Appendix 3 - Report of mental health services observed in Trieste, Italy - January 2006
Senator Lyn Allison,
Chair, Senate Select Committee on Mental Health
demographics and the development of its health system is different from that of
Italy there are some lessons to be learned from the mental health services in
Trieste region – a system that is world renowned. Some of these are:
accessible, community-based intervention is successful in reducing serious
episodes of illness that require acute care and therefore cost
teams must have a comprehensive range of clinical and psycho social skills and
that the sole focus on mental health by these professionals leads to high
levels of expertise and effective treatment
services must provide or be closely linked with housing, employment and social
reintegration provision for minimising psychiatric disability
It is possible to
treat the vast majority of people with mental illness in an environment free of
physical or chemical restraint if their human rights and their experiences are
respected and services readily accessible
That families and
carers can be relieved of the most onerous caring tasks if they are engaged
with and informed by service providers in the care provided.
A brief history
reform commenced in Italy in the early 1970s when institutions were unlocked,
patients free to come and go and, over time, retrained staff and services were
transferred into the community. The
Trieste asylum once housed 1,200 patients but now 94% of mental health budget
is spent on expert, community-based centres.
These centres – of which there are four in Trieste serving a population
of 250,000 – provide full clinical and psychosocial support and the service
costs half that of the former institutional arrangements of usually permanent
Health and social
services are well integrated, employment rates are high, demand for acute care
is low and functioning levels of those affected by mental illness are high.
Medication has been significantly reduced and few with mental illness are
caught up in the criminal justice system.
Italy is divided
into 20 regions and the Trieste region – Region Friuli-Venezia Giulia – is one
of four regional governments that have autonomy over their health and other
Community-based mental health services,
difference between the Italian and Australian systems is that mental health
services provided to people with mental illnesses are delivered by
multi-disciplinary teams of mental health workers at each of the community-based
mental health centres (MHC). Clinical support is available 24 hours a day, 7
days a week. Staff morale and commitment
are set at around 1 per 1 000 residents and the Trieste region has 237 mental
health workers – 28 psychiatrists, 7 psychologists, 180 psychiatric nurses, 10
social workers and 6 psychosocial rehabilitation workers.
MHCs have an open
door policy, are in airy, well designed buildings with ample multi-purpose
indoor and outdoor spaces. They are
abuzz with activity, provide accommodation for up to 8 ‘guests’ overnight or
longer, as necessary, and three meals a day are served to many more. No one is turned away, yet it is unusual for
all beds to be occupied.
An unwell person
is assessed by a mental health worker very soon after they present at the
centre. Two psychiatric nurses are on duty overnight.
MHCs are drop in
centres and provide lots of formal and informal engagement between staff and
people with mental illness and their families and, importantly, with the
Eight beds in the
psychiatric ward of the general hospital are used principally by those with a
mental illness that also require treatment for a physical illness and are
rarely fully utilised.
The commitment to
deinstitutionalisation, re-engagement with community. civic rights,
integration, innovation and evidence-based practice drives service
consumer/advocacy sector has not evolved as it has in Australia, because
services are there for people who need them and social cooperatives and work
give people with mental illness a meaningful voice.
The Trieste region’s achievements include:
An average of
only 7 per 100,000 residents are subject to involuntary treatment (and none in
2004/5 in one of the 4 areas) compared with 30 per 100,000 Italy-wide.
ECT is no longer
No one with
mental illness is homeless in the region
Only 1 mentally
ill person is in a forensic hospital
have been reduced by 30% over the last 8 years
400 people with
mental illness are employed on award wages in social cooperatives operating
business ranging from restaurants, horticulture, gardening, the arts, museums,
hotels, etc and 30% of these people are affected by psychosis. A further 200 people are employed in private
Some philosophies and rationale underpinning
Trieste’s mental health system
That people must
have the opportunity to be not just patients but people who are individuals with
complex lives and needs
That the social
capital of relational resources of individuals, measured by trust, reciprocity,
the use of the power of negotiation, political awareness and civic
participation, are positively correlated with health conditions.
participation in society is an important indication that the person is emerging
from isolation. The terms ‘recovery’ and ‘emancipation’ are used to emphasise
the lack-of-freedom, the loss of rights, the denial of access to resources and
the effort which must be made in order to “come back”.
That belonging to
a place, or a group, can provide a sense of communality with other people’s
citizenship rights (political, legal, social) of an individual and the
acquisition of material resources (housing, jobs, goods, services), training
(living and work related) and information (psycho-education, social awareness)
are all necessary for recovery.
