Therapeutic value of freedom

 1945, war

In May 1945, my father-in-law, a Major with the 28 Māori Battalion, was stationed in Trieste, in Northwestern Italy. They were tasked with managing a stand-off between allied forces and Yugoslav partisans who wished to incorporate the city of Trieste into Yugoslavia after the war. Their mana and reputation, ability to firmly engage and garner respect while treading gently in a delicate – potentially volatile -  environment, contributed to Trieste remaining a part of Italy.

1996, disillusion

I mention this as a preface to my remarkable exposure to Trieste. In 1996, I was becoming dis-illusioned with my formative experiences with mental health services in Aotearoa New Zealand. 

1998 , transformation

But I came across a paper describing a remarkable transformation that had evolved in Trieste following the closure of the psychiatric hospital during the 1970s.  The paper spoke of services being offered only in the community through five mental health centres. These centres, open to receive guests 24 hours per day each, offered beds 5-6 for hospitality (ie. these were not hospital / inpatient beds – and were often empty). The centres were completely unlocked. Not only was there a complete absence of any restraints, but a virtual absence of compulsory “treatment” (just 5-6 per 100,000 population, compared to around 95 per 100,000 in Aotearoa New Zealand.)

These seemed astonishing claims - to the point of being unbelievable.  Part of me was left wondering, “where’s the catch?”

In 1998 I had the opportunity to attend a Conference in Trieste. How they had transformed their mental health services was the theme explored over 4 days. 

An open door, and no restraint

The very first speaker spoke to the “therapeutic value of freedom”. I was riveted by the concept, by the language and the unusual and seemingly obtuse juxtaposition between health care / treatment and “freedom”. An “open door, no restraint” approach, that supports people’s recovery and citizenship, was the core starting place from which they developed the service – not a later or eventual refinement to be added. We certainly didn’t talk about any such things here in New Zealand in the late 1990s.

 In fact, this experience was the closest I’ve come to an epiphany.

 Here's what we can learn

• Holistic care and support that focuses on the whole person, rather than the “disease”
• An ecological approach that responds to the realities of a person’s life, their relationships, social and cultural connections
• A human rights-based approach that ensures people’s legal, civil and social rights.

 A beacon of hope, relevance and fidelity

The disorienting transformation of services in Trieste – from the 1970s until the present day – have represented a beacon of hope. This, not because of any “Eureka moment”, nor hint of “perfection” achieved in responses to poor mental health; but in their retaining absolute relevance and fidelity to those original values and principles.  

Reanimating a vision of psychiatry

An achievement they may also claim in Trieste is in reanimating a vision of psychiatry that can assimilate alongside people in their community, their social and cultural world. This is so critical to what has been achieved. The transformation also exposed elements of psychiatry that tend to anchor the discipline to a past – looking past a current world that represents volatility, uncertainty, complexity and ambiguity (VUCA).

The real challenge is answering the questions the Trieste experience provokes

For those of us looking to transform our responses to poor mental health and wellbeing, a priority is less about transporting the Trieste (or similar) approach to these shores. The real challenge will be in answering questions the Trieste experience should provoke - questions such as:

• Why are we [still] so reliant upon the use of restraints (particularly seclusion), coercion and compulsory treatment to support care and treatment?
• Why are “bed numbers” such critical indicators of service resourcing and utility. Why are beds used as a place to “put people”, rather than a tool that may be considered – alongside of other tools  -  to support a person’s recovery
• Why have the existence of mental health services in Trieste represented both an irritating “stone in the shoe” for many existing services, an inspiration and such a beacon of hope for others?
• Why do we remain so doggedly determined to continue [still] just chasing demand? Instead, isn’t it beyond time that we began to seriously address causes?
• Finally, are we clear on what the actual problem is that our mental health policies are trying to solve? What presumptions underpin the definition of these problems and how are they represented? How do these presumptions routinely direct us to the same old answers?

It can be emulated

 The UK is following on

Hope springs from Trieste

For my father-in-law and his comrades in the 28 Māori Battalion, Trieste offered a bookend to their WWII service in Europe. The end of the war gave way to optimism and potential for a brave new future. For myself, 50 years later, after the city was supported to remain a part of Italy, Trieste continues to provide nothing less than remarkable and serendipitous, personal and professionally relevant inspiration. Most importantly, it offers hope.