Jumping off the bandwagon: Does the Basaglian de-hospitalised model work outside Trieste?

Introduction

Australian policymakers often cite the Trieste mental health system in reports promoting the transfer of resources from hospitals to community services. The so-called ‘Trieste model’ appeals to both the left and right of politics: the left celebrates the Trieste mental health system’s great achievements with social inclusion, and the right understands that minimising hospital bed numbers is necessary to contain healthcare costs. Hence, government reports present the Trieste model as an exemplar of best practice. And there is a broad consensus among Australian mental health professionals supporting community-focused care.

However, O’Connor and Clark (2019) warn against policy prescriptions where all parties are ‘jumping on the bandwagon’. While mental health policy is complex, governments look for simple solutions, which are chosen because they follow the political zeitgeist; gurus and their disciples actively promote them; and their uptake around the world encourages further adoption. Based on their description, we argue the Trieste model is a policy bandwagon. Is it time to critically scrutinise the Trieste model, and whether it should be cited as an exemplar of best practice for this country?

La libertà è terapeutica (Freedom is therapeutic)

Franco Basaglia was the charismatic Italian psychiatrist who established the Trieste model in the 1970s, and his disciples still actively promote his legacy (Portacolone et al., 2015). Inspired by the writings of Erving Goffman, Michel Foucault and Jean-Paul Sartre, together with the views of British anti-psychiatrists, R.D. Laing and David Cooper, his reforms were based on the ideology that ‘Freedom is therapeutic’: if the asylums caused negative symptoms in severe mental illness, then closing them could eliminate these symptoms.

As the director of the San Giovanni asylum in the Adriatic port city of Trieste, Basaglia led a movement that promoted patients’ human rights, eliminated physical restraint, pioneered 24/7 community mental health centres, established community residential care and finally closed the asylum. These reforms created the ‘Trieste model’, which is community focused with a single general hospital unit (with six beds for acute stays) – the most distinctive feature of the model is this extremely low provision of hospital beds (2.5 psychiatric beds per 100,000 population) (Portacolone et al., 2015).

Basaglia’s reforms proved to be sustainable in Trieste, a prosperous city (population 250,000) with an ageing demographic without a large cohort of younger adults with severe mental illness. There is surplus housing, as the population is decreasing, and the Italian government recognises accommodation as a right of citizenship. Trieste has strong family networks, and low rates of substance abuse; hence, ‘people with severe mental illness who are homeless, as well as addicted to drugs, poor, and without family support practically do not exist in Trieste’ (Portacolone et al., 2015: 689), thereby reducing the need for inpatient admission. The further away from the favourable social and demographic circumstances of Trieste, the harder it may be to implement the Basaglian model.

In 1978, Italy passed Law 180 (the so-called ‘Basaglia Law’), where the Basaglian reforms were codified as closing the asylums, establishing acute units in general hospital with a maximum of 15 beds, restricting compulsory admission and creating community mental health centres. These measures could be described as de-hospitalisation, where out-dated asylums are closed without substituting non-acute beds in modern standalone hospitals.

While suicide rates rose during the asylum closures, Italy has low suicide rates, despite low rates of compulsory hospitalisation (Barbui et al., 2018). However, there are concerns about piecemeal implementation of the Basaglian reforms (Barbui et al., 2018; Carta et al., 2020; De Girolamo and Cozza, 2000). Several problems emerged, for example, length of stay in general hospitals was too short, leading to frequent relapses. Also, private residential psychiatric facilities operated in Italy, which has been a ‘remarkable and unforseen outcome’ of the Basaglian reforms (De Girolamo and Cozza, 2000).

The greatest difficulties occurred in the less affluent regions with a lack of resources, low staffing levels and poor quality services (Barbui et al., 2018; Carta et al., 2020). Without adequate rehabilitation, trans-institutionalisation occurred from mental hospitals to community residential facilities, which became ‘homes for life’ (Barbui et al., 2018) Journalistic and judiciary reports denounced abuse and violence in the so-called protected houses (Carta et al., 2020). Finally, a recent review of Basaglia’s reforms found limited evidence for better patient outcomes with the Trieste model, due to ‘scarce attention’ to scientific measurement (Carta et al., 2020).

The Trieste model in Australia – lost in translation

A recent Taskforce on Southern Tasmania’s mental health services provides a careful examination of the Trieste model in the Australian context, as ‘perhaps the most often cited example of the benefits of a mature, stable integrated system of mental health services’ (www.dhhs.tas.gov.au/news/2019/mental_health_integration_taskforce_report: p. 9). The Taskforce report notes the striking similarities between mental health reform in Trieste and Australia through the phases of closing the asylums, shifting resources to the community and limiting supplies of hospital beds.

Based on workshops that examined best-practice models of mental health integration, and the opportunities and challenges associated with trying to apply a Trieste-like model in Tasmania, the Taskforce concluded, ‘the Trieste model was transferrable to Tasmania and could be adopted in totality provided the Australian health and social service system, which varies greatly from that in Italy, was considered in the model’s implementation’ (p. 19). The Taskforce cautioned that the social and cultural differences between Australia and Italy as well as the disconnected silos in Australia’s public sector, and limits on funding might constrain the effectiveness of a Basaglian-Trieste model. Such problems may explain why Australian policymakers have been unable to fully de-hospitalise and establish a community-focused model that matches the reported success in Trieste.

The then Director of the Trieste Mental Health, Roberto Mezzina and colleagues, placed similar importance on social and cultural factors when examining the Trieste model’s transferability to San Francisco (Portacolone et al., 2015). The authors concluded that the wholesale translation of Basaglian reforms to San Francisco was inconceivable. While Trieste’s socio-cultural circumstances facilitate the model, San Francisco’s marginalised mental health population faces far greater adversities.

While there is minimal research on optimising psychiatric beds, which is a major deficit in the literature on deinstitutionalisation, the need for inpatient care is probably related to the epidemiological, cultural, social and demographic context. As Mezzina and colleagues note (Portacolone et al., 2015), the Trieste model requires a low youth population, low rates of drug use and adequate housing with high social inclusion. Under these circumstances, community-focused de-hospitalised systems can work, as long as rehabilitation prevents trans-institutionalisation to under-regulated community residential facilities.

In mental health policies covering Australian regions with less favourable circumstances, it is misleading to cite Trieste as an exemplar, and more appropriate models should be selected. After 40 years of effort, it is time for policymakers to jump off the Trieste bandwagon and seriously question whether the Trieste model presents the right balance of hospital and community care for our unique cultural and social contexts.