A public mental health model in Italy earns global praise. Now it faces its demise Trieste has a reputed approach to bringing people with mental illnesses out of hospitals and into the community. Now the region's hard-right politicians are breaking the system apart.

A public mental health model in Italy earns global praise. Now it faces its demise

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Half a century ago, the Italian city of Trieste stopped committing mentally ill people to asylums. Today the Trieste model is recognized by the WHO as the world standard for community psychiatry. The model's been adopted by dozens of countries. But NPR's Sylvia Poggioli reports that the Italian system is now being dismantled.


UNIDENTIFIED PERSON #1: (Speaking Italian).

UNIDENTIFIED PERSON #2: (Speaking Italian).

SYLVIA POGGIOLI, BYLINE: Radio Fragola, Strawberry Radio, broadcasts from one of the many pavilions of the former mental asylum in a large park above Trieste. Along with the radio station, buildings host concerts, plays and university classes. And a patient-run cooperative staffs cafes, hotels, museums, libraries and computer services throughout the city. A slogan painted on a building proclaims, freedom is therapeutic. Next door to Strawberry Radio is Strawberry Patch, a cafe and meeting point.

Renzo Bonn, a psychiatrist and former director of mental health services in a nearby city, says for decades, the mentally ill were forcibly enclosed here.

RENZO BONN: And so you lose all your civil rights. You couldn't vote. You couldn't receive an inheritance. You couldn't get married.

POGGIOLI: Some were locked in cages, tied in straitjackets and subjected to freezing water baths, electroshock and lobotomies. If patients were not released within 30 days, confinement could last indefinitely.

BONN: So the result was the people, once in the psychiatric hospital, all their life in psychiatric hospital.

POGGIOLI: That changed in the late '60s with another psychiatrist, Franco Basaglia, who saw asylums as dumping grounds for the poor and deviant, as he explained in this 1969 TV interview.


FRANCO BASAGLIA: (Through interpreter) When patients are tied up, subjugated and held captive, I don't believe any kind of therapy can help them. I don't see a possible cure when there's no free communication between patient and doctor.

POGGIOLI: Basaglia revolutionized the asylum. He knocked down walls, abolished the tying up of patients and encouraged them to take control of their lives. Soon, not only were patients running a cafe on the grounds and earning wages at real jobs, they were holding hospital-wide patient assemblies.

Pantxo Ramas, who is in charge of the asylum archives, says it became a cultural hub, including a memorable 1974 concert for patients by jazz master Ornette Coleman.

PANTXO RAMAS: And Ornette Coleman said this was the most deep free jazz concert he did in all his life.

POGGIOLI: Shortly before the concert, Ramas says, a 50-year-old female patient walked onto the empty stage and started playing a harmonica. Coleman joined her, and they played for more than an hour.

RAMAS: He lost sense of who was a musician, who was an audience, who was a doctor, who was an artist, who was a listener. And I think that's a moment of poetry, and I feel that this place is a place full of poetry.

POGGIOLI: Basaglia's reforms ultimately led to a 1978 law that abolished all of Italy's mental asylums. He died in 1980, but his work continued. And the Trieste model of community-based, publicly funded mental health care has been emulated in several Italian regions and more than 40 countries. But now it's being dismantled by the region's right-wing administration.

Roberto Mezzina, former director of mental health services in Trieste and now vice president of the World Federation for Mental Health, says for decades the goal of the region's right-wing politicians has been to put an end to the Trieste model and move toward privatization.

ROBERTO MEZZINA: Because this was also a symbol of something that was created in the area of social rights, human rights, et cetera, and was considered part of the leftist culture.

POGGIOLI: In early October, the regional government announced plans to close seven of the 22 community mental health centers and to reduce hours in the remaining centers. It also plans to cut the number of senior psychiatrists and department heads while keeping numerous staff positions unfilled. Repeated requests by NPR for comment to regional health authorities have gone unanswered. Prominent psychiatrists from across the world have signed petitions to save one of the world's premier public health services from being handed over to the private sector.

Dr. Allen Frances, professor and chair emeritus of psychiatry at Duke University, says instead of using coercion and medication as the solution to all problems, there's humanity and community spirit behind the Trieste model.

ALLEN FRANCES: The community was primed to see the mentally ill not as a nuisance to be exiled to hospitals, prisons and jails or left homeless on the street, but rather as potentially very useful citizens who deserved attention and resources of the city and could make a meaningful contribution to it.

POGGIOLI: One patient who experienced the mental health care revolution is 75-year-old Giordano Vascotto.

GIORDANO VASCOTTO: (Through interpreter) I got here when I was 9. It was 1955. I remember the month - October. The windows were locked. Doors were locked. Then they gave me electroshock. Many years passed.

POGGIOLI: After some 20 years of confinement, Vascotto was released.

VASCOTTO: (Through interpreter) After the asylum, I rolled up my sleeves and went to work, first in a cemetery, then trash collector and doorman. Years passed, and now I'm retired.

POGGIOLI: Like other patients, Vascotto can frequent mental health centers open 24/7 that are more like clubs that provide meals and where there's always a willing ear. Dr. Mezzina says that in Trieste in the last 15 years, rates of suicide, drug addiction, hospitalization and homelessness have been significantly reduced. But he stresses that the COVID-19 pandemic has demonstrated the weakness of private sector hospitals, pointing to the many Italian residences for elderly care where the virus spread uncontrollably, triggering record numbers of deaths. And the pandemic itself, he adds, has provoked a rise in psychiatric problems.

MEZZINA: Common mental disorders - anxiety and depression, post-traumatic stress. We have numbers that are doubling the number of young clients, for instance. In youth mental health, there is a huge increase.

POGGIOLI: In an appeal written for the British medical journal The Lancet, Dr. Frances of Duke University says saving Trieste is not just a local Italian issue.

FRANCES: When Trieste dies, it certainly kills the inspiration for other places to copy it.

POGGIOLI: Plus, he adds, it's economically unwise because not providing proper services for the mentally ill means the city will end up paying more for police, emergency rooms and prisons.

Sylvia Poggioli, NPR News, Trieste.


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