By Rob Waters
February 2020
Source: Health Affairs
Photo Source: Unsplash,
SECTOO
Abstract
In Trieste, Italy, local leaders have transformed how mental health care is provided. Other cities have taken note.
Wellness: The Trieste model, in Italy, does not just provide services to people suffering from mental health issues; it also supports wellness to prevent people from getting sick.
Community workers have helped bring together residents of the Zindis micro-area to provide mutual support. Here, some residents eat lunch in the small community center.
Spend a week in Trieste, Italy, and the first thing you may notice is what’s missing. There are no tents on the sides of roads or under bridges—a common sight in the cities of California, where I live. There are no cardboard boxes serving as mattresses for distressed, disheveled people. No one sleeps on the sidewalk or publicly confronts the voices in their heads as passersby avert their gaze.
Something else you won’t see—if you visit Trieste, as I did in July 2019, to check out its world-renowned mental health system—is uniforms. At the city’s four community mental health centers and the small psychiatric emergency unit at Ospedale Maggiore, one of the city’s hospitals, there are no doctors in white coats or nurses with nametags. Nor are there metal detectors or armed guards screening people who come in the door. A janitor mopping the floor is the only person in work garb.
At the Barcola Community Mental Health Center, a two-story building across the street from the city’s most popular beach, it’s hard to tell patients from staff members. The center has the casual feel of a recreation center, and patients (or “users,” as they are referred to here) come and go as they wish, dropping in to have lunch, chat with friends, meet with therapists, get medication, or simply hang out. It’s a bustling place, where people knock on closed doors then enter immediately, walking in and out as meetings proceed. No one seems to mind the interruptions.
If someone has a mental health crisis in Trieste, a team from Barcola or one of the three other mental health centers will quickly be dispatched to address the person’s needs. In such cases, the team members—rather than police—will be the first responders, and the person in crisis most likely will already know them.
Trieste, wrote Allen Frances, a former chair of the Department of Psychiatry at Duke University School of Medicine, is “the place I would most want to be if I had a severe mental illness.”1 By contrast, he wrote elsewhere, the US may be “the worst place in the world to have a mental illness.”2
Opening The Doors
With its bustling port on the Adriatic Sea, Trieste sits at the crossroads of Western and Central Europe and has a population of more than 200,000. Long coveted as a gateway to the Baltics and Eastern Europe, the city—closer to Zagreb, Croatia, than it is to Rome—has often changed hands, being controlled at various times by Romans, Venetians, and the Austro-Hungarian Empire. Trieste became part of Italy following World War I, but for nearly a decade after World War II, it was an independent city-state under the protection of the United Nations. In 1954 it was again made part of the Italian Republic, and today it contains a mix of ethnic Slovenians, Croatians, Hungarians, and Italians.
Trieste: The Italian city of more than 200,000 residents sits on the Adriatic Sea at the crossroads of Western and Central Europe.
In the 1960s and 1970s Trieste and the nearby city of Gorizia became epicenters of a revolution against psychiatric abuse.
In the 1960s and 1970s Trieste and the nearby city of Gorizia became epicenters of a revolution against psychiatric abuse. In those days, people deemed mentally ill in Italy and Europe (as well as the US) were kept in enormous asylums, often for the rest of their lives. In 1961 Franco Basaglia, a young psychiatrist, was named director of the Lunatic Asylum of Gorizia, a mental hospital that confined some six hundred people.3
Basaglia was a member of a prominent Venetian family, and as a medical student, he had been jailed briefly for antifascist activities near the end of World War II. As John Foot, a professor of modern Italian history at Bristol University in England, described in his 2015 biography, The Man Who Closed the Asylums: Franco Basaglia and the Revolution in Mental Health Care, Basaglia was horrified by what he saw at Gorizia: people in shackles, locked in isolation and drugged into catatonic states, spending their days sitting and staring into space. It brought him back to his own period of imprisonment, as he later wrote: “Thirteen years after I graduated, I became the director of an asylum and when I entered the building for the first time, it took me straight back to the war and the prison. It didn’t smell of shit, but there was the symbolic smell of shit. I was convinced that that institution was completely absurd, that its function was only to pay the psychiatrists who worked there.”3(p13)
People were placed in the asylums based on a 1904 law aimed at those “affected by any kind of mental illness [who are] dangerous to themselves or others or cause public scandal and they can’t be conveniently kept or cured outside of asylums.”3(p19) Inside the walls, inmates were stripped of their civil rights, dressed in uniforms, and often had their heads shaved. Torture and suicide were common, “too normal to even cause surprise or comment.”3(p20)
Foot explains how, over the next two decades—first in Gorizia and then, starting in 1971, at the much larger mental hospital in Trieste—Basaglia worked first to open the doors of the asylums and then to empty them, while radically transforming the outlook of both staff and residents. In Gorizia, Basaglia and his colleagues worked gradually, eliminating the use of confinement, giving inmates freedom of movement within the institution, and creating assemblies where patients and staff members discussed all that was happening as they worked together to overturn the institution. Journalists and filmmakers documented the changes.
