Trieste’s mental healthcare model is under threat, claim supporters of the community based approachBMJ 2021; 373 doi: https://doi.org/10.1136/bmj.n1597 (Published 21 June 2021) Cite this as: BMJ 2021;373:n1597
Experts in Italy and beyond claim that right wing politicians are seeking to dismantle one of the world’s most celebrated and progressive mental healthcare systems, established in the port of Trieste.
The city’s mental healthcare model, based on the theories of the reforming psychiatrist Franco Basaglia, who believed that psychiatry in large institutions unfairly ostracised people with mental problems, has seen a radical switch to community based care.
While it is not without controversy, proponents of the Trieste system in Italy and around the world say that it is more humane, more effective, and even economically more viable.
But political upheavals, organisational changes, and encroaching privatisation in the northern Italian region of Friuli Venezia Giulia, have led to an outcry among professionals and some politicians who say that the system is under attack, although the regional government denies this.
The fears have led to a petition on Change.org to “save Trieste’s mental health system,” signed by eminent mental health experts. The petition claims that the region’s right wing regional government, “on poorly informed and ideological grounds, is fast and impulsively dismantling Trieste’s wonderful system of community care . . . that has made Trieste a beacon of hope for the world’s most vulnerable citizens.”1
Among the signatories is the US psychiatrist Allen Frances, professor emeritus in psychiatry at Duke University in North Carolina and chair of the DSM-IV Task Force. He tweeted, “I never beg, but I’m begging now: If you care about mental illness, please sign [the] petition to save Trieste’s great mental health system—model of best practice for the entire world.”
A chief concern among people who back the Trieste system is that well qualified candidates for the vacant post of mental health director have been excluded from being considered for the post.
“It’s clear that local people with better CVs were blocked from the process,” said Roberto Mezzina, psychiatrist and former director of mental health in Trieste and current vice president World Federation for Mental Health’s European region. “The process of dismantling the Trieste model began when the right took over the region in 2018, by merging authorities and centralising power.”
A public letter signed by an international group of mental health experts including Benedetto Saraceno, former mental health director at the World Health Organization, said that the Friuli Venezia Giulia region, in which Trieste lies, was aiming to give the city’s mental health director job to a candidate who was “completely alien to consolidated . . . progressive care, and who, instead, came from backward services, from psychiatric wards that are often closed and that still use physical restraint.”
In 2018 Massimiliano Fedriga, a member of the far right Lega party, became governor of Friuli Venezia Giulia. He now heads a regional coalition with the even more extreme Fratelli d’Italia party and the conservative Forza Italia.
Mezzina said, “Their aim is to take back control by putting in place a director of mental health services under the control of the regional politicians.”
A group of centre left regional councillors has pledged to fight further changes—and has even invited Fedriga and his vice president and councillor in charge of health services, Riccardo Riccardi, to spend half a day with patients, families, and staff to see how the service “is viewed with envy and admiration from across the world.”
One of the opposition councillors, Andrea Ussai of the Five Star Movement, said, “We are not defending positions of power but a model that’s been shown to work in Italy . . . and we’re alarmed that an ideological approach by the centre right is trying to dismantle the services and gradually entrust all of them to the private sector.” The Five Star Movement is considered right wing because of its anti-immigration stance, although it describes itself as a movement that does not fit the traditional right or left model.
Riccardi told The BMJ that despite the criticism he regarded “Franco Basaglia as the father of an innovative culture in the field of mental health [who has] revolutionised the entire Italian psychiatry,” giving rise to a model “that is still innovative today.”
And he denied that political considerations were downgrading services or leading to inappropriate managerial appointments.
“The aim of the Friuli Venezia Giulia region and its regional health service is to further improve the level of care, gauge best practice, and provide services to the community,” he said. “In Friuli Venezia Giulia, the assignment of managerial positions is based on the results of examinations, tests, and curricular assessments that take into account the professional qualifications.”
He added that the “goal of psychiatry should be to guarantee the best possible service to patients, and not to waste precious energy in an attempt to build fiefdoms that can only damage the health service.”
The Trieste way
Trieste’s radical overhaul of mental healthcare began in 1980 with the closure of the city’s main psychiatric hospital. The city developed a network of easily accessible services in the community, based on four community mental health centres, which are open 24/7 with a small number of beds. The general hospital retained a unit for psychiatric emergencies.
The philosophy underpinning the new approach was that people with mental health problems still deserved their right to citizenship and the ability to participate in the social life of their community.
A rehabilitation and residential service has worked alongside charities and special facilities for patients to get together with families and healthcare workers to discuss recovery. Some critics of such systems say that they are less suited to highly deprived areas and may result in the most seriously ill patients being jailed instead.
The system was praised by many foreign mental health experts, however, and has influenced practice in other countries including the UK. In Birmingham, the rapid closure of three old-style asylums and the creation of an alternative model of community based mental healthcare in the 1990s was influenced by Basaglia’s work.
A group of psychiatrists wrote in the Lancet in 2019, “This profound transformation of mental health care would not have been possible without the active collaboration and joint working of health professionals from Trieste, where Basaglia’s legacy led to the creation of one of the most innovative and progressive mental health systems.”2