CASE STUDIES

Community Mental Healthcare

TRIESTE, ITALY

The Trieste response to mental ill health is world famous. When Trieste’s Psychiatric hospital closed in 1980, a new vision for mental health services took shape in the city. Psychiatric institutions were replaced by a network of services that would be fully embedded in the community, highly accessible and with a low threshold of access.

The service offer is delivered primarily through four Community Mental Health Centres (CMHCs), which are open 24/7 and have a small number of beds. Practice in the CMHC multidisciplinary teams is informed by the interplay between medical and social determinants of mental illness. Mental health clinicians work to understand and support people’s mental health problems and a network of social cooperatives offer training, employment and social support services, including activities for families and carers.

Living Well system features:

Outcomes

Are accountable for people centred outcomes that promote choice, recovery and citizenship

Strengths

Work holistically, building up and on people’s strengths

Citizens

See people as citizens within communities, rather than ‘patients’ or ‘professionals’

Collaboration

Work collaboratively
and flatten hierarchies

Voice

Put the voice of lived experience at the centre of services and the system

Access

Provide timely access to support where it is needed

Networks

Activate supportive

social networks

Learning

Having permission to test and learn together

Support is underpinned by a culture recognising the right to be ‘mentally different’, as opposed to 'mentally ill'. It focuses on people’s right to citizenship and to participate in the social life of their community. There is no restraint, and staff have confidence that service users can manage their own risk. The local hospital only has a handful of inpatient beds, mainly used for emergencies. People have agency, options and choice, however unwell they are. Life stories and aspirations are embraced as the main tools for recovery.

Trieste represents a relational response to mental health. However ‘mentally unwell’ you are, you are not ‘othered’ by medical diagnosis, restraint or containment. By contrast, staff work in relationship with people’s subjectivity, their personal reality. People’s right to be different is recognised across the city, among citizens from all walks of life.

In taking this relational approach, the city has helped people lead better, more fulfilling lives, integrated them into the community, reduced suicides and homelessness, and achieved an impressive reduction in the financial cost to the system over the last 50 years.

The difference it makes

Number of mental health inpatients and emergency presentations

Incidents involving people with mental health issues and law enforcement officers

Suicide rate

People with mental health
issues that get into
employment

Number of involuntary treatments

“The focus is on the person; the illness is put 'in brackets.' Long stays in hospital never treat mental illness; they often make it chronic and promote demoralization, along with new and worse symptoms. For deinstitutionalization to work, there must be not just the closing of hospitals, but also the opening of society. Patients had not only to be discharged from closed units, but also embraced by open communities. This doesn’t happen without a lot of organization, preparation, hard work,persuasion, and occasional turmoil.”

- Dr. Mario Colucci, Psychiatrist *

* World’s best and worst places to be mentally ill, Psychology today Dec 2015
https://www.psychologytoday.com/us/blog/saving-normal/201512/worlds-best-and-worst-places-be-mentally-ill

From the evaluation

The radical reform of mental health services that started off in Trieste in the 70’s has had a very significant impact in the city and also an important influence on mental health services across the country.

Psychiatric hospital closure: In 1980, after 9 years of phasing out, Trieste’s psychiatric hospital was closed and replaced by a network of mental health care services in the community. Following in Trieste’s footsteps, all psychiatric hospitals across Italy were closed by the year 2000.

Support in the community: across town there are approximately 50 sites where mental health activities of different kinds are carried out.

A radical reduction in the number of psychiatric hospital beds: in 1971 there were 1200 beds in Trieste’s psychiatric hospital. In 2015 there were 6 acute beds in the general hospital; 26 community crisis

beds across the four mental health centres; and 35 places in supported group homes.

Better outcomes for service users: in a sample of high priority users a 5 year follow up showed a high rate of social recovery, reduction of symptoms and increased social functioning. There was also a 70% reduction in days of admission. Other studies report a 50% reduction of emergency presentations at the general hospital over 20 years and evidence that CMHCs are effective in

crisis resolution and in preventing relapses. Moreover, qualitative research highlighted the connection between recovery, social inclusion and participatory citizenship.

40% reduction in suicide rate: Trieste’s suicide prevention programme has succeeded in reducing the suicide rate by 40% over 15 years.

The lowest rate of involuntary treatments
across the whole of Italy: in 2016 only 20 people underwent involuntary treatments. This is equivalent to less than 7/100.000 inhabitants.

No psychiatric service users are homeless: there are no homeless clients because the CMHC beds function as shelters until suitable accommodation can be found.

Employment and integration: about 250 people every year are in grant-funded professional training and about 10% of them find jobs in the social or private sector.

Forensic hospital closure: the number of inpatients in forensic hospitals had been steadily declining, from an average of 20 in the ’70s to an average of 0.5 in the noughties. Trieste’s forensic hospital was finally closed in 2015.

Lower cost: in 1971 the budget for mental health services amounted to the equivalent of €26 Million. In 2001 it was €14 million.

Fewer staff: in 1971 there were 524 members of staff. Today they are 220.