In the first round, participants received an open-ended questionnaire with four exploratory questions addressing the foundational dimensions of a rights-based approach in mental health. Responses were limited to a maximum of ten lines per question. Specifically, participants were invited to reflect on the following topics, in line with the aim of the study, as detailed in Appendix 1:

• The perceived benefits of combining national and international strategies;

• Key actions to promote human rights and recovery;

• Positive practices or structural elements observed at the Cagliari consultation-liaison center;

• Recommendations to strengthen rights-based practices in similar settings.

Participants’ responses were collected and analyzed qualitatively in order to develop the items for the second round of the procedure.

Open-text responses from the first round were analyzed using inductive thematic analysis, with the aim of identifying conceptually saturated themes and organizing them into a coherent structure.

An initial coding of the data was independently conducted by two members of the research team, who reviewed all responses question by question. Emerging codes were discussed collaboratively, and overlapping or redundant categories were consolidated. The analysis prioritized conceptual clarity, consistency across questions, and fidelity to the language and perspectives of participants.

An inductive, semantic thematic analysis was conducted following Braun and Clarke’s six phases (familiarization; initial coding; theme searching; theme review; theme definition/naming; reporting) [35]. Two researchers independently read all responses end-to-end and wrote analytic memos; generated line-by-line descriptive codes; and collated codes into candidate themes at the semantic level. A codebook was then produced that specified for each code: label and definition. Disagreements were resolved through discussion; a third senior researcher adjudicated unresolved cases and audited the codebook to ensure conceptual clarity.

After iterative review, the team agreed on a final set of themes for each Round-1 question. Each theme included: (a) a concise definition; (b) inclusion/exclusion notes; and (c) 1–2 verbatim quotations selected for clarity and representativeness. Frequencies were tabulated only to enhance transparency (e.g., “theme mentioned by ~⅔ of respondents”), not as tests of generalizability. This process resulted in a finalized codebook documenting the thematic structure of Round-1 data (see Table 2 for an example). These themes formed the conceptual foundation for the second-round questionnaire, ensuring that each item was empirically grounded in participants’ qualitative input.

Building on the finalized codebook, Round-1 themes were translated into closed-ended items (see Appendix 2) for Round-2 through a controlled feedback procedure:

• Theme distillation: for each question, we selected the most saturated and conceptually distinct themes, excluding marginal ideas while preserving diverse perspectives, especially those grounded in direct practice;

• Operational wording: we drafted clear and mutually exclusive options reflecting those themes, avoiding redundancy and double-barrelled phrasing;

• Prioritization constraint: a single-choice format was used to elicit relative salience rather than consensus;

• Clarity and consistency check: the research team reviewed items for comprehensibility and semantic independence, ensuring consistency with participants’ original wording (semantic fidelity).

This process resulted in eight structured items for Round-2, each corresponding to a distinct and data-grounded theme derived from Round-1 analysis.

Based on the analysis of the first round, a structured questionnaire was developed for round 2 (see Appendix 2), with the strategic aim not merely to confirm previously expressed views, but rather to stimulate critical comparison and promote more operational and focused reflection among participants. Specifically, the questionnaire was designed:

• To translate the most saturated and recurring themes into clear, distinct, and mutually exclusive response options;

• To encourage prioritization, ask participants to select only one option per item;

• To avoid vague or redundant formulations, thereby improving specificity and interpretability.

Consistent with the aim of mapping a plurality of positions rather than driving convergence toward consensus, we designed the second round using forced-choice items, in which each panellist was asked to indicate a single top priority. This choice is methodologically justified as an intra-respondent prioritisation device rather than as a consensus mechanism. Adding an ipsative/forced-choice phase has been shown to elicit clearer and sometimes counterintuitive priority structures [36], and forced-choice responses nonetheless appear to yield valid and reliable evaluations of quality [37]. Used in this way, forced-choice questioning clarifies which option each expert would back if compelled to choose, while analysis of the overall distribution of selected priorities preserves the plurality of perspectives sought in a policy Delphi. In line with this rationale, the second-round questionnaire consisted of eight multiple-choice items, each offering 5–6 mutually exclusive options. Participants selected only one option per item, thereby operationalising the forced-choice prioritisation approach described above.

