. We work along—not together—with other organizations that have similar views to ours. There are plenty of them. We work with a lot of national organizations. We are an umbrella organization. A lot of national organizations are doing the work in a lot of countries. We have representation in 40 countries and with 40 national organizations doing the job in those countries.

Cooper: So that’s why you’re being humble, because there are organizations you work with that are doing some of the same things, but you’re doing something different, or you wouldn’t exist. I would think that there is a need for the organization to exist.

Guinea: Yes, yes. I think as a professional organization, we are quite different from other organizations. For instance, you have the World Psychiatric Association (WPA), which is the biggest psychiatric organization in the world. In WPA there are a lot of different opinions. You have quite conservative and progressive opinions. When I say “conservative,” it is medical organizations that have a medical and biological approach to these problems. And when I say “advanced,” I mean people who believe mental illness or disability is a construct with biological, psychological, and social aspects, and we have to work in all of the aspects.

What is particular to us is that we work on the psychological and social aspects. And we are not very keen to be near the drug industry. It is another line.

Cooper: I picked that up. Do you know Dr. Liberman out of UCLA?

Guinea: Yes, of course. I met him at a conference. We are not friends, but I know him.

Cooper: Oh, good! We did a two-part article on him years ago about his work in psychosocial rehabilitation.

Guinea: I think he was one of the pioneers in that field of research, along with maybe Marianne Farkas and William Anthony in Boston. There are also people working in different parts of the world. You find people doing a very nice job in Brazil, Thailand and Spain. But Bob Liberman was coming from the US and was one of the pioneers in writing and doing worldwide research on psychosocial psychology.

Cooper: I’m glad you met him. Are you familiar with the United Nation’s (UN) Convention on the Rights of Persons with Disabilities (CRPD)? 

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Guinea: Oh, yes, of course I’m familiar with it. I’m actually writing an article about it right now for a journal.

Cooper: Tell me about that. Have you been able to attend any of the Convention or the state parties? It’s usually held in June in New York.

Guinea: No, unfortunately I’m not able to go.

Cooper: That’s where we go. How is your organization connected with the UN?

Guinea: We used to be connected with the UN, but it is kind of expensive to be connected with all organizations. We had to pay dues of $1,000 to the UN each year. But the relationship became a bit “loosey.”

Cooper: (laughs)

Guinea: We also were connected with the World Health Organization (WHO), but there are more and more requirements. So our connection is quite loose with different organizations. We have agreements with the Western Psychological Association (WPA) and other professional organizations. But since we do not run programs that require a lot of money, our links are quite theoretical. When we can, we used to have a representative in the UN committees. But this person retired. (laughs) So now we don’t have a connection with the UN.

Cooper: Who are you working with for this paper on the CRPD? How did that come about?

Guinea: The paper is for a Brazilian journal. Last month I was in Florianópolis in Brazil. There was a conference there organized by the Brazilian organization for mental health. The topic was “Citizenship and Human Rights in Mental Health,” which is our approach. So I am working on the meaning of the UN Declaration of Human Rights and the UN Declaration of the Rights of People with Disabilities in the field of mental health. That is what I am writing about in this article.

Cooper: Have you looked at the current rules and at what the CRPD has produced around mental health?

Guinea: Yes, I’m quite familiar with that.

Cooper: Are you writing it in such a way that will support it or maybe identify a better approach to what they’ve written so far?

Guinea: Well, no. Personally speaking, and I say personally speaking because our organization has not made an agreement or a comment on that. Most of our delegates support our approach. But still, there are some remaining discussions about how these declarations should be implemented. I think we support the philosophy of these declarations, and in particular, for instance, we support the philosophy of no coercion, no forced treatment, and the right to receive not only treatment but to maintain civil rights. For us, this means states and policymakers must work to make this chapter of rights effective by investing more in mental health, which is basic, because the investment in mental health is very, very slow in most countries, in particular with other aspects of medical treatment. So we believe in the principle of equity, which means everyone should receive the right treatment and support, and there should be no excuses about lack of funding.

Cooper: How do you deal with patients who have spiraled into psychosis in such a way that they may potentially harm themselves or others?

Guinea: Well, this is one of the more difficult issues to address. From my perspective, a good relationship—and by that I mean a collaborative relationship with the person who is seeking help—is the basis for everything. We should work toward a positive, collaborative relationship. This means professionals should have the training to understand that and also the time to invest, because this kind of approach requires time and training. This would be my first approach.

There are a number of issues under discussion about how to better ensure the protection of a person who is mentally distressed and unable to make the best decisions about his or her life. Of course we are, as I said before, trying to exclude any type of coercion and instead explore all possibilities for a collaborative approach.

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