Fences and walls were knocked down by patients themselves as an “overjoyed” Basaglia watched, “laughing and clapping as he looked on,” according to one nurse quoted by Foot.3(p133)
A patient-run newspaper was established and chronicled the changes. Some patients were released, but the hospital was now being run as a “therapeutic community”—in large part because Basaglia and his colleagues lacked the legal authority to close it down.3
In Trieste, Basaglia moved much more quickly. San Giovanni Hospital went from a population of 1,182 in 1971 to 51 in 1977, with another 500 or so remaining in the buildings as guests and volunteers who were free to move about the city. Volunteers, artists, and political activists descended on the grounds of the sprawling asylum, which became part of the countercultural moment.3(p341) Basaglia’s work helped galvanize a global patient liberation movement and, in Italy, led to the passage in 1978 of Law 180—better known as Basaglia’s law—which banned the creation of new mental hospitals, ordered the phasing out and emptying of all existing ones, and mandated that patients receive care in the community whenever possible. It limited psychiatric units to fifteen beds located within general hospitals.
Nowhere in Italy was this model better implemented than in Trieste, where Basaglia forged a new community-based system from the ashes—and budget—of the 1,200-bed hospital. The funds that had been spent running the sprawling asylum didn’t disappear, as they did when mental hospitals were shuttered in the US. When Trieste’s asylum finally closed in early 1980, Franco Rotelli, Basaglia’s successor as mental health director, was able to use the funds supplied by the regional government to run the new system and develop a new approach to care.
“The conversion of the money, keeping the budget as a whole and transforming the old psychiatric hospital into the new mental health department, was a necessity,” says Roberto Mezzina, a psychiatrist who retired in October 2019 after four decades of working for the Trieste Department of Mental Health—the last decade as director. “The director of the hospital became, in fact, the director of the mental health department and got to convert the same amount of money into community services.”
The US has also seen a decline in the number of people confined in psychiatric hospitals and other residential facilities—from 471,000 in 1970 to 170,000 in 2014, according to a 2017 report.4 But these closures were not followed by the creation of a nationwide system of community mental health centers—as President John F. Kennedy had envisioned when he signed the Community Mental Health Act in 1963, a month before he was assassinated. The funds used to operate the hospitals “did not follow the people who’d been released back into the community,” says Ronald Manderscheid, executive director of the National Association of State Mental Health Program Directors and a coauthor of the 2017 report.
“One consequence of all that,” he adds, “is that the jails have become the new mental health institution in America.”
Over the years Trieste’s approach has gained international recognition, and mental health professionals have flocked to the city to examine the system there.
Trieste’s intentional efforts to move away from institutional and purely clinical treatment to something much more holistic and flexible represent a stark contrast with what many
Americans are likely to encounter when seeking mental health care in the public system. Over the years Trieste’s approach has gained international recognition, and since the Basaglia years, mental health professionals interested in reform—an average of a thousand per year, according to the mental health department—have flocked to the city to examine the system there.
In 1987 the World Health Organization designated the department a collaborating center able to advise countries on deinstitutionalization and the development of integrated, comprehensive services. A steady stream of foreign delegations has found its way to Trieste’s community mental health centers and the sloping grounds of San Giovanni Park, where the headquarters of the department remains. The beautifully maintained buildings of the old asylum offer no hint of the brutality they once contained.
Recently, community leaders and mental health administrators from Los Angeles, California, including the county’s mental health director, Jonathan Sherin, have made the trek. What they’ve seen there has inspired them to begin developing a pilot project based on the Trieste model that they plan to develop in Hollywood over the next five years, with $117 million from a voter-approved fund that supports mental health services. Whether the project can succeed in a city so culturally and economically different from Trieste—and with such large numbers of people struggling with homelessness and mental illness—is far from clear. What is clear is that mental health reformers from Los Angeles and many other cities around the world think that the Trieste model may represent a vital path toward creating badly needed change. (Health Affairs will examine Los Angeles’s plans in the March 2020 issue.)