Quantitative data from round 2 were analyzed using descriptive statistics. For each item, the number and percentage of selections were calculated. Options receiving the highest selection frequencies were interpreted as signals of greater salience (majority preferences) rather than consensus, with particular attention paid to items consistently ignored or receiving minimal support, as these too offered insights into what participants did not prioritize. Given the exploratory purpose of the study, the goal is to map diverse expert views and detect nuanced areas of convergence.

Original prompt: “What benefits can working both on a national level and through international projects bring to promoting and implementing a human rights-based approach in (mental) health services?”

Most respondents emphasized the value of integrating national and international levels to strengthen human rights-based mental health care. The most saturated theme (identified in approximately two-thirds of responses) was the ability to adapt global models to national contexts. This was seen as a way to enhance reform efforts and overcome systemic limitations. A majority also noted the importance of international cooperation in facilitating the exchange of good practices and mutual learning. Several participants highlighted how international frameworks can lend political legitimacy to rights-based reforms, making them harder to marginalize. Themes with medium saturation included: the role of international collaboration in training health professionals; and, to a lesser extent, the empowerment of service users through exposure to international standards. Less frequently, participants warned against the risk of uncritical transfer of models across contexts.

These themes directly shaped the structured items in Round 2, which asked participants to distinguish between adaptive, pedagogical, and political benefits of international engagement.

Original prompt: “What key actions or measures do you believe are essential to implement in mental health services to ensure human rights and promote a recovery-based approach?”

There was strong semantic convergence around the need for systemic change in both service organization and daily practices. The most saturated themes (appearing in over 75% of responses) were: the active involvement of persons with psychosocial disabilities in both governance and individual care planning; and the need to strengthen training for professionals on human rights, shared decision-making, and trauma-informed care. A significant number of respondents also stressed the importance of shifting from custodial to community-based models of care. Themes with medium saturation included efforts to reduce cultural, economic, and geographical barriers to access. Less commonly, respondents mentioned the need to monitor human rights implementation and to integrate mental health into broader public policies. These findings informed Round 2 items asking participants to prioritize among participation, training, accessibility, and service transformation.

Original prompt: “Which specific aspects identified during your visits to our center in Cagliari (Italy) do you consider most crucial for promoting self-determination, awareness of rights and social inclusion of persons with psychosocial disabilities?”

Respondents consistently highlighted the relational dimension of care observed at the Cagliari center. The most saturated theme (appearing in approximately 75% of responses) was the emphasis on a person-centered, non-hierarchical relationship between users and staff-based on active listening, flexibility, and respect. Roughly half of the participants praised the center’s commitment to promoting self-determination, including mechanisms for shared decision-making and meaningful participation. Several also noted the center’s connection with community resources as an important driver of social inclusion. Themes with medium saturation included the welcoming, informal atmosphere and the ongoing training of staff. Marginal themes included the use of expressive and artistic media. These observations informed Round 2 questions focusing on practical strategies to support self-determination and the professional roles involved in fostering rights-based practices.

Original prompt: “What recommendations would you suggest for implementing in our center in Cagliari in order to improve the approach for promoting the rights of individuals with psychosocial disabilities?”

Responses fell into three main categories, which were reflected in the second-round questionnaire: strengthening community orientation, diversifying therapeutic approaches, and improving service accessibility. Two-thirds of participants recommended reinforcing connections with local communities through collaboration with associations, social services, and informal networks. Half of the experts emphasized the need to expand available therapeutic options, including greater involvement of peer-supporters and recognition of experiential knowledge. A third of the responses focused on making the center more accessible, particularly through digital tools and outreach strategies to rural or underserved populations. Themes with medium saturation included cultural sensitivity training and the use of multilingual tools. These themes were translated into structured items in Round 2, allowing participants to prioritize among community engagement, accessibility, diversity of approaches, and intercultural competence.

“What is the main benefit of international collaboration in promoting human rights in mental health services?”

