16 December 2019

MENTAL HEALTH

The country that closed its psychiatric hospitals

Italy believes anyone can live freely, with the right support

By Ian Birrell

Elisabetta Paci spent a year planning to take her own life after deciding her departure from the world would be best for everyone, even her two young children. She had long suffered from anxiety and depression, perhaps the legacy of stigma suffered as a child brought up by a young single mother in a strictly Catholic country. Then her state of mind deteriorated after marrying an alcoholic who was controlling, jealous and suspicious whenever she was out of his sight. “I was very afraid of him. He did not beat me but words and behaviour can hurt more than a punch in the face.”

When the former English teacher woke up after her suicide attempt, having been discovered unconscious following an overdose and rushed to hospital, she blamed herself. “I was very pissed off when I did not succeed,” she said. “I thought to myself: I’m so clumsy I can’t even kill myself. I was very angry.”

Her life was saved – but her mental health struggles did not disappear. There were five more bids to kill herself over the next seven years, while such were her anxieties that often she could not bear to be alone for even a second.

Elisabetta Paci

Yet despite clear risks to herself and arguably to her children, Elisabetta was never sectioned and incarcerated in a psychiatric hospital. She was never forced to live amid the chaos of an institution detaining people with depression, delusions, personality disorders and other mental health difficulties. She was never restrained by teams of nurses when her stresses exploded in frightening crisis. And she was never put in seclusion to endure long days on her own trapped in a lonely cell.

The reason is simple: she lives in Trieste, a port city of 240,000 people on the north-east tip of Italy that famously pioneered an alternative approach to mental health and sparked revolutionary reform across the country.

Italy has closed down its psychiatric hospitals, unlocked the doors of secure units, stopped restraining patients and recently became the world’s first nation to end use of forensic psychiatric hospitals. It proclaims consensus, consultation and human rights – as opposed to a system reliant on coercion, forced sedation and high-security units.

‘‘I am very lucky to have been sick in Trieste,’ said Elisabetta, 59, discussing her troubled life story over a bowl of tomato and mint pasta in a restaurant on the site of the city’s former asylum.

Today her health is much improved. She works as a peer expert, helping other patients with mental health problems, although still talks twice a week to her therapist.

So I ask what would have happened if she had been sectioned? “I would have lost my children, who would have been given to another family. This would have given me reason to really commit suicide. It would have been a disaster, ruining my children’s lives and destroying my family.”

This woman’s recovery is testament to supportive mental healthcare. I met her on a trip to Trieste prompted by insights I gained into Britain’s increasingly-coercive psychiatric services during a year-long investigation which became a campaign to stop the abusive detention of people with autism and learning disabilities.

A series of official inquiries have confirmed my revelations that such people are being warehoused in secure psychiatric units due to lack of cheaper, kinder and often more effective support in their own homes and communities. The stories I kept hearing from distraught patients and their families were disturbing: locked up, forcibly sedated, violently restrained, even fed through hatches. Many are held by inadequate private providers that have muscled in on this lucrative sector, with some families even silenced by court-imposed gagging orders.

 

Then I began hearing from other distressed families, who talked of denial of rights for people with mental health problems. They spoke about similar problems of abusive practices masquerading as ‘care’ and ‘treatment’, often in secure units many miles from their homes. The same private operators, charging thousands of pounds a week while paying frontline staff peanuts. Their claims were backed by data that shows rates of involuntary admission almost quadrupling since the landmark 1983 Mental Health Act with a hefty surge in recent years – and yes, increasing reliance on private hospitals run by multinational operators.

Perhaps most striking were the words of Tom Burns, professor emeritus of social psychiatry at Oxford University and a former government adviser. “If I was going to be mentally ill,” he told me. “Then I would want to be mentally ill in Trieste.”

This made sense after I wandered around a cluster of yellow buildings that once housed an asylum high above the port but now are filled with mental health services, addiction clinics and social enterprises to help vulnerable people – and then met Roberto Mezzina, until recently, the director of Trieste mental health services. “We have open doors everywhere,” he said, a colourful artwork on the wall displaying their services as he outlined theories of community-based provision, civil rights and social justice. “Our belief is anyone can live freely in the city with the right support. We have proved this over many years now. There is nothing positive about coercion. There is no study showing it has worked anywhere in the world.”

