Psychiatric care in Spain has undergone significant changes in recent decades, both in terms of legislation and concept, with the purpose of establishing a model of care for people with mental health problems (MH), integrated into the social and healthcare network and guaranteeing care of equal quality and excellence to that provided to people with other health problems.1

Among the changes that have taken place in the care of MH problems in recent decades are the integration of psychiatry with the rest of medicine; improved knowledge of the pathophysiological bases of symptomatology; the discovery of genetic risk factors for different psychopathological dimensions and mental disorders; the integration of more effective and efficient psychotherapeutic techniques, and the development of safer and better tolerated drugs.1,2

María Moliner's “Dictionary of Spanish Use” defines “humanise” as: “to make something more humane, less cruel, less hard for mankind”.3 In the context of health and social-health care, humanisation implies an approach to the person with health problems as a person and not as a problem or illness, in terms of human quality, promoting empathy and a holistic approach.4–7 Of course, MH must be included in this humanisation process. Humanisation is not restricted to healthcare professionals in contact with patients, but affects the culture of healthcare organisations, administration and healthcare policies.4,5

Humanisation is both in the spirit and the letter of the documents that underpin the framework of MH care, such as the UN Declaration of Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care,8 the UN Convention on the Rights of Persons with Disabilities9–11 or the World Health Organisation's Global Mental Health Action Plan 2013-2020 (according to which “regardless of age, gender, socio-economic status, ethnicity or sexual orientation, and in accordance with the principle of equity, people with mental disorders should be able to access, without risk of impoverishment, essential health and mental health care services that enable them to recover and enjoy the highest attainable standard of health”12).

However, despite this progress, there are still many challenges, especially in the field of humanisation of MH care, which the various MH plans and strategies, both at national and regional level, are attempting to resolve. In Spain, the latest National Health System (NHS) MS strategy is that of 2009-2013.13 Currently, and after more than 8 years of fruitless work, a new NHS MS strategy “promoted under the basic principles of respect and autonomy and the recovery of the rights of people with MS problems”14 is in the process of being drawn up. It is to be hoped that this new plan will prioritise the promotion of emotional well-being in all areas, promote the participation of people with SM problems and their families, taking into account their needs, expectations, experiences and relationship with the social environment, and highlight education for SM as a tool to combat any kind of stigmatisation. This is in line with international recommendations for the humanisation of MH care.

In this context, this study presents the results of a project guided and organised by the HUMANS Foundation, whose objectives were: 1) to identify, through expert consensus, which measures and actions related to humanisation are included in the MH plans of the Autonomous Communities (ACs) of Spain; 2) to analyse the implementation of humanisation measures and actions in each of the different MH plans and strategies of the ACs, and 3) to identify, through expert consensus, common and priority key points when designing and implementing a common and homogeneous strategy for quality and sustainable MH, which takes into account, above all, people with MH problems and their environment, and which provides the necessary and most appropriate resources for the promotion of their recovery.

The HUMANS Foundation promoted and developed this project between September 2018 and February 2019. The HUMANS Foundation is a foundation made up of leading professionals and institutions from the social and healthcare world, whose main objective is to facilitate humanisation processes in healthcare organisations, in professional attitudes and in the organisational processes of healthcare centres.

The working group of this project was made up of professionals in the field of MH, users of the MH network, patient and family associations, heads of institutions and politicians and social agents involved MH care throughout Spain. The project was developed in sequential phases in accordance with the following objectives

Firstly, the group of experts identified the measures and actions related to humanisation that are included in the different MH plans of the Autonomous Regions. This task included the analysis of the current situation of the Autonomous Regions’ strategic MH plans in relation to the humanisation of healthcare. The collection of contributions from each expert was carried out using a modified Delphi method based on Design Thinking. Design Thinking is a process that focuses on solving the real needs of people, involving them in the solution from the beginning of the process by understanding their concerns and providing solutions adapted to the user.

