Most users of psychiatric services shows jointly clinical severity, disability and marginalization so complex that it can not be answered fully only within the same services.

Within the Mental Health Department of Lecce, in the Mental Health Center of Casarano it is started the Natural Social Network Project “One for all and all for one” aimed to provide a more adequate response to the needs of these patients.

It will be identified patients with most psychosocial problems according to frequency of hospitalizations, emergency visits and rating scales (Brief Psychiatric Rating Scale, Life Skills Profile and Short Form 36 Health Survey). Then it will be identified with the patient a “facilitator”, or a person outside the CSM and longer fit into the everyday life of the patient (eg, relatives, friends, etc..). After that, the various parties involved (doctor, nurse, facilitator and user) agree an individual program based on which we make a psychoeducational path. The process will be checked quarterly with the presence of all the parties involved and monitored monthly or on the basis of needs.

After one trial year it is expected a substantial improvement by the patient in the satisfaction of his needs and more generally in his rehabilitation.