The San Giovanni Park, Trieste's former provincial psychiatric hospital, now houses the mental health centre

Mezzina, originally from Bari, told me he had never used restraint on a patient during his 41-year psychiatry career in Trieste. This is striking if you consider these violent techniques were used at least 97,000 times in English mental health hospitals in 2016/17, injuring 3,652 patients. “We do not use restraint,” he said. “We have approved, people-centred plans that are based on negotiation – sometimes very exhaustive negotiation. You have to listen to patients and understand them. If a person wants to go then we must convince them to stay since there are no locked doors. We must eventually convince them to take medicine but within a range of other care offers. This is all based on principles to respect people if they are in a state of severe suffering, just as if they had cancer.’”

This should not be a radical approach. Partly it is based on ideas of destigmatising mental health by treating it like any other form of illness. Yet it felt inspiring to hear after listening to so many awful stories of British citizens locked up and abused in grim secure units.

So what happens if someone is in crisis and becomes angry? “We ask them what is their problem,” replied Mezzina with a smile. “If they turn over a table there will be other patients around who might ask why they’re being disturbed when trying to read their paper, just as in a bar or other social situation. We might suggest a coffee, a walk around the streets, an ice-cream – we use a lot of gelato therapy.”

Roberto Mezzina

The Trieste system relies on a network of 24-hour community facilities, with beds for those needing somewhere to sleep, lounges for daytime and experts on tap. Later, I visited one unit, listening as a team of psychiatrists, psychologists and nurses discussed that day’s new arrivals. The first case sounded like something from a gangster film: a student with depression from an abusive background whose Sicilian family had been placed under police protection after his mafioso brother turned informer. “He has a deep void within him,” said one nurse. After lengthy debate, the staff agreed on two therapy sessions and then directing him to one of their self-help groups.

This Italian experiment – inspired by counter-cultural ideas in the 1960s seeking to overthrow established orders and influenced by controversial ideas bubbling away in British psychiatry – was detonated by a charismatic Venetian psychiatrist called Franco Basaglia. He had spent time in prison towards the end of World War Two for anti-fascist activities and when he went to work in asylums found a chilling echo of Nazi concentration camps. Behind the high walls were hundreds of shaven-headed inmates, stripped of dignity, hope, possessions or rights and subjected to brutal abuse. ‘It took me straight back to the war and prison,’ he wrote later.

 

Basaglia’s first attempt to free patients in Gorizia fell apart due to internal bickering and local political opposition. Then he moved to Trieste in 1971, where those 30 yellow buildings on the hillside above the city housed similar scenes of repression with patients in cages and tied to beds. I was given a fascinating tour of the site by a former patient, who explained how it was built for 400 people by wealthy merchants at the start of the 20th Century after the city grew rich from trade into the Austro-Hungarian empire. He showed me assessment buildings for men and women by the main gates. “The higher up the hill you were placed, the better and less restricted your life. No adults ever left after entering.”

By the time Basaglia arrived as director, arguing that “freedom is therapeutic”, there were more than 1,200 patients crammed in the asylum. He moved fast to introduce his revolutionary ideas by freeing them from chains, finding them jobs, fixing homes in the city, introducing arts events and setting up democratic structures to discuss the hospital’s running. One released man killed his parents, underlining the risks. Basaglia and his disciples pressed on, shrugging off manslaughter charges over the murder, and in 1977 he declared at a press conference that the hospital “no longer exists”. In just six years, he had dismantled a giant asylum by liberating its inmates.

The following year Italy’s parliament passed a remarkable law named after Basaglia blocking any new admissions to the country’s public psychiatric hospitals, which held almost 80,000 people. By the end of the century, they had all shut – replaced by beds in general hospitals and much smaller community facilities, albeit of widely-differing quality.

The Criminal Psychiatric Institute in Aversa, southern Italy in 2014 when it was slated for closure

In contrast with Britain, use of compulsory admissions has fallen drastically to about one-fifth of our rate – and authorisation is renewed weekly, not left up to six months without review as under our law. Italy went even further in 2015 by phasing out forensic hospitals, placing in residential facilities those deemed dangerous but unfit to be tried for alleged offences – although critics insist it is little more than a cosmetic change.

