Trieste: History of a transformation

" … the important thing is that we have shown that the impossible becomes possible. Ten, fifteen, twenty years ago, it was unthinkable that an asylum could be dismantled. Asylums could become closed, and more closed than before - I do not know -, but, at any account, we have shown that the mad can be assisted in another way, and this evidence is basic. I do not believe that the fact that an action can become general means that one has won. The important point is another one: Now one knows what can be done. This is what I have already said thousands of times. In our weakness, in the minority we represent, we cannot win, because it is the power to always win. We can at most convince. In the moment we convince, we win, that is we give rise to a transformation situation, difficult to recover."
Franco Basaglia, Brazilian Conferences, 1979

The annual World Health Day, April 7th, 2001 was devoted to mental health. On that occasion, Mrs. Gro Harlem Brundtland, WHO General Manager, exhorted all governments to take concrete action and launch information campaigns in order to combat the prejudice, and social exclusion which still affected the lives of the more than 200 million men and women worldwide who suffer from mental disorders. With the slogan "Stop exclusion. Dare to care" the WHO also underlined its invitation to close all psychiatric hospitals, in both developed and undeveloped countries.
In a booklet published on that occasion, we read:
"...In Italy, the 1978 Reform Law initiated a process to supersede psychiatric hospitals with the creation of community-based services which enabled patients to continue living their lives in normal social contexts. The Italian city of Trieste created a significant network of community-based services, protected flats, and coops that train and employ psychiatric patients. The Trieste psychiatric hospital was shutdown and replaced by 24hr community services. These centres provide care, psycho-social rehabilitation, social assistance and crisis interventions if necessary. A number of protected flats were set up for chronic and severe patients, offering a friendly non-medical environment, while employment opportunities have made full social reintegration possible for many patients..."
This authoritative opinion represents the culmination of a 30-year transformation process. While the history of this long journey has yet to be written, we can sketch out the salient moments and phases.

Moving beyond the Psychiatric Hospital

In August 1971, Franco Basaglia became Director of the Trieste Psychiatric Hospital. Upon assuming his post, he formed a team of young doctors, sociologists, social workers, volunteers, and students from all over Italy and Europe, who had been attracted to Trieste by the current debate on psychiatry and total institutions, which involved operators, scholars, politicians and the media.
Basaglia had achieved national notoriety with the publication of "L'istituzione negata" ("The Institution Denied") in 1968, which was based on his attempts to apply the therapeutic community model in the neighbouring town of Gorizia during the 1960s. In documenting his efforts to humanise the institution, Basaglia declared for the first time that psychiatric hospitals could not be reformed: as instruments of social control they could not provide the care for which they were intended and, in fact, produced the very illness they were supposed to cure.
His intention in coming to Trieste was thus to finish the work begun in Gorizia, to go beyond the asylum and establish a network of alternative community services that could perform all of the functions of care, hospitality, protection and assistance that it had been the psychiatric hospital's task to provide.
This was an extremely difficult challenge, for despite several attempts at reform in France and England after WWII, noone had actually succeeded in shifting the axis of care from the hospital to the community. The intended reform had no know-how or consolidated practices upon which to model itself, while the legal framework was still based on the concept of danger.
In 1964, Basaglia had written as follows on the urgent need to "deconstruct the psychiatric hospital:
"When the ill person enters within the walls of internment, he enters a new dimension of emotional void (what Burton calls "institutional neurosis", but I would simply call "institutionalisation"). He enters a space which was originally created to render him inoffensive while providing a cure, but which is instead, and paradoxically so, designed to the total annihilitation of his individuality and his full objectivication. If mental illness is, at its root, the loss of individuality and freedom, in the asylum the ill person finds the place where they will be ultimately lost and become the object of the illness and of repeat admissions. The absence of any project or future, the constant dependency on others without any personal incentive, the organisation of each day according to the dictates of the institution which, as such, is incapable of seeing the person or his individual needs: this is the institutionalising scheme which asylum life is based on."

