Origins of the Trieste System of Mental Health

The story of the remarkable evolution of the Trieste system runs parallel with changes to the American system of mental health, but the trajectories have resulted in completely different outcomes for the people serviced by these systems.  

Both Italy and the United States were involved in the movement to bring an end to the horrible conditions that played out in the asylums and institutions in the middle of the 20th Century.   

Fast forward to the 21st Century, over 50 years later, and Los Angeles is emblematic of what we see in cities throughout the United States as we confront the human pain associated with a fragmented system. We can trace the origins to President John Kennedy calling for a community-based system of care in the U.S. in his last major policy address in 1963. That community-based system was never realized. Over time, there was a gradual devolution of authority from the federal government to the states. In California, by the 1980’s, there was a gradual devolution of authority to the 58 counties, culminating in the 2011 elimination of the California State Department of Mental Health, a capstone to the withdrawal of accountability for mental health care from the state. There are a number of good books to consult to capture this history, and these are listed here.

Conversely, in Italy, largely led by the visionary psychiatrist, Dr. Franco Basaglia, a revolution was underway that persists to this day. As a young psychiatrist, influenced by time he spent imprisoned in Venice during WWII as a member of the anti-fascist resistance, he railed against institutional life. In 1961 he was assigned to head an asylum in Gorizia (in the same province as Trieste) and he instituted a radical change in how to engage with the patients there. As documented in the excellent book, The Man Who Closed the Asylums, he was horrified by the conditions he witnessed and at the outset he initiated changes that flew in the face of conventional “treatment.” For example, he outlawed restraints, unlocked the wards, instituted meetings between patients and staff and required that the doctors shun their white coats. 

He moved to Trieste’s asylum in 1971 as  the “democratic psychiatry” movement was gathering momentum. He believed in the promise of recovery for mental patients and pushed for measures to re-integrate people back into the community and into places where they connect with family and friends and could find meaning through work. He announced that the asylum in Trieste would close in 1977 and that was an impetus to push for the closure of asylums throughout Italy.  

The Italian Parliament passed Law 180 in 1978 (known as Basaglia’s Law) and that led to the dismantling of the asylum system throughout the country.  So, as the United States reneged on the promise of community-based care, Italy created a community system of care focused upon treatment, recovery and prevention.