Trieste has just two forensic beds, both in a day centre which is used by other clients – and no-one has absconded since the law was changed. “We considered it a shame to still have forensic units after 40 years of unlocked doors,” said Mezzina. “We were obliged to have them but we wanted to open these doors too. We believe it should always be therapeutic, persuading a person to stay. We tell people now that if they leave the facility, then we would have to call the police. No-one has gone in three years.”

Although revered in many nations, Basaglia’s reforms were largely rejected in Britain – perhaps because of his ideological fervour. Yet during our discussions, Mezzina told me a significant story from his first few months in Trieste that cast light on an issue that has long troubled me: why is there so much abuse towards vulnerable patients in our secure hospitals? I find it impossible to understand why anyone would ever beat, bully, mock or taunt an inpatient, regardless of the pressures. So are these all-too-frequent incidences due to the dehumanising nature of imprisonment – or do they expose disturbing societal attitudes towards people with autism, learning disabilities and mental illness?

An inmate of a psychiatric hospital in Naples, 1988

 

When he arrived from Puglia in 1977, most of Basaglia’s work emptying the asylum had been completed, so the young doctor was sent into a ward holding 30 of the final institutionalised patients. “These were the remnants, after everyone else had been discharged. They were the most difficult in terms of physical conditions – very old, sometimes incontinent, still wearing uniforms like pyjamas.” First, his team gave them their own clothes and bedside lockers for possessions, with their own keys, then two months later took them to a hotel in nearby mountains for a week’s holiday. Eventually, most of the group moved back into the community.

The lives of these people improved as their rights were restored. Yet the impact on nurses was equally profound. “They were terrible, stealing things and abusing the patients,” said Mezzina. “But then they discovered that the patients were not such bad people, that they had human values like them and could be rehabilitated. Some of those nurses went on to become fantastic community workers, really caring. I call this parallel empowerment – power should be bottom up and challenge everyone. You cannot change the system otherwise.”

This affable psychiatrist takes pleasure from his role helping close the last unit in Trieste’s asylum and believes this incident gave him insight into how patients can become abused in such places. “The institution branded people as objects, not as human beings, and if people are stripped of their identity and degraded, treated only as patients devoid of any rights in locked rooms, then this ends up impacting on everyone.”

Italian psychiatrist and neurologist Franco Basaglia posing in 1971 in the mental hospital of Colorno, which he ran

I fear he is right: stripping human beings of rights and then locking powerless people in secretive units can foster abuse, especially in a society so contemptuous of things such as autism, dementia, learning disabilities and mental illness. This underlines the need to be wary of such situations. Instead, we see rising reliance on coercion in our mental health services: 24,576 involuntary hospital admissions in England in 1988/89 rising to 43,356 cases a year by 2007/08 and then 63,049 cases in 2015/16.

Today, more than half those admitted are on compulsory basis – and almost four in 10 patients are then subjected to subsequent coercive measures such as restraint, seclusion or enforced sedation within four weeks of their admission.

Far from unlocking doors and trusting people with mental illness, Britain seems to have been consumed by fear. We talk about ending the stigma of mental health but have a system that views patients through the prism of danger. This follows a series of high-profile murders by people with mental health issues, dating back to the stabbing of musician Jonathan Zito by a paranoid schizophrenic called Christopher Clunis in 1992. Such stories, given heavy play in the media and pointing fingers of blame, fuel public association of mental illness with violence and spark a political reaction. But risks are so low a British-Australian study calculated it would take successful treatment of 35,000 people with schizophrenia to prevent one such ‘stranger’ killing.

I spoke to several psychiatrists for this article, some sceptical about claims made for the Trieste model, despite its status as a World Health Organisation centre for research and training in mental health. Professor Burns, for instance, praised its “old-fashioned” approach to building relationships but argued some of their claims were overblown and data questionable. But everyone accepted that the UK system now revolves around risk analysis rather than treatment. “We are not allowed to use clinical judgement, which essentially involves a diagnosis of risk,” said Burns.

Broadmoor psychiatric hospital

Most blamed funding shortfalls and reduction of hospital beds. This forces patients to be treated in secure units often far from homes and families, which can intensify stresses.