During the second round of the Delphi survey, participants were asked to identify what they considered to be the primary benefit of international collaboration in advancing human rights within mental health services. A clear majority (78%) selected “mutual exchange and learning”, emphasizing the value of reciprocal sharing of good practices and capacity building across national contexts. This may reflect a vision of international cooperation as a horizontal and dialogical process, where knowledge and innovation are co-constructed rather than transferred unidirectionally. In contrast, “local adaptation of global strategies” was chosen by only two participants (22%). While this indicates that contextual implementation is still valued, it appears to be perceived as a secondary, operational aspect, rather than the core benefit of international engagement. Notably, none of the participants selected options related to access to economic or technical resources, policy alignment with international frameworks (e.g., CRPD), increased user participation in policymaking, or professional training on human rights. This lack of convergence around more instrumental or structural dimensions suggests that respondents may perceive international collaboration as most valuable when it fosters mutual empowerment and collective development, rather than when it provides predefined resources, policy frameworks, or training initiatives. This perspective may imply a preference for a model of collaboration that prioritizes co-learning and the exchange of practices over top-down standardization or technical assistance, which may be perceived as prescriptive and externally imposed aspects of international partnerships, as shown in Table 3.

“What do you consider the main limitation or risk of international collaboration in promoting mental health service reform?”

In the second question, participants were asked to identify the most significant limitation or risk associated with international collaboration in the reform of mental health services. The option selected most frequently was “lack of adaptation to available resources”, chosen by 5 out of 9 respondents (56%). This concern indicates the perception that internationally proposed reforms may be economically or organizationally unsuitable for local health systems, highlighting a need for feasibility and sustainability in international collaboration. The second most cited risk was the “risk of cultural imposition”, indicated by 3 participants (33%). This response points to apprehension that imported models may fail to respect local cultural, social, and economic contexts, potentially undermining both their acceptability and their effectiveness. Only 1 participant (11%) selected “local and institutional resistance” as the primary risk, while none of the respondents chose the remaining three options: loss of national control, excessive emphasis on foreign success models, or idealization of foreign models. These results, summarized in Table 4, suggest that participants may be less concerned with political or ideological risks (such as loss of autonomy or idealization of the “foreign”) and more attentive to contextual mismatches that could compromise the relevance or applicability of imported reforms. The low selection of resistance-related or nationalistic arguments indicates that opposition to international collaboration is not rooted in protectionism, but rather in the pragmatic need for contextual alignment. In summary, the findings underscore a view of international collaboration that must remain flexible, adaptive, and locally responsive, rather than standardized or prescriptive in nature. For these experts, the success of transnational partnerships in mental health reform depends on their ability to respect and work within local constraints, both systemic and cultural.

“What action do you consider a priority to ensure human rights and promote recovery in mental health services?”

The most frequently selected option was “social inclusion”, chosen by 4 out of 9 respondents (44%). This indicates a strong emphasis on access to employment, housing, and education as foundational conditions for autonomy and psychosocial well-being. The second most selected priority was “staff training”, indicated by 3 participants (33%). This underscores the recognition that mental health professionals require targeted education on human rights and recovery-oriented practices to effectively shift service culture toward more rights-based and recovery-oriented approaches. “Active user involvement” was chosen by 2 respondents (22%), highlighting the relevance of user participation in service design and decision-making, though this was not identified as the top priority. None of the participants selected the following options: Legislative reforms, Rights monitoring, or Recovery tools. The distribution of responses is reported in Table 5. These results suggest that participants tend to prioritize concrete, structural conditions (such as inclusion and professional education) over legal or procedural mechanisms for change. The lack of selection for legislative reform or monitoring implies that, while important, these may be viewed as secondary or supportive measures, insufficient on their own to promote recovery and rights in a meaningful way. In summary, the responses reveal a shared belief that ensuring rights and recovery in mental health requires addressing social determinants and empowering professionals, rather than relying solely on top-down reforms or tools.

“How can the decision-making power of users in mental health services be strengthened?”

The responses were evenly distributed across several options, suggesting multiple complementary pathways are considered important for user empowerment, as shown in Table 6. Two options were selected most frequently, each by 3 out of 9 participants (33%): “Decision support tools”—including recovery plans and structured supports to help users articulate their preferences and “Role in governance”—involving users in the design and management of services and policy-making. These selections suggest that respondents place equal value on individual-level autonomy-enhancing instruments and systemic user participation in governance. This pattern suggests a dual-level empowerment strategy, combining personal agency with structural influence. Following these, “Access to information” was selected by 2 participants (22%); “Overcoming paternalism”, referring to a cultural shift in clinical practice to ensure users are actively involved in therapeutic decisions, chosen by 1 respondent (11%) and “Peer support” that did not receive any votes. These findings suggest that participants favor structural and procedural changes, such as governance roles and decision-support mechanisms, over purely cultural or peer-led approaches. The absence of votes for peer support may reflect its limited institutional integration or a perception that it is less effective without systemic recognition and structure. In conclusion, participants endorse a multifaceted model of empowerment, one that combines access to tools and information with the opportunity to shape services at a governance level. While cultural transformation (e.g., overcoming paternalism) is acknowledged, it appears secondary to more tangible and systemically embedded mechanisms.