Changing the Internal Organisation

On December 31st, 1971, there were 1182 inmates hospitalised in theTrieste Psychiatric Hospital, with a yearly turnover of about 1300 patients. More than 90% of these were mandatory internments (Italian Law 36/1904), with very few persons benefiting from the voluntary hospitalisation which had been recently introduced in Italian legislation (Italian Law 431/1968). The use of voluntary hospitalisation would, in fact, become an important tool for guaranteeing patients their rights by increasing their freedom of movement both inside and outside of the hospital and giving them more power in terms of care and assistance.
From the very outset of Basaglia's directorship, great stress was placed on the reorganisation of internal spaces and on breaking down the rigid, professional hierarchy which regulated the relationship between staff and patients. The transformation was initially conceived as a progressive reduction and restructuring of the hospital into "open communities", with the hospital divided into 5 "areas", each with their own staff, that corresponded to five geographical areas with the city and province.
Daily meetings were held each day by the entire staff, as well as by each individual workgroup in order to discuss and debate the work being done. The inmates also participated in periodic meetings coordinated by Basaglia in order to discuss the changes taking place. The doors of the wards were unlocked and shock therapy and all forms of physical restraint were prohibited. Division by gender was also abolished, and mixed wards established.
Life in the hospital was enlivened by parties, bars and an inmate newspaper, and patients began to circulate within the city, both alone and in small groups. Thanks to funding by the Provincial Administration, inmates began to receive subsidies which permitted them access to public places.
The changes taking place began to create resistance in the nursing staff and alarm in the local population.
"...the dominant ideology was that the ill were dangerous and had to be shut up in an asylum. The first thing to do, therefore, was to convince people that this was simply not true. Day by day we attempted to show that changing the relationship with inmates also changed the meaning of those relationships. As nurses began to realise that their work could be different, they became agents for change. In order to change the views of the general public, it was first necessary to reintroduce the mentally ill into the streets, into social life. This provoked an aggressive reaction on the part of the local population, but it was necessary to create this state of tension in order to show that a change was taking place. In training the nurses, the important thing was to create a new type of operator who was not dependent on doctors but could take decisions on his or her own." (Franco Basaglia, Brazilian Conferences, 1979)

The Restoration of Rights

The first five years were dedicated to reconstructing the needs and personal life stories of the interned, in order to reestablish relationships with their families and places of origin. With the break-up of the large wards, living groups and group apartments were created, first within the hospital and then within the city. There was a systematic involvement and training of nurses in order to enable them to abandon their traditional functions as "guardians" and begin to take an active and responsible role in the transformation process.
One of the most important initiatives was the establishment of the "United Workers" Cooperative" in 1972, which organised 60 inmates in order to clean the wards and kitchen and maintain the asylum grounds. Each coop member/asylum inmate signed a contract and received a union wage, completely inverting the exploitation of inmates which went under the name "ergotherapy" and opening up the way to the important use of social coops in therapy and rehabilitation in later years.
The recognition of the right to work, and the dismantling of large wards into smaller autonomous living units clearly showed that it was not disability or illness in themselves, but the legal/administrative status of "inmates" which prevented rehabilitation. Negotiations thus began with the provincial administration to make day/nighttime care and hospitality available – as a right - to those people who, while not requiring hospitalisation, still needed to remain as "guests" because of the lack of housing, work and a social network.
"In those first years, attention was given to speaking with families and caregivers in order to change the status of the patients with respect to the restoration of civil rights and the possibilities of income.This was the only thing that could enable us to emancipate people from psychiatric control. Inmates had to be recognised as people with identities that had not been totally objectified by the institution and psychiatry. We concluded that it was not possible to have a proper relationship with them if their status as citizens had been first given back to them." (interview to Franco Rotelli, 1978)

Creating a Relationship Between the Hospital and the Community

Although the greatest effort was concentrated on the institution, in 1973 several important initiatives had already begun to look beyond the ayslum walls and towards the community, especially the restoring of family relationships, the accompaniment of inmates within the city and the search for work and housing for those inmates who were ready to be released. During this same period, the hospital began to open up to the city with exhibitions, parites and concerts on the asylum grounds open to the public. These experiences would lay the foundation for an alliance between psychiatry and sectors of the general population, including the women's and students' movements, political organisations and trade unions, the media and opinion-makers and intellectuals and artists.
A painting/sculpture/theatre/writing workshop was established in the first ward t o be completely emptied ("P"). Here "Marco Cavallo" was built, an 8ft tall blue-painted horse of paper-machè and wood which became the symbol of the desire for freedom on the part of all the inmates. On the last Sunday in March, 1973, Marco Cavallo was carried around the streets of the city at the head of a procession of operators, patients, artists and ordinary people. During this period, holidays and daytrips into the city and elsewhere also became more and more frequent.
In 1973-74 the hospital was reorganised, with patients being grouped not according to the severity of their illness (agitated, violent, chronic, etc.) but based on their area of origin within the city, a division of the territory which is essentially maintained by the 4 Mental Healthcare Centres today. A workstyle was thus introduced which aimed at releasing and supporting patients in their own homes and neighbourhoods. The assumption of new cases also came to rely ncreasingly on cooperation with other institutions, agencies and citizens groups in the city.
The work outside the hospital, with its problems, successes and conflicts, brought about the first and most significant changes in both the therapeutic practice and the institutional and administrative organisation, and became the "hands on" training school for doctors and nurses alike.