Secondly, with the aim of analysing the implementation of humanisation measures and actions in the MH plans and strategies of the ACs, the heads of all the ACs were asked to complete a survey, agreed by the working group, on their perspective in relation to “humanisation in MH”. The survey included the following questions (Table 1): 1) Does your Autonomous Community have an MH plan with a specific section on humanisation? 2) Is there a line or action plan on humanisation in the current MH plan of your AC?, 3) Does the word humanisation appear in the mission, vision or values in the current MH plan of your AC?, 4) Does your AC have specific budget items aimed at promoting the humanisation of MH care? 5) Does your Autonomous Community have a specific person in charge of the plan or actions related to the humanisation of MH care? 6) Does your Autonomous Community have training programmes aimed at training all health and non-health personnel in contact with people with mental illnesses on MH? 7) Does your C.A. include training programmes aimed at health professionals related to the humanisation of health care in MH? 8) Does your C.A. have any measures aimed at encouraging the participation of people with MH problems and their relatives/relations in the plans for the improvement of services? 9) Does your AC have protocols/procedures/guidelines related to the humanisation of MH care, 10) Does your AC have specific measures aimed at reducing the number of mechanical restraints? 11) Does your C.A. have measures aimed at promoting and encouraging the rights of people with MH problems with regard to therapeutic decisions? 12) Does your C.A. have an agreement aimed at promoting adequate coordination between the judiciary and MH services? 13) Does your C.A. include measures to facilitate the participation of people with MH problems and/or family members/relations in the design of initiatives related to the humanisation of MH? 14) Does your local authority's MH plan include proposals for activities aimed at the attention and humanisation of care for people with mental illness who are particularly vulnerable and at high risk of social exclusion?, and 15) Does your local authority's MH plan include measures aimed at reducing stigma towards people with MH problems?

The questionnaire used to answer the second objective was developed by a multidisciplinary group based on the MH plan of one of the communities with an MH strategy.

Thirdly, a broad, multidisciplinary group of people involved in MH care (users of the MH network, patient and family associations, MH professionals, institutional and political decision-makers and social agents involved in MH care throughout Spain), proposed, after consensus, the key common and priority points that should be included in a common and homogeneous strategy for quality and sustainable MH, which takes into account, above all, people with MH problems and their environment, and which provides the necessary and most appropriate resources for the promotion of their recovery.

The multidisciplinary working group was made up of 21 people (12 men and 9 women) from Andalusia, Catalonia, Valencia, Extremadura, Galicia, Madrid and the Basque Country, and included professionals from health management, psychiatry, clinical psychology, nursing and social work, and representatives of associations of people with mental illness and MH problems and associations of relatives of people with mental illness and MH problems.

The multidisciplinary group discussion began with the identification of those involved in the humanisation of health care in MH. The technique used in this case was the so-called stakeholder map. This technique allows us to identify all the profiles involved in the specific field where it is applied. The aim is to gain a deeper understanding of the environment surrounding people with MH/citizenship problems in the field of MH. The stakeholders identified were: associations of people with SM problems and family members; psychiatric hospital care; primary care; research consortia; public sector employers and private sector employers; nursing staff; addiction/addictive behaviour specialists; community pharmacies; physiotherapists; security forces; media, administration and services staff; transport staff; education/education professionals; law enforcement agencies; emergency professionals; clinical psychologists; psychiatrists;, those responsible for the management and planning of MH care; prison health staff; the judicial system; scientific societies and professional associations; occupational therapists; social workers; universities (especially degrees in health sciences), and private health insurance. Once the stakeholder map was obtained, the group work continued, using the Point of View technique. This technique helps to synthesise the needs of people with MH problems/professionals and the cause of these needs, with the aim of carrying out a further study to find out how we could provide a solution to the issues raised.

The consensus processes were carried out, after the application of the modified Delphi method based on Design Thinking, by working in focus groups, composed of the members of the multidisciplinary group, with a Pareto analysis and Ishikawa (or fishbone) diagram, followed by sharing.

Advocacy for the humanisation of health care has been present in the medical and allied professions, with greater or lesser success, for centuries and, above all, since the mid-20th century.30,31 However, despite the significant efforts made in recent years to improve care in the field of MH,32,33 MH plans and strategies have not incorporated humanisation among their main objectives or lines of action, or have done so only very recently and only in some cases. For this reason, the results of this study are of particular importance, as they put on the table the current situation of humanisation in the different MH plans of the Autonomous Regions of Spain and propose, on the basis of a plural and multidisciplinary working group, a roadmap for improving the humanisation of MH care that should be a pillar of the expected MH strategy being prepared by the Spanish Ministry of Health.

Humanisation is a trendy word. It appears in medical congresses and conferences, it is talked about in debates and round tables. The administrative and political structure of several Autonomous Regions has created general directorates dedicated to the humanisation of healthcare.34 However, humanisation must go beyond documents and become action in health plans, it must serve as a spearhead in the fight against the stigma and discrimination at a social and general health level that many people with MS problems still experience because they have MS problems.35 It must be the basis for the defence of a respectful and empathetic therapeutic relationship as the axis of healthcare activity,36,37 and promote the identification of healthcare priorities with people with MS problems and their families at the centre of the activity.38 Carlos Mañas Gómez has eloquently reminded us of this: “If the humanisation of psychiatric healthcare does not materialise via the senses (with a sincere look, with a complicit tone of voice...), capable of baptising a two-way communication between the affected person and the specialist, it is an incomplete humanisation”.39

Initiatives such as the present project1 or the consensus document on the humanisation of care in short psychiatric hospitalisation units, promoted by the Madrid Psychiatry Society Madrid,39 favour the implementation of humanisation measures with a real impact on clinical practice and health and social-health care activity.