“Which health promotion strategy is most effective in fighting stigma?”

Reflecting a diversity of perspectives on anti-stigma strategies, the responses reveal a clear preference for community-based and educational interventions, with a wide distribution across several categories. The most frequently selected option was “Local communities—Social and work inclusion projects”, chosen by 4 out of 9 participants (44%). This reflects a shared belief in the transformative potential of direct inclusion in social and occupational environments as a means to normalize and destigmatize mental health conditions. Two other options were selected by 2 participants each (22%): “Media and institutions”—emphasizing the role of public campaigns and documentaries in raising awareness and “Schools and universities”—promoting the integration of mental health education into curricula from an early age. Only 1 participant (11%) selected: “Users as leaders”—involving people with lived experience as the primary agents of anti-stigma campaigns. Notably, no participant selected “Healthcare workers—Mandatory training to eliminate stigma within services”. The distribution of responses is reported in Table 7. These findings suggest that participants perceive community-level interventions, particularly those that enable social and professional inclusion, as the most effective long-term approach to combating stigma. Educational and media strategies are also seen as valuable, but somewhat secondary in impact. The low endorsement of user-led initiatives and the absence of support for professional training may point to a perception that stigma is rooted in broader societal structures, rather than primarily within services or among professionals. Alternatively, this could reflect skepticism about the efficacy or current institutional support for these approaches. In conclusion, the responses highlight a preference for structural, community-based strategies while institutional campaigns and user-led efforts were endorsed less frequently, indicating that anti-stigma work is most effective when embedded in everyday environments that promote participation and inclusion.

“What is the main barrier within services to promoting the self-determination of persons with psychosocial disabilities?”

The responses reflect a relatively balanced distribution across different types of structural and cultural limitations, as shown in Table 8, suggesting that barriers are perceived as multifaceted and interrelated. The most frequently selected response was: “Control-oriented approach”—described as a clinical culture more focused on protection than on autonomy—chosen by 3 out of 9 participants (33%). This reflects a critical view of the underlying philosophy of care, where users may be subject to paternalistic dynamics that inhibit autonomy. Two other options were selected by 2 participants each (22%): “Insufficient training”—indicating a lack of staff competence regarding human rights and autonomy-oriented practices—and “Few practical tools”—such as the absence of recovery plans or decision-making supports. Another 2 respondents (22%) chose: “Institutional barriers”—referring to rigid regulations and limited resources. No participant selected: “Lack of a dedicated role”—i.e., the absence of a professional figure explicitly tasked with supporting autonomy.

The relatively even distribution of responses reveals a shared understanding that barriers to self-determination are both systemic and operational. The most frequently identified issue, the control-oriented model of care, suggests that cultural transformation is seen as a precondition for advancing rights-based practices. However, the simultaneous emphasis on training, tools, and regulations implies that changing professional attitudes is not sufficient on its own. The absence of support for the creation of a dedicated professional role may indicate that participants see self-determination not as the task of a single figure, but as a responsibility to be integrated across the entire service system, or as something that does not require the support of a specific operator, but rather arises from contextual conditions or from the will of the individual user. In summary, these findings suggest that promoting self-determination requires multi-level interventions, addressing institutional rigidity, professional development, resource availability, and, most importantly, a shift in the foundational ethos of care from control to autonomy.

“What should be a further priority for a coercion-free center like ours?”

Reflecting a diversity of priorities, participants identified three options as additional strategic priorities for a coercion-free mental health center, each selected by 2 out of 9 respondents (22%): “Active user involvement”—highlighting the importance of including service users in decision-making processes and governance; “Social and work inclusion”—referring to partnerships with companies and communities to foster social participation and “Monitoring of quality and rights compliance”—including independent audits and structured user feedback. The full distribution of responses is presented in Table 9. “Inclusive cultural approach”—cultural mediators and practices adapted to the beliefs and values of the community; “Facilitated access to services”—through telemedicine, digital tools, and spatial accessibility and “Diversified therapeutic approaches”—the integration of holistic and innovative methods that respect individual preferences each received 1 vote (11%). The absence of a dominant response suggests that participants view the development of coercion-free services as a multifaceted effort, where diverse dimensions, cultural, organizational, and therapeutic, need to be addressed simultaneously. The equal prioritization of governance, inclusion, and quality monitoring indicates that respondents value user-centeredness, participation, and accountability as fundamental pillars of non-coercive practice. At the same time, the singular selections for culturally sensitive care, access, and therapeutic diversity highlight an awareness of specific operational levers that can enhance user experience and reduce the perceived need for coercion. In summary, the findings portray a shared orientation toward a pluralistic model of innovation, where no single intervention is sufficient, and priorities must be tailored to the specific needs, values, and social contexts of the people served.

