An introduction to the Trieste model, and why it matters

A Guest Post by Vincenzo Passante

My name is Vincenzo Passante. I studied psychology in Trieste, Italy, but I have been living and working in the UK for over 8 years now. I run a podcast, A Place of Safety?, and I am active on twitter, where my handle is @apospodcast.

Some readers may have heard that the so called “Trieste model” of mental health care has been under threat in recent years, due to hostile actions taken against it by the local right wing government. A petition has been launched to save the system, and this was signed by prestigious professionals from all over the world.

The WHO considers the model to be a world standard for community psychiatry, so much so that it included it in a guidance document on community mental health services (by the way, an episode of my podcast was suggested in the “additional information and resources” section).

The system has been celebrated by Dr Allen Frances, a legend in the field of psychiatry, and has attracted attention by prestigious news sources. As an example, a few years ago the BBC prepared a short documentary about the system entitled, Trieste’s mental health revolution: ‘it’s the best place to get sick’

This approach is the basis (at least on paper) of the entire mental health system in Italy. So what is the “Trieste model” exactly?

In 2015 a historian, Professor John Foot, wrote a must read, brilliant history of this revolution. The book is entitled “The Man Who Closed the Asylums: Franco Basaglia and the Revolution in Mental Health Care” and it focuses on how the “Psichiatria Democratica” movement (which I will refer to as “the Basaglian movement”, or “the Basaglians” from now on), lead by a psychiatrist named Franco Basaglia and others (most notably his wife Franca Ongaro, who was a key figure in this respect), revolutionized the Italian mental health system in the 60’s and 70’s.

Franco Basaglia

While this was the past, it is important to understand that the movement’s theoretical assumptions and its history are closely intertwined, and that one cannot truly understand the latter without knowing about the former. Basaglian theory developed hand in hand with the practical concerns that the movement tried to grapple with during the change process and, in this respect, a key limitation I have in this blog post is the impossibility of fully explaining important concepts, which I will only be able to address superficially.

Anyone who is interested in the Trieste model should therefore get to know its history, what the Basaglians always stood against in traditional psychiatry but also how they differed from other movements critical of psychiatry in the way they envisioned change.

While the Basaglian approach had significant influence outside Italy (for example in South America), it has been almost completely ignored in the US, and the UK has arguably been the most resistant country in the world to Basaglian practice since the 80’s, with the beginning of a change of heart becoming evident only in very recent years. As a Basaglian who is originally from Trieste and now lives in the UK, I therefore face an up-hill task in influencing the English speaking world on this subject.

A key difference between the UK system and the Italian system, even beyond Trieste, is legislation. The origins of current mental health legislation in Italy date back to 1978, when “Law 180”, also known as the “Basaglia law”, came into effect. A few months after, law 180 became part of the broader general health legislation (with minor modifications) and stopped existing as a law in itself. Since then, nation-wide legislation has not changed.

The legal basis is the same in every part of the country and was originally a compromise between different stakeholders. The reform determined the gradual dismantling of all psychiatric hospitals, outlawed building new ones and established alternative institutions, including crisis services. The Basaglian movement was the driving force behind this process and it obtained most of what it wanted, so much so that some erroneously confuse Basaglia’s ideas with the way services are currently organised in Trieste, where Basaglia had been the director of the asylum before it closed.

Legislation also regulates involuntary care, which is its main function. In Italy, involuntary hospitalization in a general hospital psychiatric ward can only happen if the person needs urgent treatment, refuses treatment outside the hospital and an alternative solution cannot be found. In theory, this is intended to result in a negotiation, which will bring an end to involuntary care once an agreement is found on treatment. Regardless of where in Italy one lives, this makes long term hospitalizations very difficult.

Beyond the basic requirements outlined above, different parts of Italy apply the law, which lacks detail in some respects, differently. The best example of its application is by far Trieste. Basaglia left Trieste in the late 70’s and died in 1980, but Basaglian principles are still the basis of mental health care there.

The system in Trieste is organized around a number of community mental health centers, the number of which varied across the years. Aside from a brief period for one of them currently, they are normally all open 24/7. These settings include beds for people who need them, but are also places where people can meet to pass some time with others, see a psychologist or another professional. They are therefore both crisis and not-crisis services, in line with the idea that “freedom is therapeutic,” which was one of the mottos of the revolution.

There is also a general hospital ward (the last time I visited, in April this year, it had 7 beds and 5 were occupied, but before the local government started cutting services, this place was often almost empty). There are no locked doors and no restraint is used across the whole mental health system. Conflict is resolved by means of negotiation and compromise. Help is not structured around treatment pathways based on a diagnosis (or alternative fixed conceptualizations), but on the person’s whole life and needs across the board. This does not mean that disorders are not believed to exist, nor that technical interventions are not used, but that we “put the illness in brackets” and that we operate way beyond treatment. It means that intra-psychic problems exist within a whole life and societal context and that the context in itself can be part of both the problem and of the solution. The approach is to suspend judgement on the exact nature of a person’s problem at the beginning of the relationship, and gradually help the person make sense of their life within a dialectical context.

These are the basic facts about the system and the vision of care that underpins it. The reaction from UK professionals to this picture is sometimes enthusiasm, sometimes curiosity and sometimes skepticism.

