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From the asylum to territorial services for mental health
Which problem does it help to solve?

Basaglia wrote in 1964 that the "destruction of the psychiatric hospital" was "something urgently needed" "... From the moment he goes behind the wall of internment, the patient enters a new dimension of emotional void (the result of an illness described by Burton as Institutional Neurosis, and which I would call simply institutionalization); the patient is put into a place that was originally created to render him inoffensive while offering treatment at the same time; it is in practice a place that was designed paradoxically for the complete annihilation of the personality, a place of total objectification. If mental illness is, at origin, a loss of individuality, of liberty, for a sick person an asylum is nothing more than a place of permanent loss, in which they are objects of illness and subjected to the pace of internment. The absence of any future prospect, being constantly at the mercy of others without the slightest personal affection, a life dictated only by organizational needs which - as such – cannot take into account the individual and their particular circumstances: this is the institutionalizing setup that marks life in the asylum.”

In the 2010 publication: Mental health and development: targeting people with mental health conditions as a vulnerable group, the WHO stresses that ... Despite their vulnerability, people with mental health problems - schizophrenia, bipolar disorder, depression, epilepsy, alcohol use disorders and drug problems of childhood and adolescence, intellectual delays - are been largely overlooked by development programs. This happens despite the widespread nature of mental health problems, their economic impact on families and communities, and related phenomena of discrimination, marginalization and stigmatization. The mental health problems affect millions of people around the world. The World Health Organization (WHO) estimates that 151 million people suffer from depression, 26 million from schizophrenia, 125 million people suffer from alcohol use disorders, 40 million people suffer from epilepsy, and 24 million suffer from Alzheimer's and other dementias. Every year there are approximately 844 000 cases of suicide. In low-income countries, depression is a major issue, almost like malaria (3.2% vs. 4.0%), but the funds invested to combat it are a very small fraction of the total allocated.

In the world, large portions of the population still live in conditions of oppression due to various factors: extreme poverty, economic and cultural imbalances between rich and poor countries, lack of recognition of basic human rights. In a context marked by deep inequalities, people suffering from mental disorders are one of the most oppressed minorities, not only because it is a group which is usually denied citizenship rights but because the denial of access to certain rights is legitimated by a misunderstanding of the scientific status of "disease".

Most funds for psychiatric hospitalization are still invested to hospitalize or segregate people suffering from mental disorders in closed institutions. Therefore a priority for governments is to promote policies which, with a view to the closure of all places of restraint and confinement, give impetus to interventions focusing on the creation of mental health services that operate in local area with a mandate to identify operational choices and health promotion strategies and access to rights.

The WHO is providing support to all countries interested in implementing policies for the reform of mental health services. In this framework, the Department of Mental Health of Trieste has been recognized as a WHO Collaborating Centre to provide politicians, civil servants and professionals in interested countries with the knowledge accumulated over the last 40 years. The Trieste experience, which back in the 70s was a futuristic plan, is still continuing to experiment innovative ways of “how to” to provide care to people in need, while respecting their rights and helping them integrate into social and working life.

In August 1971 Franco Basaglia, taking over the psychiatric hospital in Trieste, formed a working group made up of young doctors, sociologists, social workers, volunteers and students from different Italian and European cities. Many were attracted by Trieste because of the relevance of the issues on deinstitutionalization of asylums in the media, social movements and in the political debate. In his book “The denied institution” (1968), while documenting their efforts to humanize asylums, Basaglia denounces for the first time the fact that psychiatric hospitals do not meet the objectives of assistance and care, since they operate according to the rules and laws of public order and social control; in effect they are the producers of the disease.

Trieste’s goal was to go beyond the asylum: transforming the organization of the service to replace it with a network of territorial services with multiple functions of care, accommodation, protection and assistance. The challenge was difficult because, despite the many experiences of reform started in France and England after World War II, no one had ever really been able to shift the focus of care from hospital to the community. There was no knowledge or established practice to underpin the reform process. Even legal rules and laws were still based on judgments of the danger posed by the mentally ill, and were not in themselves sufficient to promote a process of real openness and civilization of psychiatric care in the direction of a territorial approach.

The main goal was to change the place of treatment to change the methods of care; it was not enough to change just one or the other. The focus had to be shifted from the disorder itself to the whole person: their needs and rights, while also focusing on capacity and resources. Interventions had to target not only the individual but also the context, the network of belonging and social reference groups.

In other words, the task of the central and local governments is to promote citizenship for the most disadvantaged and vulnerable population. More specifically, people suffering from severe mental disorders need access to material and economic aid, even transient, to earn an income and make a decent living; satisfactory living conditions in homes, the chance to live in communities and also in protected and semi-protected transitional accommodation; work placement in relation to their needs, capacities and inclinations; access to education, information, training, social contexts and opportunities, the chance to take part in different activities and have free time.

When a person goes through the experience of mental illness, he risk losing their essential personal and social rights. In 1995, the Department of Mental Health of Trieste approved the "Bill of Rights for Users" of mental health services. These rights are normally enshrined in the Italian constitution but in reality they are hardly applied to people suffering from mental disorders. But this is also and above all the work that the Department carries out to guarantee the concrete and daily exercise of these rights to people suffering from mental disorders. But, above all, it is the work carried out by the Department to guarantee that people suffering from mental disorders can exercise their concrete rights.

Finally, one of the problems that the territorial organization of services has helped to resolve in a different way was that of taking charge of moments of crisis and their evolution. The non-bureaucratic approach to crisis situations, outside the medical model, tends to reduce the use of hospital admissions or make them unnecessary, working to re-establish conditions of equilibrium as rapidly as possible. This approach decreases the risk of relapse. In this way, crises become part of the personal history, with their own meanings to be understood, reconstructed and satisfied by activating resources and links.

The territorial services adopt an operating style that differs from the clinical hospital model. They go to the patients, no longer using filters and strict, standardized skills, but enhancing social network relations, insisting on the quality and abilities of people rather than symptoms. These are models that do not define protocols and hospitalization operating times, but take care at the specific program of each person, while maintaining the quality of their home space, furnishings, cleanliness, and food, as well as the quality of relationships.

In Italy the process of replacing archaic cultures and laws, in contradiction with the general system of mental health instituted by the transformation of mental hospitals, is still in progress. In 2011 the community is still working on the closure of six forensic psychiatric hospitals that are still in use, where 1200 people are hospitalized and deprived of basic rights. Also in this case, the psychiatric mental health services that are already taking care at national level of about 1,000,000 patients are the alternative to institutionalization.