“How do you imagine the mental health center of the future?”

In this final question, the responses reveal a clear orientation toward community-based, socially integrated care models, with limited interest in technocratic or institutional alternatives. As shown in Table 10, the most frequently selected option was: “Full community integration—Mental health connected with employment and social life”, chosen by 5 out of 9 participants (56%). This suggests a strong convergence around the idea that the future of mental health care lies in embedding support within everyday life contexts, promoting inclusion, and reducing isolation.

The second most selected response was: “Center without walls”—Support through mobile teams, digital tools, and community spaces, selected by 2 participants (22%). This model emphasizes decentralization, flexibility, and accessibility, aligning with international trends in community mental health reform. Another 2 participants (22%) opted for: “Recovery budgets for users”—Freedom to choose care and services. This indicates support for user-directed models that prioritize autonomy and personalized care pathways. No participants selected: “Management without traditional professionals”—in which peer supporters take central roles. “Advanced technologies and AI”—including virtual reality or artificial intelligence applications. These results suggest that the future envisioned by participants is one where mental health care is fully embedded in the social fabric, closely linked to employment, relationships, education, and housing. The lack of support for purely technological or peer-led models may reflect skepticism toward disintermediation or an awareness of the institutional and cultural changes still needed for those innovations to be viable at scale. The fact that more than half of the panel chose community integration confirms a shift from the concept of the center as a place, toward one of function, connection, and presence within the community. In summary, the envisioned future mental health center is one that is inclusive, mobile, and relational, less reliant on physical infrastructure and more focused on supporting people in the spaces where life and recovery actually happen.

A synthesis of cross-cutting themes and response patterns is presented in Table 11. Several high-salience themes identified in Round 1—such as social inclusion, participatory governance, relational models of care, and attention to contextual adaptation—re-emerged in Round 2 as the most frequently selected options, indicating continuity in thematic salience across rounds. The Round 2 responses were reviewed across all eight items and grouped into broader macro-themes to capture recurring patterns of prioritization and areas of convergence among participants. A first consistent pattern concerns participatory and relational models. “Mutual exchange and learning” was identified as the main benefit of international collaboration (78%, Q1), and “full community integration” was the most frequent vision for future services (56%, Q8), with limited support for institutional or technological options across items.

Empowerment through shared governance was also reflected in respondents’ selections. Equal priority was assigned to governance roles and decision-support tools (33% each, Q4), indicating interest in both structural and individual-level mechanisms for enhancing user decision-making.

Consistent indications of skepticism toward top-down or standardized approaches were observed. The most frequent limitation of international collaboration was “lack of adaptation to available resources” (56%, Q2), followed by “cultural imposition” (33%, Q2). Options related to legislation, monitoring, training-only approaches, or advanced technologies received no support.

Responses concerning barriers to self-determination reflected a multifactorial view of barriers (Q6): selections were distributed across control-oriented culture (33%), insufficient training (22%), lack of tools (22%), and institutional rigidity (22%).

Regarding priorities for coercion-free practice, respondents expressed a pluralistic vision for coercion-free care, with responses evenly distributed across several strategies and no single dominant option (Q7). Finally, social determinants as levers of change were reflected through the prominence of social inclusion across several domains. Social inclusion was the most frequently selected priority for promoting recovery and rights (44%, Q3) and the most selected anti-stigma strategy (44%, Q5), and it aligned with the preferred future vision of services centered on community integration (56%, Q8). Overall, the data portray a consistent preference for participatory, community-embedded and context-sensitive models rather than standardized or technocratic reforms. Across all questions, participants emphasized that respect for human rights cannot be separated from social inclusion, shared governance, and the everyday contexts in which people live and recover.