This is one of three blogs from network members who visited Trieste in Italy to learn more about its pioneering model of mental health care.
Reflections on Trieste: Catherine Scott
What they do
In the 1970s, the approach to mental health care in Trieste underwent a ‘revolution’. Through the leadership of Franco Basaglia, the then Director of the Mental Health Department, a process of deinstitutionalization began. This included the closure of the psychiatric hospital that had more than 1200 inpatients in 1971, and the development of community mental health care that valued the needs, rights and responsibilities of every individual.
The paradigm change: they changed the system and changed people’s thoughts.
Mental health care and support moved from managing ‘danger’ and ‘public scandal’, where people were removed from society regardless of diagnosis, to an approach that sees each individual as more than a diagnosis. Now they start with the person.
Now people who access mental health care in Trieste are guests. The structure of the Community Mental Health Centres (CMHCs) means that everyone can come and go as and when they need to.
Community Mental Health Centres:
In 1978 it became law that there must be a CMHC for ever 150,000 people. Trieste has four CMHCs, each covering an area of about 60,000 people.
CMHCs must be open 12 hours a day seven days a week. In Trieste, these Centres are open 24/7, seven days a week. Each centre has 6 beds.
provide respite for people
provide shelter at night for those who need it
act as a community meeting place
are a place for clinical interventions
are a based from which home treatment is delivered – a psychiatrist and a nurse go out and visit people daily using one of the CMHC cars
CMHCs are a place where people can go to do social activities. There are people who go daily to get drugs administered to them. Meals are provided for all those using the Centre.
There is free access. They don’t have to be referred by their GP. People can just turn up.
In some areas of Italy where there aren’t strong community mental health centres, they become overcrowded, and restraint/compulsory treatment may be used.
The CMHC is responsible for people in the catchment area they are in. There are no other places people who are experiencing mental health difficulties can go.
In other areas of the world, there is somewhere else to put failures.
Psychiatric Emergency Unit:
There is a Psychiatric Emergency Unit (PEU) that acts as a first point of contact for many people experiencing mental health problems. It is based in one of the General Hospitals in Trieste.
It works in tight integration with the CMHCs. It has 6 beds and admissions last 3 to 4 days. Patients then go to their CMHC or home, with different pathways of support in place depending on need.
Unlike other care and support approaches, there is no ‘special place’ for someone to go when they are in crisis.
Severe and extreme acute crises don’t often happen in Trieste. They don’t wait for people to get to that point. Those who are seen as high risk are supported at the first presentation of difficulty.
People in Trieste are supported by the same team of professionals regardless of how they are – they will see the same professionals when they are in crisis and when they are not.
As a consequence, there are low numbers of involuntary treatment – on average about 20 per year. From January to July 2019 there were only 2 cases of involuntary treatment in one of the CMHCs we visited.
When involuntary treatment is used, it can only be for 7 days.
The approval process for involuntary treatment is agreement from 2 psychiatrists, and it has to be signed by the regional mayor.
The difference between the recovery house compared to hospital? Freedom.
A resident in a Recovery House
One resident say that being in a recovery house rather than in hospital meant they could socialise, see who they wanted, go where they wanted. They said being in this kind of community gives them time to discuss and explore issues.
They said they don’t feel hospitalised; they don’t feel helpless.
Budgets and costs:
Through use of Personal Budgets, support can be wrapped around the person. Rather than sending the individual to another agency, things are brought to them. It’s holistic.
Most support outside of CMHCs is provided by social cooperatives and other voluntary sector organisations.
The cost of supporting someone in an apartment is the same as if they were in a psychiatric hospital. But this way, they can access that support in their own community.
It’s strategical outsourcing: not for monetary gain, but because it’s better for everyone.
People with complex needs:
Criteria used to identify people who may have complex needs were: ‘revolving doors’; people who had come into contact with the criminal justice system; dual diagnosis; those who presented as suicidal.
There are 100 users on this list in the CMHC we visited.
Staff have a meeting about these individuals twice per month, but are flexible and respond when needed.
They keep a record of all meetings/interventions so they can see when they were last in contact, what happened, and how closely they need to support the individual.
How they do this
Specialism vs generalism:
They don’t have specialist teams like we have in the UK, for example perinatal mental health, crisis team, early intervention psychosis team. It’s all integral. They treat the person depending on their needs at that time rather than using a diagnosis.
There’s social and clinical intervention. It’s not fragmented. They work together to build the best approach for the individual.
There are regional aims/goals/standards, but these have to be flexible.
This is challenging when some professionals want to stick by the rules. But if putting the rules in place leads someone to crisis, they have to deal with it. So they become flexible.
Support in the community:
Rehabilitation is not a specific technique, or a period of treatment. It’s a cultural approach.
You need to invest in other agencies.
If you don’t have strong organisations in the community, then the system can’t effectively support individuals in the community.
By investing in social cooperatives, you’re investing in something that gives direct support to your community. It helps break the stigma, and shows the public it’s not for life. People are capable.
How people are treated:
Creating a relationship with people was seen as essential.
Each individual has same team of support from the moment they come into contact with the Mental Health Department all the way through their pathway of recovery. The professionals really get to know the person.
They respond to the needs of the person in that moment. But to do this requires flexibility in the system. For example, it took 5 hours to convince someone it was better to take the medication they were being asked to take than to have compulsory treatment. Supporting someone in this way allows their relationship to build.
Flexibility in the system is needed to do this.
BUT the right of the person is more important.
There’s no restraint or seclusion. There are no locked doors. People can come and go out of the PEU and CMHCs as they please.
If an institution or professional is “violent” with a person, then moments of violence/aggression from that person will be high.
An important thing to note is that they don’t have integration between the Mental Health Department and the Alcohol/Substance Abuse Department. However, they do have integration between mental health, community services and social interventions. And that is a start.
It is not about diagnosis. It is about the situation and need of that individual in that moment. They put the diagnosis in parentheses, and look at the person as a whole.
Trieste is not a fixed model. It’s an experience. It’s evolving and changing as is needed.
Culture is shared in all parts of the system
People’s personal stories are key. In UK, we speak about treatment, not people’s experiences
Trieste has created a systemic offer of rehabilitation and social inclusion alongside a community mental health approach. But a note of caution: CMHCs can become Psychiatric Units in the community unless it includes social inclusion
Personal budgets are essential
Trieste was incredibly inspiring. The humanity, compassion and respect everyone has for people experiencing mental health issues is deep-rooted throughout their culture and day to day life.
I am intrigued about how they managed to achieve complete cultural transformation alongside system transformation. I understand how many decades it has taken for it to get to this point. It has realigned my focus on the long term goal, and helped me move away from the scepticism I’ve previously held about how successful we would be in moving towards this approach in the short-term.
I believe it requires a full system and culture change.
The York MCN network is beginning this work focusing on those experiencing multiple and complex needs. This is a collaborative effort across the different sectors, and a core group of committed individuals across the system working to achieve our aim of better outcomes for this group of individuals. This cuts across multiple departments, organisations and comes down to both cultural and system-wide transformation in the way we view, approach and support people in need.
I think the most important thing that needs to be worked on is engaging the wider system and community.