‘Relentless Negotiation’
When I visited Trieste, I joined a group of therapists and psychiatrists from York, England, as they converged on the Barcola Community Mental Health Center. A smiling man with silver hair offered a handshake as he greeted each visitor and asked their first name—and then bestowed on each the celebrity last name he knew they’d always wanted: “Anthony…Hopkins,” “Naomi…Campbell,” “Steve…Jobs.”3 I felt a pang of regret when I short-circuited his gag by introducing myself as Roberto Benigni. He looked crestfallen but recovered quickly, and when I returned the next day, he called me Benigni.
Inside, psychiatrist Chiara Luchetta and Daniela Speh, coordinator of international training activities, described the program’s operating principles and an underlying philosophy summed up in a single word: accoglienza, best translated as “welcoming.”
“We don’t have a waiting list,” Luchetta said. “You don’t need a referral. You can have one, but you can also walk in and talk to people directly.” Doors are open from 8:00 a.m. to 8:00 p.m., and there are staff members on duty twenty-four hours a day to respond to crises. The center has six beds that can be used by people who are suffering at home or need a break to stabilize from a crisis. The doors to the rooms are open; there are no restraints or guards. Staff members dress in everyday clothes. The furniture and aesthetic are homey.
Involuntary treatment is a rarity in Trieste. In 2018, eighteen patients were treated against their will out of the almost five thousand people who received services from the Trieste Department of Mental Health, according to Mezzina, the just-retired director. About halfway through 2019 only two patients had been involuntarily treated at Barcola, Speh told the visitors. “We went two and a half years once [starting in 2003] without a compulsory treatment,” she said. “Then Mezzina went away on vacation, and the next day we did a compulsory treatment. He was really mad,” she added, with a laugh.
The resistance to using coercive treatment—a legacy of Trieste’s central role in the movement for patients’ liberation during the Basaglia era—remains a bedrock principle, and one that distinguishes Trieste from many other places. The visitors from York were impressed but skeptical. They wanted to know how often Trieste’s mental health teams compel patients to take medication and how they manage without restraints.
If you seclude or restrain someone, it will alter your relationship with the patient, Speh said. And if a person runs away, you may have to search for them. “Sometimes it’s good that the person wants to go away,” she said. “It’s normal. You have to remember all the time that the person is like me, like you. You can’t treat the person in a bad way with a lot of rules and barriers and then say, ‘OK, are you well now?’ No, it’s impossible.”
If it becomes absolutely necessary to bring someone in for forced treatment, it’s essential that the clinician be directly involved, Speh said, and not delegate the process to the police or leave the person alone in a seclusion room. “You have to be there in every moment during the crisis,” she added. “If you’re there, [the person] will come to understand that you were there during the difficult moment.”
“You have to always negotiate about what is the best pathway when you have a person in crisis,” she said. “If you can’t seclude, if you can’t restrain, you have to find alternatives. Maybe you go outside, go for a walk, have a coffee. If the institution is so hard, with a lot of rules and distance and locked doors, it increases the risk of violence because the institution itself is being really violent.”
This stance—which Sherin described to me as “relentless negotiation”—is a hallmark of the Triestian approach.
Here’s what Francesca Santoro, a psychiatrist at Barcola, says it looks like. She and a colleague were out, driving in a white Fiat Punto to visit patients in their homes. They stopped at the apartment building of an older patient who had stopped taking her medication and was experiencing some psychosis. (Note: Throughout the story, patients’ names have been omitted and some details changed to protect their confidentiality.)
Santoro rang the doorbell and identified herself, but the woman refused to let them in. After a few attempts to convince her, Santoro called a friend of the woman’s—she had the number in her cell phone—and left a message. Then she pressed the doorbells for every apartment in the building, hoping someone would buzz her in. Eventually someone did, and she climbed the stairs to the third floor. Santoro knocked on the door.
The woman yelled through the closed door that she wouldn’t let the visitors in and that they should go away. Santoro kept talking, coaxing and wheedling in a calm voice. The next-door neighbor, an older man in a wheelchair, opened his door to see what was going on, and she and Santoro chatted. The patient’s friend, meanwhile, called Santoro back and said she’d try to convince the patient to let the team members come back, perhaps the next day.
