Appendix 3 - Report of mental health services observed in Trieste, Italy - January 2006

Senator Lyn Allison,

Chair, Senate Select Committee on Mental Health

3.1 While Australia’s 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:

Early, easily accessible, community-based intervention is successful in reducing serious episodes of illness that require acute care and therefore cost
Mental health 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
Mental health 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

3.2 Mental health 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 institutionalisation.

3.3 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.

3.4 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 expenditure.

Community-based mental health services, Trieste style

3.5 A significant 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 is high.

3.6 Staffing levels 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.

3.7 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.

3.8 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.

3.9 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 outside world.

3.10 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.

3.11 The commitment to deinstitutionalisation, re-engagement with community. civic rights, integration, innovation and evidence-based practice drives service delivery.

3.12 A separate 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 used
No one with mental illness is homeless in the region
Only 1 mentally ill person is in a forensic hospital
Suicide rates 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 firms.

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.
That 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 experiences.
That the 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
That an individual’s strengths and experiences must be built upon and a sense of ownership of and responsibility for their actions accepted
That the 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 region

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
Individual projects, developed for each person engaged in MHCs, including objectives and time frames
An open door policy
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 employers
Services that 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
A prison consultancy service
Basic and professional training activities

National Government initiatives in mental health

3.13 Legislation in 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.

3.14 Overall health 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.

3.15 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.

3.16 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

3.17 The National 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.

3.18 The Trieste region currently has only one forensic patient and every effort is taken to keep people with mental illness out of the criminal justice system.

3.19 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 appropriate.

3.20 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 deteriorate.

3.21 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 health teams

3.22 The courts 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

3.23 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 initiatives

3.24 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.

3.25 Social 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.

3.26 Every year there are 120-150 trainees in social cooperatives and open employment, of which 30 became employees.

3.27 The indicators of rehabilitation through work include improved socialisation, self-care, family relationships, lower admission rates and less medication.

3.28 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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