On a visit to Trieste
Earlier this year, five professionals who all work in psychiatric services in Oslo went on a study trip to Trieste. En route, two of us went to Rome, which we have also visited on previous study tours. Our colleagues there outlined a negative picture of Italian psychiatry. The centres lack the resources necessary to stay open 24 hours, and they are unable to help all those who need it. The shortage of resources was partly explained by the financial crisis in Italy, but also partly by the outflow of considerable funds from psychiatry to private clinics and nursing homes.
Until recently, Italy had a separate forensic and security psychiatry that dealt with those who were considered dangerous and could be sentenced to detention in a mental institution. In 2015, security psychiatry was relocated from the Ministry of Justice to the Ministry of Health. We were told that patients who are dangerous or sentenced to psychiatric treatment are now detained in small, reinforced, secure psychiatric units that focus on therapy, social psychiatry and rehabilitation.
From there, we continued to Trieste. Our programme was arranged by the World Health Organization's Collaboration Centre for Research and Training there, and we were taken on a visit to a number of different psychiatric services. The director of the mental health administration in Trieste, Roberto Mezzina, claimed that there was close to no use of coercion, few admissions and virtually no acting-out in their local setting. The Greater Trieste region has approximately 240 000 inhabitants and four local psychiatric centres with six beds in each. Each centre has a catchment area of 60 000 inhabitants. In the whole of Trieste, there are no more than six emergency psychiatric beds.
In Norway, dangerous and demanding patients fill the beds in central institutions. Where are such patients in Trieste? We were told that since focus is placed on human rights and the freedom of the individual, this freedom comes with a responsibility. The majority of criminals are in prison, and the local psychiatric centre provides follow-up as required. During our visit, the forensic psychiatry unit in Trieste was empty. Those who had been referred there had completed their treatment and been rehabilitated back into society.
The work cooperatives play a key part in the treatment and rehabilitation of patients, who are actively engaged in meaningful activities, with a focus on individual adaptation here as well. The cooperatives are intended to be useful and competitive. The authorities make provisions for work grants and social grants, and enterprises that hire persons with reduced functional capacity are exempt from paying employer social security contributions.
At Barcola, the local psychiatric centre, we heard about a flexible approach that puts the patient's project at its centre. If the users' condition worsens and they reject help, they are not abandoned: 'The users have the right to walk out, but we have the right to go after them'. If an ill person refuses to receive treatment, the staff continues to show concern, seek him or her out and offer flexible solutions. This involves some negotiation and requires great patience. Much of the activity is ambulatory, and approximately 100 users call into the centre every day for group therapy, conversation or practical help, or to participate in self-managed user groups. We were told that two-thirds of the users have psychosis-type disorders, but it was emphasised that services and interventions were decided on the basis of functions and needs, not just the diagnosis. Drugs were administered in accordance with international guidelines and with the aim of providing the smallest possible effective dose. Therapies are holistic, with the primary emphasis on relationships, the patient's project and continuity. Our impression concurs with the findings in a Dutch study of service provision in Trieste (7).
Stays in the emergency psychiatry ward are kept as short as possible, often just to a single night. Patients tend to arrive when crises occur in the evening and night time. The goal is to achieve that the treatment is voluntary and to bring the patients out to the centre as quickly as possible. If patients need to be admitted to the emergency ward, a therapist from the centre provides follow-up during the admission period.
The social services engage in extensive outreach activities, voluntary work on activities and distribution of food. References were made to Basaglia, human dignity, freedom, flexibility and integration into society. The healthcare and social workers appeared to be genuinely engaged in the users' situation and were willing to go to great lengths to help them. They talked warmly about their collaboration partners. We were struck by a system where everybody seemed to pull in the same direction. The people of Trieste are said to be more reserved and sceptical than other Italians, so it was claimed that the success in Trieste has come in spite of a closed and sceptical culture.
In Trieste, there are reportedly no private clinics and nursing homes. Patients with addiction disorders in addition to mental disorders are treated in separate programmes for drug-related care. Psychiatric services provide guidance as needed. Patients with minor mental disorders are treated by their GP, occasionally by a psychologist or psychiatrist in private practice.