The First Community Mental Healthcare Centres

At the beginning of 1975, there were 800 inmates in the hospital, 90 of which were interned, 150 voluntary and 460 guests, with a turnover of about 1700 annually. Many of those who had been released had found new living accomadations, either with families or, more often, in group homes or council housing.
The first community residences were activated in 1975-76. Initially intended for patients recently released from the psychiatric hospital, almost immediately they began to be used for crisis situations and as day centres, thereby reducing the number, frequency and length of hospitalisations.
The first Mental Healthcare Centres were thus established before Law 180, working and developing alongside the still functioning psychiatric hospital despite the lack of a regulatory or legal framework (Italian Law 431 (1968) only provided for "Mental Hygiene Centres"). This was, in fact, the most delicate phase during the entire transformation process, with two organisational, financial and care systems (especially nursing care) working simultaneously. The risk was paralysis, but with the strengthening of the community services and the growth and development of the 24hr Mental Healthcare Centres it was possible to successfully pass through this transitional period.
At the beginning of 1977, there were 132 inmates, 51 of whom were involuntary, and the remainder voluntary, with 433 guests. In February of the same year, a 24hr psychiatric care service was established in the Emergency Room of the General Hospital, with the aim of filtering the psychiatric demand and providing more appropriate forms of crisis response than the automatic and routine recourse to mandatory hospitalisation. The service would remain active until 1980 when, pursuant to Law 180, it became the Psychiatric Diagnosis and Care Service, with the functions of primary care, consultancy in hospitals wards and referrel of cases to MHCs.
At the end of 1976, with the crisis of the Provincial Council, headed by Michele Zanetti, which had supported the reform process until that moment, Basaglia decided to publicly announce the closure of the psychiatric hospital as an irreversible fact:
"An important result for us is that the community Centres, despite the sometimes uneven levels of care, have increasingly become points of aggregation for former inmates, new users, and other citizens. These persons, who often have nothing in common at the outset, progressively discover a substantial alliance based on their common needs and the common oppressions to which they are subject. The other important fact is that so-called "management of the ill" changes from the total management of the person and his life within the hospital. With the end of paternalism and the beginning of negotiation, this total takeover of a person's life is replaced by a mutual process which allows for disagreement." (The Closing of the Psychiatric Hospital, Press Conference, 1976)

The Closure of the Psychiatric Hospital

On May 13, 1978, due to intense pressure by the deinstitutionalisation movement in Trieste and elsewhere in Italy and the threat of an abrogative referendum on Law 36/1904 which, if successful, would have created a legal void for psychiatry in Italy, the Italian Parliament passed the Psychiatric Reform Act (Law 180) which provided for the gradual closing down of psychiatric hospitals and their replacement by community-based services. However, at the time the Law was passed, the Trieste psychiatric hospital had already ceased most of its former functions.
In November 1979, Franco Basaglia left Trieste for Rome, where he had been summoned to direct the psychiatric services in the Lazio Region. In Trieste his place was taken by Franco Rotelli, who had the difficult task of finally closing down the psychiatric hospital and confronting the mounting criticism regarding its "state of confusion and decline". The new management also had to reinforce the still poorly-defined community services and completely reorganise the use of resources. These were thus transitional years in terms of organisation, adminstration and management, in which the psychiatric reform had to be reconciled with the National Healthcare Service and the transfer of competencies from the Province to the newly instituted Local Healthcare Units.
On April 21, 1980, the Provincial administration passed a resolution declaring that the Trieste Psychiatric Hospital "could cease its functions and therefore be abolished". Franco Basaglia would die in August of the same year.

The Establishment of the Mental Healthcare Department

In 1981, the Mental Healthcare Department was established, thereby guaranteeing the technical, administrative and planning unity of the community services network, together with its programmes and activities. The operational standards of the 5 Mental Healthcare Centres (reduced to 4 in 1996) were more precisely defined, with each MHC serving a catchment area of about 50,000, and equipped with 8 beds and a canteen for day visitors and overnight guests.
Together with the walk-in service, home care and social support, the Department, based on a special agreement with the Justice Ministry, also began to work intensely in the local prison in order to provide therapeutic continuity for inmates with preexisting disorders, as well as care for those who developed problems during their incarceration. The service also worked to promote alternative measures to imprisonment and avoid transfers to forensic prisons.
Residentiality was reinforced in each area, in order to provide hospitality not only to those recently released from the psychiatric hospital, but also for users with difficult family or housing situations. Rehabilitation, training and socialisation programmes were developed, which included leisure activities, workshops and remedial education and literacy programmes. In the mid-1980s the coops were also strengthened in order to provide more occupational training and employment opportunities for primarily young, disadvantaged users. During the 1990s, "social enterprise" would coincide with an intense programme for the full exercise of the rights of citizenship by users of the mental healthcare services. A series of empowerment/emancipation programmes focussed on housing, work, socialisation, education and training, giving rise to networks, forums and self-help groups for risk groups (especially young adults).

