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Mental-health care, Italian-style:
When Trieste closed its asylum in 1980, it revolutionized community psychiatry
by Jeff Hienrich
The Gazette
27 November 1999

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www.triestesalutementale.it

"Vincenza? Vinc-e-e-enza!" Making a house call in the city's south-end Chiarbola quarter, psychiatrist Massimo Marsili rings the bell and hails the old lady through the blue shutters of her ground-floor apartment.

"Vincenza Zanetti, 72, is home, but she doesn't answer. She's inside, obsessively covering her few possessions in sheets of newspaper and scrubbing the floors and countertops with rubbing alcohol.

She's a miser, and the Valium she takes does little to rein in her mania. She hoards everything, even her bags of kitchen garbage. And she has a pathological fear of infection.

That much becomes apparent when, coming to the door in a mangy dressing gown and slippers, she finally allows Marsili and social worker Antonio Chiurco into her foul-smelling lair.

"Close the door!" she commands. The two men can barely breathe, so strong are the alcohol fumes, but they don't mention it. They want Zanetti to recognize their faces, confide in them, let them help her.

It's their job. They work for one of the world's most avant-garde government psychiatric agencies, the Mental Health Department of Trieste, a northeastern Italian city of 260,000 bordering the former Yugoslavia.

It has been almost 20 years since Trieste closed its psychiatric hospital, a forested hilltop complex of 40 villas built as a lunatic asylum in the waning days of the Austro-Hungarian monarchy, when the Adriatic city was the empire's principal seaport.

Until its last unit was padlocked in 1980, the hospital and its 22 walled-off hectares of buildings and parkland in the San Giovanni quarter had been home to 1,200 psychiatric patients. Wards of their doctors and subjected to now-discredited treatments like heavy electroshock therapy, they lived shut away from the city down the hill.

Today the gates of the hospital are open, and villas that once housed agitati, semi-agitati and other insane people have been turned into offices, apartments, classrooms and workshops. There's a cafe, a theatre and even a radio station, all run by psychiatric patients. There's a documentation centre, where patients are busy transferring all the paper files of Trieste's municipal government onto CD-rom.

Off the grounds, in the city itself, there's much more. Besides the former hospital, six other mental-health centres are scattered throughout Trieste and its suburbs, offering treatment and even lodging. As well, there are 30 group homes for patients unable to live on their own. And there are several business ventures, too. Patients run four co-operatives, doing business with the general public; there's a seaside hotel, a trattoria, a bar, even a private gardening service for local corporations.

All this, and at a fraction of the previous cost. In fact, with half as many nurses, less administrative overhead and tighter budgets, Trieste's community-based approach to psychiatric care runs on half the state subsidies of the old psychiatric hospital - with far happier results.

It's a model of de-institutionalization that has inspired governments in Great Britain, Spain and Canada. Doctors and social activists who have visited Trieste say the work done there is a revelation.

"For us, Trieste is like the Vatican - it's the top," said Longueuil patient-rights advocate Paul Morin. A sociologist, he first saw Trieste in 1976, when few Quebecers were interested in the city's mental-health reforms.

"Trieste is a beacon. It shows us what community mental-health care can really be: psychiatry with a human touch," said psychiatrist Alain Lesage of Louis-H. Lafontaine Hospital, Montreal's largest mental hospital. A top Quebec authority on community care, Lesage studied in Verona, Italy, in the mid-1980s. Part of his research involved observing the Trieste experiment - and bringing some of its lessons home.

"Trieste is a 'best practice,' " he said, using medical jargon for a model clinical practice that is an example for others of how to dispense good medical services. They include hospitals like Louis-H., an east-end institution that has seen its number of beds drop from 6,000 - before de-institutionalization started 40 years ago - to 2,200 in 1994 and 900 now.

What's behind Trieste's renown? Call it daring. Convinced it was doing more harm than good by treating patients within a hospital, it voluntarily shut down its facility.

"We've demonstrated that there is really no justification for making people live in a hospital for years and do nothing," said Dr. Franco Rotelli, who took over as head of mental-health care after the closing and is now in charge of all of Trieste's health services, including psychiatry.

"Instead of keeping our hospital open and offering complementary services on the side, we closed the hospital down and offered true alternatives, so that we can now practice a different kind of psychiatry."

The Mental Health Department is a decentralized institution. Instead of one big hospital, there are the seven centres around Trieste and its suburbs where patients get counseling, have their medication dispensed and even get emergency lodging. The old hospital complex is a shadow of its former self. The full story is now being written outside its walls - in the community.

"When a hospital is closed, the only option for patients doesn't have to be the street," Rotelli said. "There's much more we can do for them, much more that they can do for themselves, with our help."

In all, the mental department's staff - including 25 psychiatrists, 8 psychologists, 178 nurses and 10 social workers - attend to about 3,000 people a year with specialized programs tailored to them. One-quarter of Trieste's population is over 65, the highest concentration in all Italy, and that's reflected in the health centres' demographics - people like Zanetti.

One of the seven mental-health centres is dedicated to women only, while others have programs tailored to everyone from children and youths to Trieste's large Slovenian and other former-Yugoslav minorities, who make up 15 per cent of the population.