There is also increasing use of private firms, which hold about one-fifth of detained patients despite a series of damning inspection reports, media exposés of abuse and highly-critical inquests following tragedies.

But one leading psychiatrist said almost the only option for treatment left was inpatient care after slashing of community services such as day hospitals, drop-in centres and short-term respite. “If there is an 18-month waiting list for psychotherapy then for many people help arrives only in a crisis and when inpatient care is the only option,” he told me.

That analysis is shared by mental health workers on the ground. ‘”They cut back on community services and this means people go into crisis, so have to be detained,” said Sue Sibbald, a peer worker in Sheffield, adding that reductions in their local health teams made it far tougher to access crucial secondary care. “People with more complex needs, such as personality disorders and alcohol addiction, are being held for years in psychiatric institutions. No-one is speaking up for them since often they have traumatic family backgrounds. There are a lot of unheard voices.”

 

Britain is far from the only Western nation seeing this shift to detention – although any pressure on beds should only add to the growing concerns over holding 2,255 people with autism and learning disabilities in psychiatric units.

Yet secure units are expensive and soak up funds. Trieste’s open-door approach is said to have ended up costing just 39 per cent of its old asylum, which needed far higher staffing levels to guard patients round the clock.

SP Sashidharan, honorary professor at Glasgow University’s Institute of Health and Wellbeing argues that psychiatric practice in the UK has increasingly tilted in favour of risk assessment and risk management over understanding and addressing the actual needs of patients.

Long stay patients at the Warley Psychiatric Hospital, UK, closed in 1999

“As a result, psychiatric practice has become more repressive and there is increasing alignment of mental health and criminal justice systems.”

Sashidharan pointed to a recent study that found one in six patients in some London secure units failed to hold any meaningful, one-to-one discussion with staff over their previous seven days. “It is like a prison. You take your medicine and eat your food but it is just a cell without any meaningful human interaction,” he said.

Another key measure of control introduced more than a decade ago are Community Treatment Orders, which give doctors legal rights to impose housing and lifestyle rules on patients after release from hospital. Any breach of these ‘psychiatric Asbos’ can force recall into a secure unit.

Yet Burns, who advised the government over their introduction, now argues studies have invalidated use of these instruments. “There have been three high-quality trials and they don’t work,” he said, admitting he was mystified by their failure. They remain in use for almost 5,000 people, however.

One person shocked to see inside the British system was Vincenzo Passante. He joined a home treatment team in London after studying psychology in Trieste – only to quit in despair after 18 months. “I thought it was a good chance to put my training into practice but it became a deep ethical issue and I felt it hard to justify my presence,” he said. ‘”In your crisis services you don’t build relationships – you just ask patients basic questions such as ‘do you want to hurt yourself or others’ and if they say yes to these kind of questions, the system locks them up. This undermines any sense of trust and implicitly encourages people not to talk about how they feel.”

Passante said he found the focus entirely on evaluating the danger of patients and that critical discussion within his team was discouraged.

“This is a very violent and repressive response. It is a system without hope. In Trieste we understand that madness has a value and humanity beyond danger.”

Britain was once a pioneer in closing down asylums, debating innovative ideas in psychiatry and attempting to end demonisation of mental illness. But as we ratchet up the use of coercion, have we moved a little closer back to those dark days of Bedlam? “If your country does not address fundamental principles you will just keep on expanding those secure units,” said Mezzina. “I am sorry to say this system is a shame in the UK.”

Perhaps we need to learn from Trieste, taste the freedoms of gelato therapy, stop locking up so many people and start remembering this is at heart an issue of profound human rights.

Photographs Raymond Depardon/Magnum Photos, Simone Donati/TerraProject/Contrasto/eyevine, Getty Images

 

Further reading

Michel Foucault’s Madness and Civilization: A History of Insanity in the Age of Reason from 1961 explores the evolving meaning of madness in European culture, law and politics.

This piece by the Wall Street Journal calls for a new generation of flexible, varied institutions across the US to help reduce the number of mentally ill adults in prison.

The Atlantic ran a series of accounts written by people who have experienced living in a mental health hospital.

This report by The King’s Fund looks at the deinstitutionalisation of mental health services in the UK.

Matt Haig’s memoir Reasons to Stay Alive is a personal account of his battle with mental illness and explores how to live better, love better and feel more alive.