Isabel Schwarz Travel Fellowship: How an Italian mental health visionary inspired Anne Kendall to make a trip to Trieste

Dr Franco Basaglia,a psychiatrist from Trieste, revolutionised mental health services in Italy during the 1970s. Anne Kendall, while she was group manager for mental health services at Bath & North East Somerset Council, heard about Basaglia’s achievements from a colleague and felt inspired to look his story. She found that in many ways he was the architect of community-based mental health treatment.

Basaglia was credited with tearing down the gates of the old-style asylums in Trieste and developing a service model that is still admired 30 years on. But to really appreciate his legacy – he died in 1980 – Kendall wanted to find out first-hand how the service Basaglia created worked in practice. Thanks to the Isabel Schwarz Travel Fellowship, Kendall and two colleagues visited Trieste last November to see how its system compared to their own.

Trieste is a city of 240,000 people. Its population is served by four mental health centres whose multi-disciplinary teams consider all aspects of the client’s life – work, housing and relationships, as well as medical – when treating them. Kendall says this is a different approach from that in the UK where services are usually provided through different teams and tend to focus on a person’s symptoms.

“It has created a one-stop shop of community teams, day services and in-patients,” she says. “All the staff know all the service users and hear about problems sooner, so unpredictable crisis situations are rare.”

Another difference is the low eligibility criteria to enter the service for treatment, something that reduces stigma and permits self-referral.

An important feature of the service is the strong links it has with social co-operatives in the city. Many of these businesses employ people with mental health problems, so providing an outlet for them to rebuild their lives through meaningful employment.

Kendall says this reflects the high expectations the service and staff have for their patients. This is exemplified by a woman with mental health problems who was imprisoned for murder but allowed to work during the day in a social co-operative so that she could learn skills for when she was released.

“This is such a contrast to our approach,” says Kendall. “Our expectations can be low. Recently I was involved in a consultation on the future shape of day services in an authority where the model put forward seemed to encourage low expectations. If staff have low expectations how can we help service users have high ambitions for themselves and help motivate them to achieve?”

In Trieste, she says, this ambition is driven by the positive approach of staff from the top down. “All the people we met were great leaders, passionate and committed. They are clear about their vision and where they want to go.”

However, Kendall says there are problems. Although housing all staff under one roof helps break down professional boundaries, the lack of management structures has led to a system that is dominated by doctors.

“Doctors still have a lot of power in the system,” says Kendall. “The lack of separate management structures means there is no counter-balancing and questioning of them.”

The formal influence service users have under the Trieste system is also less than in the UK. Kendall says: “The participation committee collapsed (the reason given was there was so much informal contact with service users) and they are trying to resurrect it. However, this has a consultative role only, not a decision-making one – service users and carers have a limited role in that.”

Kendall is already putting into practice lessons from Trieste in her current role as an area manager for mental health charity Rethink. The principles of “working in meaningful partnership and reducing the number of organisational boundaries” are two of them.

On a practical level, involving service users in mainstream activities, particularly employment, as a norm is another.

And she believes the voluntary sector can play an important role in implementing one of the key lessons. “The thresholds for accessing secondary mental health care are getting higher. [The voluntary sector] can do preventive and maintenance work with them once they’ve been discharged from the statutory sector.”

LESSONS LEARNED

● Low eligibility for accessing services breaks down stigma around mental health problems and reduces the need for compulsory admissions.

● Create strong links with mainstream activities to help build client confidence.

● Aim high: expectations for what service users can achieve should be ambitious.

● A joined-up system with few professional boundaries reduces the risk of unexpected emergencies arising, people falling between services and unnecessary delays in service provision.

This article appeared in the 24 May issue under the headline “Wooed by an Italian model”