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From the asylum to territorial services for mental health

"... The important thing is that we have proved that the impossible is possible. Ten, fifteen, twenty years ago it was unthinkable that an asylum could be destroyed. Maybe the asylums will again be closed and more closed than before, I do not I know, but anyway we have shown that a mad person can be assisted in another way, and this demonstration is of crucial importance. I do not think that just because something becomes generalized it means that the battle has been won. The important thing is that now we know what we can do.”
                                                      Franco Basaglia, Brazilian Lectures, 1979

In 1978 in Italy, the law that reformed psychiatric assistance, also known as Law 180, started a national process to eliminate mental hospitalizations by the end of the 90s, closing all asylums and introducing at the same time, many new community services that allow mentally disabled people to conduct their lives in a normal social contest. This law, which was the first of its kind in the world, radically changed care and assistance methods.

In August 1971, Franco Basaglia became director of the Provincial Psychiatric Hospital of Trieste, where there were 1182 inmates. There, he started his work on transformation, rehabilitation, and the construction of alternatives. This process was carried on by a team of operators and involved institutions, organizations, associations and volunteers from all over the world. By 1980, under the supervision of Franco Rotelli, the new community services had already replaced the old assistance methods.

For over 30 years the city of Trieste (240,000 inhabitants) has not had any kind of mental hospital. The asylum was replaced by 40 different structures with different roles and tasks, such as home care for patients. The results prove that the new psychiatric assistance methods have also reduced spending in the sector. Furthermore, at the end of 1971 the budget for the management of the Psychiatric Hospital amounted to approximately 55 million euros; in 2010 instead, the management of all local services cost about 18 million euros. Staff decreased from 524 in 1971 to 225 in 2010. The 1,182 hospital beds in 1971 became 140 beds distributed throughout the entire area. The proportion of persons involved in these services each year is close to 20 per thousand people.

The Trieste Department of Mental Health
The Department’s strong points are its 4 Mental Health Centres, located in 4 neighbourhoods, each with 8 beds and operating 24 hours a day. The mental health centres provide health and social care, psychosocial rehabilitation and, if necessary, treatment in acute cases.
For those who need longer term assistance, protected apartments have been created for small groups of people, offering a friendly and non medical environment. The Habilitation and Accommodation Service coordinates the apartments (with 55 beds), habilitation, rehabilitation and social integration activities with workshops and projects across the city. Finally, job opportunities have made it possible to ensure effective integration into society. The Service coordinates 15 affiliated social cooperatives, which, through work grants, have been able to integrate about 375 people in the last 15 years.
The Psychiatric Diagnosis and Treatment Service, with 6 beds, deals with psychiatric emergencies, filters cases and orients the patients towards the local services.
The number of compulsory health treatments, with an average of 8 per 100,000 inhabitants in the last 10 years, is the lowest in Italy. No citizen of Trieste is interned in the forensic hospital.

The building that housed the psychiatric hospital was gradually returned to the city. Today it houses university departments and city services. It still plays a significant part in Trieste’s culture, a crucible of tensions and utopias, a laboratory of cultures, tolerance, and home to a beautiful rose garden.

Since 1987 the WHO has recognized the experience of Trieste as a point of reference for innovative approaches to psychiatric care. In 2010 the Department of Mental Health of Trieste was reconfirmed as a WHO Collaborating Centre for Mental Health. In 30 years, more than 50 countries in Europe and other continents have visited the mental health services in Trieste to set up similar processes with the technical assistance of their colleagues in Trieste. About 1000 persons every year take part in study-tours.