What If? Dreaming About a Moonshot for Community Mental Health

What the US can learn from Trieste, Italy about mental health

Dr. Josh Seidman is the Chief Research and Knowledge Officer at Fountain House, the amazing national nonprofit fighting to improve health, increase opportunity, and end social and economic isolation for people most impacted by mental illness. I’ve been a fan of Josh’s for some time - he’s a health policy rockstar having worked in hugely influential places like NCQA, Avalere, and The Department of Health and Human Services, that little federal agency that remains one of the most influential governmental bodies for influencing health. The views expressed in the piece are his own and don't necessarily reflect the views of his employer.

On a recent call, Josh was telling me about his time in Italy and what he learned. I immediately asked if he’d be willing to share his wisdom here with you all. Thankfully he agreed and we all will be better for it after you read this piece. Thank you, Josh! Below is what Josh wrote about his experience in Italy.

- Ben

From Josh:

It is almost pablum at this point to say that, compared to leading countries, US mental health more money for worse outcomes by focusing on the wrong things in uncoordinated ways and in siloed environments. (Of course, much the same could be said about US health care generally.) The extent of the problems is so great and the solutions require such deep structural change that it leads to a resignation about the seemingly intractable nature of our broken mental health (non-)system.

But, “what if?” What if we really studied the leading examples from around the world? What if we weren’t hardened and cynical about the entrenched powers that be that drive payment and inefficient behavior? What if we dispensed with the typical constraints that hinder our lack of imagination? What if we dared not only to dream but also to plan for a moonshot for mental health?

Trieste, Italy and a Vision for Community Mental Health

Thanks to the generosity of the Conrad Hilton Foundation and the innovative spirit of Kerry Morrison and Heart Forward, I had the opportunity to spend a week in Trieste, Italy, learning about one of the most remarkable community mental health models on the planet. This person-centered, holistic, dignified, coordinated system replaced an inhumane, asylum-focused system that dominated Italian mental health until the 1978 passage of Law 180, known colloquially as the “Basaglia Law,” in reference to the pioneering, visionary psychiatrist Franco Basaglia.

The mental health system has 3 fundamental pillars: prevention, treatment, and “after-care,” and it relies on 5 foundational principles:

· Helping the person, not the illness

· Fostering recovery & social inclusion

· Assessing practical needs that matter to service users

· Changing attitudes in the community

· Respecting each service user as a citizen with human rights

Basaglia and his disciples recognized that they system needed reorientation: Away from hyper-focus on clinical diagnosis and assessment to really understanding the person; the need to change the power dynamic to create a reciprocal relationship; and the proactive inclusion of a third partner in the discussion of an individual’s needs (a family member, friend, etc.).

What Does a Transformed Mental Health System Look Like?

What flows from these principles and reorientation? Tremendous continuity and coordination of care. Every service user (person with serious mental illness) has a care plan plan—they have ”projects” that essentially set out a plan for how someone will progress over the next few months, and then revisit periodically to determine if they’re ready to take another step forward in their recovery and rehabilitation. All the different parts of the system actually talk to each other, and they have a single electronic record for mental health support and care.

The Trieste regional health system has a mix of government-run and private organizations that comprise a whole-person approach evident by the wide array of supports: Community mental health centers, social cooperatives, associations (kind of like affinity groups), housing with wraparound services, and progressive approach to dependency/addiction, which has several components with significant emphasis on harm reduction (despite illegal drug criminalization).

The results are a minimization of crisis care. There are virtually no inpatient facilities. The entire Trieste region has a single psychiatric hospital ward with no locked doors, and has just 8 beds in a region of 373,000 people (I was told the 4 people there when I visited is a typical census). There are some additional beds available in the community mental health centers that are more there for respite than what we would think of as hospitalization.

What Do I Take Away from Trieste that Could Be Applied to the US?

· Complicated but not complex. Like many of the world’s greatest and most profound innovations, while implementing the model is complicated, they are not particularly complex solutions. Rather, successful transformation relies on executing well on some straightforward concepts and principles.

· Integrated housing model. Trieste has subsidized public housing buildings, and they have on-site housing workers at each site to support an array of life needs.

· In-the-community engagement. Although Trieste does not have clubhouses—an established evidence-based, community mental health model—they use a similar approach through a combination of social cooperatives and associations that engage service users in real-world experiences that provide what Dr. Tom Insel calls “people, place and purpose.”

· Kill the silos. Although there are some unique, specific elements of the Trieste model, there are corollaries (similar bright spots) that exist in the US. Unfortunately, they are one-off experiments or unconnected to other supports or they don’t create comprehensive ways to support and coordinate the needs of the individual.

Where Do We Go from Here?

It’s not that the US doesn’t have pockets of bright spots and great examples of community supports for people with serious mental illness. In fact, the US has some advantages, where we probably see more flourishing of peer models and blended leadership approaches that elevate the role of people with lived experience. What we don’t have is well blended financing models and a fundamental tenet of housing and mental health supports as human rights.

However, the comprehensive community-based model didn’t emerge overnight in Italy, and the only way we’re going to get there is to start trying. Finding a community to pilot this kind of coordinated demonstration effort that leverages some existing community-based infrastructure supports has the potential to lay a foundation for much more ambitious approaches over time. The new administration is looking for ways to create more efficient ways to meet the needs of complex populations, and we know the ingredients that can make that a reality.