The results of this study will serve as a starting point for the design of future programmes and strategic plans that will make it possible to achieve objectives, such as raising awareness of the need to humanise in the field of the MH in the social and healthcare environment. They will also make it possible to extend humanisation to the entire health care system, promote equity and homogeneity in the implementation of humanisation policies in the field of health care and encourage the participation of all institutions and agents involved in the humanisation process. This participation should include in the design and planning of strategies, the encouragement of evaluation and monitoring of humanisation projects, and the knowledge and shared experience of humanisation in the field of health and well-being. These objectives will be achieved through the identification of good practices and through consultation with ACs, or by defining perceived quality indicators on what we mean by humanised MH care.

In this paper, the review of the MH strategies at national and regional level, the discussion with experts and patient associations in the field of the MH and the contribution of those responsible for the regional strategic plans have made it possible to highlight that there are efforts at national and regional level aimed at improving the health care of people with MH problems and carers in the field of the MH. These efforts are heterogeneous and, although they present great strengths, it is necessary to continue working to improve the health and social care of people with MH problems and carers in the field of MH. With regard to humanisation, although most of the plans and strategies do not contain lines of action directly identified as humanising (only 9 Autonomous Regions have a specific section on humanisation in their MH plan), they do contain humanising approaches in several of their strategic lines.

The study has shown that there is a need to establish a comprehensive and coordinated response of the health and social sectors to the challenges related to the humanisation of the MH area, paying special attention to the promotion, prevention, treatment, rehabilitation, care and recovery of people with MH problems and support for caregivers.

The main areas for improvement detected by the group of experts focus on communication with people with MH problems, training for both healthcare and non-healthcare staff in contact with people with MH problems, improvement of both inpatient and outpatient spaces, reduction (with the ultimate aim of eliminating them) of coercive measures (including mechanical restraint). 87.5% of the ACs that responded to the questionnaire for the second objective (i.e. 14 out of 16) stated that they included measures aimed at reducing the number of mechanical restraints. This is a good starting point, and the efforts of the ACs to establish channels of dialogue with the judiciary are also commendable. But this is insufficient. Further progress needs to be made in improving the conditions of care for people with MH problems. As emphasised by several recent studies and the 2019 World Health Organisation (WHO) report on ending seclusion and mechanical restraints, the minimisation (with the horizon of zero) of mechanical restraints requires the availability of sufficient human resources, the continuous improvement of MH training, the presence of strategies to fight for diversity and against discrimination and stigma, the existence of adequate physical and architectural spaces and the adoption of legislation adapted to the framework of the Convention on the Rights of Persons with Disabilities.40–42Furthermore, we must take into account the results, and their important ethical implications, of recent research carried out in our country by healthcare professionals who are particularly sensitive to this issue. These studies indicate that mechanical restraints are associated with involuntary admissions,43 and that this type of admission is associated with an increased risk to one's own life or that of others, greater overall severity and more positive psychotic and manic symptoms.44,45 According to the European EUNOMIA study 15%-40% of admissions in Europe are involuntary. Within this category, 30%-50% of involuntary admissions receive mechanical restraint at some point during their admission. This means that between 4.5 and 20% of people admitted to an acute psychiatric unit receive mechanical restraint. This wide range can also be seen in the different figures between Autonomous Regions. For example, mechanical restraint was applied to around 15 of persons admitted to an acute psychiatric unit in Andalusia,46 while in the Basque Country it was 6%.45 Perhaps these figures are influenced by the fact that some inpatient units are open and therefore may be more trained in de-escalation technique. In fact, recent studies on the effect of the application of a de-escalation protocol on the reduction of mechanical restraints have demonstrated its efficacy in Andalusia and Catalonia.46,47 In relation to this, it has been pointed out that coercion in clinical practice is associated with an increase in substance use.48 Therefore, the eradication of coercive methods in clinical practice, the fight against substance use as a general policy, the creation of early detection programmes49 and education in schools would be excellent strategies.

In relation to training on the MH, it is important to recognise that 100% of the 16 Autonomous Regions that responded to the questionnaire for the second objective have training programmes aimed at training on the MH of all healthcare and non-healthcare personnel in contact with people with mental illness. This is a strength of our public health system. And it contrasts with the situation reported by the WHO on the insufficient human resources in the health and non-health fields with training in MH in the world.12 The WHO Mental Health Action Plan (2013-2020) includes, among the actions proposed, “contributing to the training of health personnel to learn to recognise mental disorders”.12

The reflections provided by those responsible for the strategies in the Autonomous Regions make it possible to identify more specifically humanising measures within the existing strategic lines of the MH plans,15–29 as well as measures or actions that are being developed outside the plans. All the strategies coincide in directing their actions towards reducing stigma, improving the care elements to which those involved have access and increasing the participation of people with MS problems, their families and relatives in the decisions that affect them. With regard to this last point, 100% of the 16 Autonomous Regions that responded to the questionnaire for the second objective reported having measures aimed at encouraging the active participation of people with MH problems and their relatives/relations in the plans to improve services. This can again be seen as a strength of our public health system.

