It has often been suggested that the process of deinstitutionalisation in Australia – moving people experiencing mental health challenges from hospital wards to community care – has been, at best, a partial success. Amongst the reasons for this partial success (or even qualified failure), the lack of sufficient funding and political will to make community supported mental health services have loomed large.
This may beg the question, was deinstitutionalisation a good thing?
Our response here must surely be yes; deinstitutionalisation brought people experiencing mental challenges out of total institutions where their rights and freedoms were often restricted or ignored. But more needs to be done.
It is at this point that it may help to consider what is known as the “Trieste Model” of mental health support. The Trieste Model began in the Italian town of Trieste at the instigation of mental health psychiatrist reformer Franco Basaglia. Trieste is a city of 236,000 inhabitants in the northeastern region of Italy, Friuli-Venezia Giulia. The model of mental health care developed there has been described as a “whole system, recovery-oriented approach”. It may provide an example of community-based mental health care in lieu of deinstitutionalisation.
The central premise of the Trieste model is that mental health treatment should place the suffering person—not his or her disorders—at the center of the health care system.
In practical terms this meant that people experiencing mental health challenges should live in the community. Their social inclusion and rights and freedoms as citizens should be respected. More prosaically, this has meant that workplaces and social cooperatives for people experiencing these challenges have been set up; that people experiencing these challenges live in the community and are indistinguishable from other citizens; that ultimately the town produced a number of highly successful anti-stigma campaigns, encouraging citizens to live respectfully and alongside people experiencing challenges.
This is not to suggest that the model has done away with psychiatrists and clinics entirely. These still have their place; albeit a limited one. They are complemented by integrated Community Mental Health Centres (CMHC’s) active 24 hours a day, 7 days a week, with relatively few beds in each of them. The CMHCs are located in nonhospital residential facilities, usually a two- or three-story house. They cannot be considered crisis centres but multifunctional spaces to which people have easy access. Users are not considered to be “patients” but “guests”.
The results of the Model are promising. Anecdotal evidence suggests empowerment of users and care givers, and resistance against passive acquiescence in mental health service. Research suggests better outcomes for patients with schizophrenia. A 50% reduction occurred in emergency presentation of general hospital casualty for approximately 20 years. High rates of social recovery have been reported, including competitive employment and living independently.
I think we can fairly say that the Trieste Model has some lessons that may be learnt in the Australian context. The treatment of people experiencing mental health challenges as citizens, with rights and opportunities within the community, is vital. The focus on the person over the illness is important. The creation of mental health service places that are not clinical, where visitors are treated as guests, rather than patients, is promising.
Ultimately, however, creating these positive changes will rely on the funding and political will of Australian State and Federal governments.
Dr. Richard Schweizer, Policy Officer at One Door Mental Health richard.schweizer@onedoor.org.au.
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Dr Richard Schweizer