They finally departed, and Santoro said they would come back—many times, if necessary. If that didn’t work, Santoro feared that the woman would become so agitated and loud that her neighbors would call the police. The police, in turn, would call the mental health center, and together an officer and mental health worker would return. But, Santoro said, “We hope to convince her without the police, so we will try and try.”
Santoro’s next stop was at the home of a middle-aged woman who has been working with the staff of Barcola for many years. She lives with her youngest son, now a young adult. She raised her children alone but had severe mental health issues after his birth.
“We had strong work with this lady to permit her to stay with the child,” Santoro said. “In another situation, probably the social system takes the baby, because the mother was very disabled. But we had a good program, and everything went in a right way.”
Santoro was invited in, and the woman explained that she feels alone and depressed because her older children have left home, and her son spends most nights out with his girlfriend. Santoro offered encouragement and listened some more. Her approach echoed something Mezzina had mentioned the day before: “Treatment is not the key,” he said. “People’s stories are. Our job is hearing people’s stories and making them central.”
‘First We Plan’
This kind of outreach is not without risks. That afternoon Santoro got a call saying that Luchetta, her colleague, had been punched in the side of the head by a distressed patient as she approached him on the street. Later, Santoro explained that Luchetta had been treated for minor injuries, and the man had been brought back to Barcola without further incident. I asked if she worries about the risk of violence, and she shrugged. “Anything can happen,” she said.
The next morning I returned to the psychiatric unit of Ospedale Maggiore, but the psychiatrist I was there to meet was rushing to another hospital to see a woman who had attempted suicide. I remained, and Alessandra Oretti, the unit director, offered me coffee and a tour.
In general, Oretti said, the unit takes people who are in crisis at night, when the community mental health centers close intake. Patients usually stay two to three days, though one patient had been there for three months. In a state of mania, he had set fire to his parents’ apartment. Being treated at the hospital was better than being in jail.
A meeting about another patient was convened, with six staff members attending. Donato Zupin, a young psychiatrist wearing a polo shirt and stylishly torn jeans, said that the patient, an elderly man with dementia and diabetes, has been living alone in a public housing unit.3 Recently he’d been agitated, disrupting efforts to treat him.
City social workers go to his apartment every day, bringing him lunch and dinner. Zupin and nurses from Gambini Community Mental Health Center visit every evening. For years, Zupin said, the man has been traveling to London, going to Buckingham Palace and announcing that he is there to marry the queen. Each time, the police call a psychiatric unit in London, whose members bring him to a hospital. Two London cops then deliver him to the mental health center in Trieste. Recently, he was planning to leave again for London, and he stopped taking meals and threw furniture out the window.
Staff members want to get him out of his apartment and into senior housing but reject the idea of a nursing home, since such facilities tend to be understaffed. Zupin and two nurses had gone to his home two days earlier, prepared to compel him to come with them. To their surprise, he opened the door and agreed to go—probably, Zupin said, because “he has a trusting relationship” with one of the nurses.
Now the team is trying to plan the next steps. Home health care is one option, but they don’t think that would work for long. Another is to move the man to a rehab unit, but they need his agreement. “We need to have a smooth path to propose to him,” Zupin said. “First we plan, then we propose.”
The day before, at Barcola, I had joined some patients for a lunch of pasta, chicken, and salad and chatted with a university graduate who speaks excellent English and works at a local city agency.3 She introduced me to Luchetta. “This is my psychiatrist and friend, Chiara,” she said. “We’ve been friends for a long time.”
“Four years ago I started hearing voices, and I don’t know why. I still hear them, and I cannot sleep at night,” the woman explained. “I don’t make friends with my voices because they offend me.” They also tell her she’s losing her job.
“Sometimes you feel better, don’t you?” Luchetta asked. Yes, the woman said, at work. She broke into a huge smile. “My chief says I work magnificently.”
But there is still a lot of tension with her husband and child at home. After she described some of it, Luchetta asked if she wanted to spend the night in one of the center’s beds. She said no, because her job gives her satisfaction and she wants to work. She prefers to stay at the center in the afternoon and go home at night. Luchetta agreed and said that she or one of her colleagues “will be a taxi driver and bring you home.”