This review of MH strategies has brought to light the general lack of budgetary allocations for MH plans. The economic endowment of the lines, measures or actions related to humanisation in MH needs greater availability of resources in order to achieve the established objectives.

The success of MH plans, including that of humanisation strategies, requires, as the multidisciplinary working group concludes, the development and use of indicators associated with the strategic lines and objectives, as these are necessary for the correct evaluation of the monitoring and results of the plans.

This study is not without limitations. The questionnaire used to respond to the second objective (“analysis of the implementation of humanisation measures and actions in each of the different Autonomous Regions’ MH plans and strategies”) does not include questions that could be highly relevant, such as the existence of open hospitalisation units. This could introduce a bias in the assessment of this objective. To minimise the risk of this bias, the questionnaire was agreed by the working group, which was multidisciplinary and representative of the Spanish state. Furthermore, this study analyses the humanisation measures included in the MH plans. This leaves out of focus some humanising measures and strategic lines of action that are not included in an MH plan.50–52 In order to include these actions, the survey completed by the heads of the Autonomous Regions (table 1) collected information on humanising measures or actions that are being developed within and outside the MH plans.

Analysis of these points has made it possible to identify common and priority key aspects that any quality MH strategy should take into consideration. Key aspects that could be materialised in 5 proposals for action:

• 1.

  To carry out a nationwide dissemination campaign with a clear and direct slogan in favour of MH and the prevention of suicidal behaviour that has resonance in the media and social networks with the collaboration of well-known personalities who contribute their experience and support to other people who are going through similar circumstances.

• 2.

  Promote forums for professionals, patients, families and/or carers to meet and develop a fruitful dialogue that can lead to improved treatment and care in the form of respect for dignity, rights and empathetic treatment in social and health care with the aim of eliminating coercive measures, holistic and personalised care.

• 3.

  Create a platform of support entities that will serve as a network to generate shared experience, coordinate resources and have a presence and its own voice in the governing bodies.

• 4.

  Implement a health education plan on MH from school age onwards. To this end, having patient-expert or experienced patient programmes is one of the most effective ways of bringing peer support to people in vulnerable situations.

• 5.

  Incorporate the development of competencies and skills in the therapeutic relationship in the curricula and continuing education of social and health professionals, so that the person is incorporated as an expert in their own health, the protagonist of their life plan and the main agent of care.

David Fraguas received funding as a consultant or speaker from Angelini, Casen Recordati, Janssen, Lundbeck and Otsuka. He has received research funding from the Instituto de Salud Carlos III (Ministry of Science and Innovation) and the Alicia Koplowitz Foundation.

Julio Zarco received funding as a consultant or speaker from Boehringer, Gilead, Grunenthal and Lundbeck.

Vicent Balanzá-Martínez received grants or funding as a consultant or speaker in the last 5 years from the following entities: Angelini Spain, Angelini Portugal, Bristol-Myers-Squibb, Ferrer, Janssen, Juste, Lundbeck, Nutrición Médica and Otsuka.

Marina Díaz-Marsá received funding as a consultant or speaker from Angelini, Casen Recordati, Janssen, Lundbeck, Otsuka, Roche and Servier.

Iria Grande received funding as a consultant or speaker from Angelini, CasenRecordati, Janssen Cilag, Lundbeck, Otsuka and SEI Healthcare.

Elena de las Heras Liñero received funding as a speaker and consultant for Jannsen, Lundbeck and as a speaker for Adamed.

Celso Arango received funding as a consultant or speaker from Acadia, Angelini, Boehringer, Gedeon Richter, Janssen Cilag, Lundbeck, Minerva, Otsuka, Roche, Sage, Servier, Shire, Schering Plough, Sumitomo Dainippon Pharma, Sunovion and Takeda.

Juan Francisco Blázquez García, Cecilia Borràs Murcia, Ana Cabrera, Julián Carretero, Agustina Crespo, Vicente Gasul, Miguel A. González, Carmen Muela Fermín Mayoral, Guadalupe Morales Cano, José Ramón Pagés Lluyot, José Romo, Bibiana Serrano Marín and Antonio Lozano Sauceda declare that they have no conflict of interest.

This Project received funding from Lundbeck. Lundbeck did not participate in the design, analysis of findings or redaction of the manuscript..