Reflection: Inspiration and instruction from a visit to Trieste

It’s not just that the work is hard, which it is, but that the system seems increasingly broken and almost perversely blocks attempts to get help or to give help.  As staff find themselves increasingly alienated from the values and passions that drew them to work in community mental health (like emotionally connecting to people in distress, listening and being there for them when they are in crisis, supporting them with skills and resources to heal and grow and rebuild their lives, freeing them from the tangles of the legacy of trauma, various mental conditions, and addictions, etc.) focusing instead on “realistic” tasks (like following bureaucratic regulations and accountability, generating revenue, and avoiding liability, limiting access to services to avoid being overwhelmed, etc.) all in an environment of deepening scarcity (especially of homes), all our time and energy is sapped away and we are too often left burned out and morally injured.  We are told we were naïve and idealistic to have ever believed more was possible; This is just the reality of treating severe mental illnesses and drug addiction in our society today.

Nonetheless, there are “bright spots,” pockets of practice, where  passion and practice are infused with enthusiasm and purpose.  These are usually on the outskirts of our system, somehow protected from it (usually by formidable personal leadership).  These “bright spots” can give us hope and direction, pointing us to what might be possible. 

Surprisingly enough, there has existed, for over 50 years, in Trieste Italy an entire system of community care serving about 300,000 people, that is a coherent “bright spot” demonstrating that our values and passions weren’t unrealistic after all.  It can be done.  And once we’ve seen that, much as we might try to push it away, explaining why “that can’t be done here,” we can’t unsee it.  And then, we may feel driven to throw off our burnout, our rationalizations, and the memories of our failures, to try again.

For those of you who have not been to Trieste, this document tries to convert the inspiration of Trieste into a concrete, actionable, believable plan.

But first a few words about how they achieved this:  

Italy experienced a traumatic experience with fascism and repression.  Many of the staff had even spent time incarcerated for anti-fascist activities.  By 1968, they were experiencing the height of the worldwide liberation movements in several ways.  Under the leadership of Franco Basaglia, the psychiatric director of the mental hospital, they tried to liberate the patients, who were profoundly neglected and oppressed, as most people in mental institutions are throughout the world.  They tried to create a more open, therapeutic community within the hospital.  They actively gave away their power over the patients, encouraging input and dissent.  They stripped away rules and locks.  They “put the diagnosis in parentheses” to relate as a fellow human to the patients.  They worked hard to develop practices that actually rehumanized and empowered people, refraining from coercion.  It was hard work and they did it together as a team (an “equipe”).  But they weren’t satisfied with a more humane institution.  They wanted to return people to their families and communities, restoring their rights and active participation.  So they opened the hospital to the community, showing people, especially artistic and socially active people, what they had accomplished and how.    They joined these community partners spreading the news throughout the community and they started working in the community, releasing more and more patients, and avoiding locking up new ones.  They created culture change. 

Over the next 10 years, they obtained the legal, financial, and political support to systematize their values and accomplishments.  They’ve worked very hard to preserve and develop their practices.   There is easy “open door” accessibility for help, and frequent community outreach.  Families and communities don’t have to rely on police for help, since mental health staff come to them, and then stick with them.  They only have six psychiatric hospital beds (and two forensic beds) in the city’s central hospital, and usually these aren’t full, because the community clinic staff do home care and manage respite beds in the community clinics.  People aren’t neglected on the streets.  They are connected to homes, jobs, and social connections partnering with non-profit “social cooperatives.”  There is active substance use outreach including harm reduction.

Given that context, here are the five key values they promote and stand by:  

1. Helping the person, not treating an illness

2. Fostering recovery and social inclusion

3. Addressing practical needs that matter to service users

4. Changing the attitudes in the community

5. Respecting the service user as a citizen with rights

The chart below uses these five key values to: (1) document the ways in which they actualize each value; (2) highlight “bright spots” in the U.S. where this is actually in practice or embraced; (3) highlight the ways in which the American system actually interferes with, or frustrates the actualization of these values.

(click to enlarge)