To address questions and concerns, I would like to briefly address a number of common objections I encounter. I hope that the following lines can be food for thought and further conversations.

• Objection: The Trieste model is not applicable to a different system structure

This is paradoxically both true and false. The Trieste model was always a challenge to fixed institutional structures, even to its own. If there is an attempt to bring parts of the Trieste model into a traditional structure to undermine it, then we are doing a good job. If we are trying to make part of the Trieste model applicable to a traditional structure, as a solution to its problems, then that is no longer a Basaglian approach. The Trieste model is an overarching approach, not a technique or treatment which is applicable to a different structure. The Basaglian approach is an attempt to overturn fixed structures from within, not to fit treatments better within them and not to create a new fixed structure.

It is not a coincidence that the main book of the movement was entitled “The Negated Institution,” and it was about the challenges of working within a violent institution (the asylum) that was to be negated with practical actions, opened up and eventually destroyed in favor of new, always provisional structures. The current system in Trieste is in no way applicable to the previous asylum system in the city.

This is what the work in this respect is about, gradually destroying unsuitable superstructures while building better ones.

• Objection: The Trieste model is unsafe

A key Trieste/UK difference in this respect is that in Trieste tragedies tend to be understood as being due to a lack of help by the institutional structure, which was not able (for whatever reason) to respond to the person’s needs. In the UK, in my observation, tragedies tend to rather be explained as being due to a lack of surveillance of the dangerous ill person by institutions.

A key Trieste/UK difference is that in Trieste tragedies tend to be understood as being due to a lack of help by the institutional structure, which was not able (for whatever reason) to respond to the person’s needs. In the UK, in my observation, tragedies tend to rather be explained as being due to a lack of surveillance of the dangerous ill person by institutions.

In other words, in Trieste there has been a shift away from understanding madness and crises univocally as dangerous. Italian mental health legislation for example (aside from forensic legislation), is not based on risk but on need.

In Trieste, this has a deep effect on how safety is created, and on what type of environments and relationships are built to bring about safety. The work done to open up Trieste’s asylum was gradual, and based on a belief and observation that as the institutions opened up, patients presented better.

Occasionally UK professionals tell me that since “people present better” in Trieste, that system cannot apply to UK settings where people present very poorly. In this respect, it is crucial that we first discuss whether violent institutions have an effect on how people present. The working assumption of the Basaglians has always been that yes, they do. In the UK, some believe that the institution (for example the locked hospital) has no effect in this respect. I am firmly of Basaglian persuasion.

The Trieste model is not safe despite the open doors. The open door is a means to create safety and it is because of Trieste’s open approach that it is safer.

So what are the outcomes of the Trieste approach to safety, compared to the UK approach?

I think it might help if I signpost the reader to a somewhat old but still relevant UK NHS (National Health Service) presentation. This is a comparison between services in West Wales and Trieste (see video below).

The main points...

Despite West Wales having a bigger population there are similar service costs, no suicides in home-like facilities in Trieste vs 7 in West Wales psychiatric hospitals over a five year period.

Bed occupancy 71% in Trieste vs over 100% in West Wales. This in the context of crisis settings heavily focused on surveillance (UK) versus services heavily focused on hospitality (Trieste).

A key challenge to this shift, in many systems world-wide, is how clinical responsibility is understood. This is often based on the rather hypocritical assumption, in my view, that freedom is mostly a risk and coercion is mostly a route to safety. This way if a tragedy happens following a coercive action (directly or indirectly), the clinicians involved in the coercive action are presumed to have done what they could, whereas if a non-coercive route is attempted and a tragedy happens, the clinicians involved will be held responsible for not coercing the patient.

Any move towards (but also any rejection of) the Trieste model needs to find a way to address this problem.

• Objection: Freedom means neglect.

A lot of anglophone professionals, when they hear about a rejection of psychiatric coercion, think of Thomas Szasz. There was a big difference between Basaglia and Szasz: the former was against institutional violence regardless of the institution in charge of it, and built a range of alternatives before closing the psychiagtric hospital in Trieste. If someone needs a bed in Trieste, there are beds available (the UK is not always so lucky, neither for number of beds available, nor for the nature of them).

Szasz did not build, nor offer anything beyond rejecting psychiatric (but not other forms of) coercion and being open to the idea of private practice or philanthropy.

The two proposals could not be more different.

Poor services do unfortunately exist in many parts of Italy due to local governments not investing in them, but this cannot be blamed on Basaglian ideas, which should be evaluated where they are applied well.

• Objection: The Trieste model can only be applied in the caring Trieste culture, or in small cities such as Trieste

When Basaglia took over as director of the asylum in Trieste, there was no community mental health system in place at all. There was also strong resistance to change in the local population.

Trieste used to have the highest suicide level in Italy. This went down significantly over the decades. The community system was built from scratch and was a result, not a starting point of the revolution.

What is known as Severe Mental Illness exists in both small and big cities; this also applies to mental health crises. While the exact structure of a Basaglian system would have to be tailored to local circumstances, the founding principles are universal.

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The Trieste model, and what it represents, is a very complex subject and it would take much more than this introductory review to discuss it comprehensively. For now, I hope this blog post has been a helpful starting point for those who are interested in learning more about it.