"Everything communicates, even silence"

What is not said does not exist, and what is not communicated says more than words. "Everything communicates, even silence", is a guiding principle in the recommendations of the Citizens' Assembly on Mental Health in the autonomous Spanish community of Valencia. In this way, the participants wanted to make it clear that more needs to be said about mental illness. "How should mental health, drug addiction and addictive behaviour be addressed in the Valencian Community?" This was the question to which the Citizens' Assembly sought answers in four meetings from 5 March to 2 April 2022.

The assembly participants were concerned that mental health, in all its aspects, is an invisible reality. The deficits identified range from education to the lack of initial diagnoses for mental illness, as well as staff shortages and lack of available funding in the public health system. The COVID-19 pandemic, according to assembly participants, showed that mental health is a problem that has not been talked about.

Recommendations basis for action plan

The last Citizens' Assembly meeting ended with the formulation of seven guidelines and about 20 recommendations to serve as the basis for an action plan. The 70 randomly selected participants of the Citizens' Assembly had listened to mental health experts in their meetings and discussed their input. On this basis, a citizens' report characterised by a broad consensus emerged. All proposals received at least 60 per cent of the votes.

For example, the Citizens' Assembly proposes that a study be conducted on mental health problems, drug addiction and addictive behaviour, and that the resources available for prevention and care in each health sector be identified. "We recommend this because mental health problems have evolved and changed with society and because there are imbalances in infrastructure and resources in different areas," the participants stress.

Raise awareness of mental illness

The Citizens' Assembly also recommends that the government raises awareness of mental health problems, addictive behaviour and drug dependence through information and awareness campaigns in the mass media. "We recommend this because we believe there is a problem of ignorance about mental health problems and a resulting social rejection, and about where to turn when needed," the citizens' report says. It also calls for good accessibility of this information. The issue should be given visibility through the media.

The assembly participants also want a plan to increase or redistribute existing resources and a review of this plan every four years to adjust it to the needs. Among the recommendations on material and human resources, the participants placed particular emphasis on the training of staff already working in the health and education sectors, as well as on a distribution of resources that should not be based on quotas but on the real needs of the population areas. Another recommendation concerns prevention in the workplace, including through workplace risk plans.

Recommendations under consideration

The Citizens' Assembly recommendations were sorted by topic and professionally assessed by experts, people with mental illnesses and trade unions, as well as by the responsible ministries. An implementation plan should have been available before summer 2022 so that the first measures can be included in the next budget, which will be negotiated in September. The drafting process will be supervised by representatives of the assembly participants.

The government of the Valencian Community has committed to respond in writing to each of the Citizens' Assembly recommendations one month, six months and one year after their publication.

"A sign of empathetic society"

"The recommendations will serve as a guide to design all possible futures," said Prime Minister Ximo Puig at the last meeting of the Citizens' Assembly. He praised the assembly as a sign of "an empathetic society that does not look away, that is not indifferent" to social problems.

Rafael Tabarés, government commissioner for mental health, is "really impressed by this process. It is very impressive to see how people with a very superficial and relative knowledge of such a complex issue as mental health have such a great capacity to listen, learn, dialogue and consult. The citizens invited were able to make very wise and informed recommendations."

"An example of democratic renewal"

For the Health Commissioner, the Citizens' Assembly is "an example of justice and democratic renewal. Citizens are moving up the ladder with this kind of process." The deliberative citizen, he said, is the next level, the one who is engaged, who has a genuine and real interest. The citizen who longs for democracy and is dissatisfied with being just a voting citizen because he or she distrusts the current democracy in the face of corruption and polarisation.

Such people are "able to participate in citizens' assemblies because they are treated with respect, because they are informed, because they can ask questions and because they can think about it. Deliberation is fundamental: "It is not about debates, but about dialogue and the elaboration of positions aimed at the common good," Tabarés explained.

9,000 people invited

For the Citizens' Assembly, the Ministry of Health had drawn a sample of 9,000 people from the Autonomous Community's population register, taking into account the criteria of income level, urban/rural, age, gender, province and health department of residence. From the applications of interested persons received thereafter, 70 full members and 70 substitute members were anonymously selected to provide a reflection of the population of the community.The Citizens' Assembly process was supervised by a panel of experts and a monitoring committee.

On 6 September 2022, Rafael Tabarés, as Commissioner for the Valencian Action Plan on Mental Health, Drug Addiction and Addictive Behaviour, announced that, in coordination with the regional Ministry of Education, Culture and Sport, he would launch a training programme on social-emotional education for teachers in public schools and vocational training centres in the Valencian Community in the school year 2023/24.

Government plans

On 23 November 2022, the Government of the Valencian Community presented its proposals to improve the treatment of mental illness. They are aimed at promoting the mental health of the population as a whole and of specific population groups, at preventing mental illness and suicide, and at eliminating the stigmatisation of people with mental disorders.

It also aims to promote research in this field and its application in clinical practice. Furthermore, the aim is to promote psychological treatments with the aim of freeing patients from medication and to support clinical psychologists. The number of social psychology professionals should meet the specified quotas in relation to the number of inhabitants.

Read more: Convenció ciutadana sobre la salut mental