That people have
a right to be treated with respect and dignity and to be partners with health
professionals in the progress of their recovery
individual’s strengths and experiences must be built upon and a sense of
ownership of and responsibility for their actions accepted
community must openly take responsibility its own mental health problems
Work is not so
much a goal as an instrument for recovery and emancipation and for defeating
stigmatisation and a very important way out of the psychiatric ‘circuit’.
Psychosocial support provided in the Trieste
Family and user
associations, clubs and recovery homes.
12 group homes
with a total of 72 beds, staffed at a range of levels according to need
2 day centres
including training programs and workshops
projects, developed for each person engaged in MHCs, including objectives and
An open door
A focus on
familial relations and engagement of the family
The engagement of
clients in regular paid employment through training and ongoing support and a
close working relationship with 13 accredited social cooperatives and private
include inpatient, outpatient and home care, individual and group therapy,
psycho social rehabilitation, a GP ‘health tutor’ and facilitation of
membership of associations and social enterprise activities
professional training activities
National Government initiatives in mental
1978 required the closure of psychiatric institutions which was carried out
over a period of some years during which time staff in those institutions were
retrained in community-based clinical services and supports and patients
transferred to community care once services were in place.
budgets are provided by the National government on a per capita basis with weightings
for disadvantage. The percentage of that
budget to be spent on mental health is not prescribed and ranges from 5% in the
Trieste -province to 2% in others.
By law, general
hospitals can have no more than 16 psychiatric beds and there must be no more
than 1 acute care bed for 10,000 inhabitants.
Where in 1971
there were more than 100,000 patients in 75 to 80 mental health institutions,
Italy with 57 million inhabitants, now has just 3,500 public psychiatric beds
(with roughly the same number in private psychiatric clinics although these are
largely for high prevalence disorders).
A further 17,000 people with mental illness are accommodated in group
homes of up to 20.
Mental health and the criminal justice system
Minister of Justice sets progressive goals to reduce the number of people in
forensic hospitals, currently down to 2 per 100,000 residents – a total of
1,100 for all Italy.
region currently has only one forensic patient and every effort is taken to
keep people with mental illness out of the criminal justice system.
The police play a
useful role in the mental health system but always in partnership with mental
health teams. For consumers who are
delusional, the police presence is often seen as an assurance that their rights
are being protected. Police receive no
special training in dealing with people with mental illness but their close
working relationship with the MHC teams has ensured their responses are
Police are often
called to attend incidents but are accompanied by a mental health worker once
it is established that the person concerned may be mentally ill and he or she
is usually taken to the MHC in an ordinary vehicle (not a divvy van). If the person arrives at the general
hospital, a worker from the MHC will attend within a very short time to assess
and usually transfer the person to the MHC for accommodation and treatment,
even if he or she has been charged with an offence. This avoids the need for people requiring
care to be in remand if their health in that environment would further
The MHC team is
involved at every stage, providing assessments and briefs for police and legal
representatives, physically taking responsibility for the person concerned and
providing treatment until they are well enough to face the charges, arranging
legal representation, providing expert opinion in court and ongoing care in
prison if a custodial sentence is the outcome.
These situations are effectively co-managed by the legal and mental
consider pleas of diminished responsibility, after a psychiatric assessment is
provided, and are encouraged to do so because of the presence of appropriate
services in the community. These services have transformed the perception once
held that a person diagnosed with mental illness is both incapacitated and
dangerous, to one whereby the community is confident that services and care are
in place to deal with the illness and to prevent violent incidents
According to the
1978 law, the city mayor (as the main health authority for citizens) signs
treatment orders at the request of two doctors. Urban police are present,
alongside mental health workers, during the administration of medication.
Social cooperatives and other employment
The genesis of
Trieste’s social cooperatives was in 1973 when patients, supported by health
professionals, won the right to turn their “work therapy” cleaning tasks into a
maintenance contract that applied union rules and salaries under a cooperative. The administration resisted this move but
capitulated after a strike supported by the union. These ‘inmates’ became workers with jobs,
salaries and rights.
cooperatives now operate hotels, successfully tender for front office and call
centre services for public agencies and museum staff, are involved in
agricultural production, gardening and craft, carpentry, photo and video
production and run a radio station. They
also provide IT services, publishing and serigraphics.
Every year there
are 120-150 trainees in social cooperatives and open employment, of which 30
The indicators of
rehabilitation through work include improved socialisation, self-care, family
relationships, lower admission rates and less medication.
The theory is
that work settings should be capable of promoting and widening other fields of
interest, develop worker/employer partnerships, job attachment and a sense of
identity and belonging. The challenge is to overcome the passive status of
being ‘assisted’ and to involve people as ‘subjects’ with their own abilities.
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