Marsili runs the mental-health centre in Domio district, in the city's industrialized southeast, next to an elevated highway. The drive out there takes him past ancient Roman ruins and Campari Soda billboards, past motionless cranes in the stagnant port and an old Austrian iron foundry, past the remains of a Nazi concentration camp (now a museum about fascism) and the sad spectacle of the city's once-bustling fish market, now closed.

His centre sees 650 patients a day; some 200 are psychotics and other "high-priority" cases who live alone and have no one else to turn to. (More acute cases are treated elsewhere, at the city's general hospital or in one of Italy's four psychiatric hospitals for the criminally insane.) The rest have more typical profiles - like Alfredo Jacopic, 53, a former crane operator. He's of Slovenian origin. He's also a convicted vandal.

Jacopic got in trouble because of his singing. Between suicide attempts, the manic-depressive used to irritate the neighbours in his apartment building by singing at the top of his lungs. After they complained, he took a pair of pliers and cut the electricity to their flats. In opera buffa style, the deed was easily traced to him: in the darkened building, his was the only apartment with the lights on. "So he was caught, and now he comes to us to make sure he's taking his medication," Marsili said.

Like the live wire that gave him away, Jacopic is ablaze with energy. Outside the centre one day last August, he bustled around the other patients, his eyes shining below the brim of a yellow Nike cap, his voice breaking into O Sole Mio. He took requests. He enjoined people to sing along. He considers his art of song a gift to others.

"People who aren't quite all there can still do good things," he said during a brief respite. "If this place wasn't here," he added, waving an arm to take in the squat building and its personnel, "I don't know what I'd do."

Sometimes a drop-in centre is not enough. But Trieste planned ahead for that: its centres have beds. When the mental anguish gets too much for Marsili's patients, they, like patients in the other centres, can sleep over a few nights until they're stable . About 850 a year use the beds set up across the city, usually staying about 12 days at a time.

There are also 30 group homes in Trieste, including 12 in the villas of the old hospital on the hill. Together they house 160 patients - people like Adriano Colla, 64. He first came to the old psychiatric hospital in 1959, when he was 24. Back then, he was "going crazy" working in a bank, and was admitted to the hospital's agitati pavilion. Now blind and hobbled by cancer, he does not remember those days with much enjoyment.

"It was like this: if you wanted to eat when it wasn't time, they put you in solitary confinement," he recalled bitterly.

But in 1971, that treatment began to change. It was in August of that year that the hospital got a new boss. He was a crusading psychiatrist named Dr. Franco Basaglia, a reformer now credited as the father of de-institutionalization in Trieste. Basaglia had spent the previous decade revolutionizing care at the mental hospital in Gorizia, an hour's train ride north on the Slovenian border. He set out to do the same in Trieste.

Basaglia was a disciple of another European reformer, British psychiatrist Maxwell Jones. In the 1950s, after a national policy of "open doors" unlocked the wards of England's asylums, Jones developed the concept of psychiatric hospitals as "therapeutic communities." Basaglia did the same in Gorizia, bringing in mixed-sex wards and eliminating staff uniforms. He encouraged staff discussion and a say for patients and their families in the treatment they received.

In Trieste, Basaglia wanted to go even farther: hisdream was to close the hospital entirely, and move psychiatric care into the community. The idea may seem obvious now, but in traditionalist Italy, it was radical. The country's own open-doors policy had begun only a few years earlier, in 1968, more than a decade after Britain's. Up until then, Trieste and other hospitals were governed by a 1904 law that forced people into asylums when they were deemed "dangerous for themselves or others, and a public scandal."

In 1968, that was amended to allow patients to commit themselves voluntarily, but for the rest the old rule applied: if you're in an asylum, you've been put there by force. Only in 1978 was de-institutionalization recognized nationally; Law 180 created decentralized mental-health districts on the Trieste model for all of Italy. But no city has gone as far as Trieste in offering new services.

Aided by young acolytes like Marsili - a Roman who moved to Trieste in 1974 - Basaglia in one decade swung the doors of the asylum wide open. Electroshocks and other controversial therapies and restraints were eliminated. Basaglia went to court for the right to give his female patients the birth-control pill - and won. Patients were encouraged to venture into town.

Under Basaglia, the hospital was divided into seven units, basing its services on where a patient was from, not what his or her behaviour and severity of illness was.

In the city, psychiatrists rented apartments under their own names, then quietly sublet them to their patients. The groundwork was laid for the hospital to move its services outside after it closed.

The movement even had a mascot: a big blue horse named Marco Cavallo, constructed of wood and papier-mache by artists invited into the hospital. Today it's the symbol of the Mental Health Department, widely reproduced on its literature and letterhead.

On a Sunday afternoon in March 1973, the statue was paraded through the streets of Trieste. A cortege of 400 patients and staff followed behind. Together they proclaimed the death of the old asylum and the birth of a new psychiatry. Colla was one of them.

"Basaglia was like a father to us," he recalls fondly. "He removed the rails from our balconies. We were free to express ourselves and say what we want - free."

Go to the Source!
www.triestesalutementale.it

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