Results of the Deinstitutionalisation Process

After more 25 years without a psychiatric hospital in Trieste the situation is as follows: the number of people referring to the mental healthcare services each year is about 13.5/1000 population (3500 users/year). Private psychiatric services remain fairly undeveloped. There has been no phenomena of transfer or placement in other institutions (trans-institutionalisation), with the exception of transfers to general medical wards for primarily elderly persons with organic illnesses concommitant with mental disorders. After the creation of the Substance Dependency Service in the early 1980s, the Mental Healthcare Department has collaborated with this Service in numerous programmes (coops, workshops, leisure time, sports).
The San Giovanni Compound, site of the former Psychiatric Hospital, currently hosts less than 50 people in a number of small residences (no patients have been hospitalised here since 1980). The service network is made up of 4 Mental Healthcare Centres for a population of 240,000 inhabitants. In 1999, the University Psychiatric Clinic became an integral part of the MHD, with its own Mental Healthcare Centre. Costs for psychiatric care have been reduced by half: in 1971 total expenditures were the equivalent of 26 million Euros; in 2003, the MHD spent less than 15 million Euros.
Staff has been reduced from 524 units in 1971 to 242 units in 2004; beds have been cut from 1160 hospital beds in 1971 to 122 beds total in 2004 (including MHCs, PDCS and residences). Recourse to the private sector is very limited with only 90 people from Trieste (2% of users) being hospitalised in private clinics outside of the Region in 2002. And finally, a single care institution, the psychiatric hospital, has been replaced by nearly 40 structures with different functions and tasks.
While these indicators illustrate the institutional change, other data indicate the meaning of the deinstitutionalisation process, with the clear confutation of commonly held prejudices and cliches:
- 24 people were admitted to forensic hospitals in 1971, with an average of 20 annually during the 1970s, while in 2004 only 2 people were interned in forensic hospitals, with an average of 0.5 over the past decade (prejudice of danger);
- mandatory hospitalisations averaged 150 in the 1970s (60/100,000 pop.); in 2003 there were only 28 Mandatory Healthcare Treatments (MHT), with an average of 11 MHTs/100,000 in recent years (prejudice of the refusal of care).
- the suicide rate from 1985-96 was 23/100,000; in 2003 it was 17.5/100,000 (abandonment prejudice)

Towards New Scenarios

In evaluating the community-based work of the past 25 years, the single most important indicator validating the work of the services is crisis intervention. The non-bureaucratic, demedicalised approach to crisis reduces hospitalisations, favours a more rapid return to stability and reduces relapses. In our view, crisis is part of a person's life-story, with its own meaning which must be understood and restored using the resources and relationships that exist in each person's own context.
The community services are very low threshold walk-in services. They avoid standardised responses and protocols and instead focus on reconstructing social relationships and networks, enhancing personal resources and capacities and aim at quality in every aspect of the therapeutic work in order to guarantee a quality relationship.
Numerous self-help groups for users and their families have been organised in recent years, with courses, regular meetings and increasingly diversified social, educational and leisure activities. The area if social enterprise and training in sectors as diverse as information technology, fashion and radio broadcasting also continues to develop, and will certainly be one of the key elements for health and emancipation in the future.
The scenarios of social enterprise, self-help, family and caretaker participation, training and diversity are indicators that confirm the effectiveness and validity of community-based mental healthcare services.

San Giovanni Compound

After being dismantled and shutdown in the 1970s, the grounds and many structures of the former Trieste Psychiatric Hospital, which first opened its doors in 1908, have gradually been restored to the City.
Currently, the San Giovanni Compound hosts several faculties and offices of the University of Trieste, 2 Slovene language high schools, the Local Healthcare Agency Administration Building, the head office of the International Maritime Academy, a Civic Theatre, a centre for the disabled, the Substance Dependency Department the offices of Industrial Medicine and the District 4 offices with related services.
The Mental Healthcare Department currently utilises ten buildings, including the Administration Building, several small residences and the former ward Pavilion "M", which hosts the Rehabilitation and Residence Department, the Polytechnic and several social coops. The historic "Il posto della fragole" bar-restaurant also remains very active, with a wide range of customers that include students, operators, users and visitors.
The San Giovanni Compound, with its beautiful landscaping and architecture, and the surrounding neighbourhoods are emblematic of the history of Trieste with its ethnic and cultural diversity, and offer the possibility for new forms of belonging and coexistence in diversity in the future.