‘Trying To Help Each Other’
The importance of meaningful work is vital to the program in Trieste, where social cooperatives—organizations with a dual role of providing services for special populations and creating jobs—were first created for former inmates of the hospital in 1973. The concept spread throughout Italy and Europe, and today the province that includes Trieste runs a rehabilitation unit with fifteen staff members that partners with sixteen co-ops that do everything from operating hotels and cafés to cleaning local hospitals and making leather bags and purses. At least 30 percent of co-op members must be current or former users of services, and all members have an equal vote on the co-op’s leadership and activities.
According to the Trieste Department of Mental Health, more than 375 users of mental health services have been employed or received work grants through this program in 2018. The rehabilitation unit also manages apartments that collectively contain fifty-five beds for people who need supportive—but nonmedical—housing.
One of the largest of the cooperatives is called Germano. It maintains public parks, hauls industrial waste, and provides janitorial services. The co-op also operates a recovery house out of a two-bedroom apartment it purchased two years ago for about 200,000 euros. The apartment provides a home for six months to four people who have been struggling with mental health issues. The apartment building sits next to Campo San Giacomo, a lively piazza centered on a 160-year-old church, where every afternoon people sip Aperol at outdoor tables while their children send soccer balls careening around the square.
I visited the apartment twice and met Sara, a nineteen-year-old resident, and Michele, a forty-seven-year-old peer support worker who’s a member of the Germano co-op. (Both asked that their last names not be used.) Sara’s arms were covered with cigarette burns and cut marks. She’d experienced mental health issues since she was nine, she said, and she first made contact with the mental health system at age fifteen when her parents had her spend a year in a hospital. Her parents, she said, “were not supportive; they are part of the problem.”
Last year she tried to kill herself. She ended up in one of the six beds at Barcola, where she stayed for ten months and worked with psychologists, peer supporters, and a psychiatrist who managed her medications. At first, “I didn’t want to talk,” Sara said. But over time, she began to discuss “all the difficult things in my past. That was the first time I did, and it helped me a lot.”
In June she moved into the recovery house along with three young men—the program starts all residents at the same time for their six-month stays, Michele explained. Three professional staff members plus Michele are available to work with residents daily, and residents get to choose which staff members they work with. Residents also work in groups to bolster their recovery and plan for the future.
Living at the recovery house has been “wonderful,” Sara said. “It’s not a mental health center, and I have a lot more freedom. I feel really understood.” The other residents, she said, “are trying to help me in different ways and we’re trying to help each other.” At that moment, she added, the group was focused on another resident who was struggling and may need to spend a few days at a district mental health center.
Even after moving out of the house, former residents can come back to connect with staff, peers, and new residents, expanding the community. Alex, a twenty-six-year-old former resident, had dropped by this day. He often connects outside of the house with other people he met there, he said. He was then working at a library in a paid internship arranged by the mental health department and had previously worked at a stable caring for horses.
Michele, the peer support worker, began struggling with mental health issues at age twenty. At the time, he said, he acted out in anger against people from the mental health system, had run-ins with the police, and was hospitalized several times. Eventually, new medications and getting linked to a job at a bookstore helped him recover. Five years ago a psychiatrist at the Gambini Community Mental Health Center convinced him to take a peer training course. He completed it and began to work as a peer supporter.
Working with people in need suited him, he said. In one of his positions, he and a colleague drove people with serious disabilities around town so they could take part in activities such as going for a swim at the beach. “I found that I am very much at ease with people with problems,” he said. “I like to enter their world with them.”
Staying Healthy
On my final day in Trieste I got to see the front end of the recovery spectrum—prevention—when I visited a village called Zindis outside the city, near the border with Slovenia. A 250-unit public housing complex there has been designated as a “micro-area,” with support from a European Union fund, and receives what amounts to community-building support.
To start the effort, staff and interns working for La Collina social cooperative went door to door to connect with residents, especially the oldest and most isolated—many of whom were widows. Now these women eat lunch together most days in a community room and help maintain a community garden. They also have pressed the local government to upgrade a soccer field for youth and to make pathways between the buildings more accessible to people using wheelchairs and walkers.
Breaking social isolation and helping people forge connections has helped residents stay socially and emotionally healthy.
Breaking social isolation and helping people forge connections has helped residents stay socially and emotionally healthy and kept them out of nursing homes and senior facilities, said Margherita Bono, a La Collina member who has spearheaded the work in the Zindis micro-area.
“This project is directly linked to the history of deinstitutionalization” begun by Franco Basaglia, she said. “It’s another step.”
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