E95 - Where are we going wrong with Mental Healthcare? (with Dr. Roberto Mezzina)

Roberto Mezzina is an Italian psychiatrist and a prominent figure in the field of mental health, known for his leadership in promoting community-based mental health care and his role in advancing the principles of the Trieste Model. Mezzina has been a strong advocate for deinstitutionalization and the rights of people with mental health conditions, continuing the legacy of Franco Basaglia, the pioneer of the Trieste Model.

Throughout his career, Mezzina has worked to implement and expand the Trieste Model's humanistic and community-focused approach to mental health care, both in Italy and internationally. He has held key positions, including serving as the Director of the Department of Mental Health in Trieste. Under his leadership, Trieste became a global reference point for innovative mental health practices.

To learn more about the Trieste model go here:
https://www.thelancet.com/journals/lanpsy/article/piis2215-0366(21)00252-2/fulltext

Interviewed by Dr. Alex Curmi, consultant psychiatrist. 

If you would like to enquire about an online psychotherapy appointment with Dr. Alex, you can email - alexcurmitherapy@gmail.com.

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Transcript

Welcome back to the Thinking Minds Podcast, a podcast all about psychiatry, psychology, therapy and self-development. Today we're going to be talking all about the three step model. The Chester model refers to a pioneering approach to mental healthcare developed in Italy in the 1970s, under the leadership of psychiatrist Franco Battaglia. This model is renowned for its progressive and humanistic approach to treating people with mental health conditions, emphasizing deinstitutionalization, community based care, and the empowerment of patients, minimizing patient coercion, involuntary treatment, physical restraint, and other harsh measures commonly used by mental health services around the world. Professor Alan Francis, who recently had on the podcast, said this about the trust model quote for people who have never seen the Chester model in action, it might sound too good to be true. How can any mental health system help patients with severe and chronic conditions, with so few hospitalizations and so little involuntary treatment. I was once among the profound skeptics, but emerging during five visits convinced me that trust is the best place in the world to be a patient with a mental disorder. Whereas visits to patients in prisons and on the streets of the USA convinced me that the US is among the worst. It is startling how well patients do when they are treated well and trusted, how much sicker they become when neglected in the USA. End quote. With us to discuss the Chester model is Doctor Roberto Messina. Doctor Messina is an Italian psychiatrist who is currently vice president of the World Federation for Mental Health for Europe. Throughout his career, he has worked to implement and expand the trust and models humanistic and community focused approach to mental healthcare, both in Italy and internationally. He has held key positions including the director of the Department for Mental Health Interest. Under his leadership, trust has become a global reference point for innovative mental health practices. If you'd like to learn more about the trust model, check out the link in the description. Thanks for listening and I hope you enjoyed today's conversation with Doctor Roberto Messina. Doctor Messina, thank you so much for joining me today. Thank you very much. You're welcome. Today we're going to be talking all about the chest model, which is something I'm very surprised that I've never actually heard about through the course of my psychiatric training. I learnt about it from Alan Francis, who we had on the podcast recently. And the more I researched into it, the more I was interested in it, because it seems like the trust model, which obviously operates interest in Italy, seems to be something of an ideal for how mental health care could be run. Uh, and lots of people visit. Lots of mental health professionals visit chest there, uh, regularly to try and figure out what what makes it work and why it's so effective. Uh, and you've had you've been responsible for for running mental health services. Interested? For a long time. I'd be very curious to learn more about the model and how it works. What differentiates it from other, more common models of outpatient mental health care? But first, what attracted you to becoming a psychiatrist and and mental health care? Thank you. Well, I was, uh, a student of medicine, and, uh, of course, I was wondering whether to go to some classical, uh, specialization, like, uh, to nephrology. And and on the other hand, I was hearing about what was going on in, in, in Trieste and some other parts of Italy because it was just one of the cities where the movement called the The Times. He Democratica also became a formal organization pushing the reform processes and the new practices forward. Uh, was operating. So I was in in my own hometown, Bari, in the south of, of, uh, of Italy, uh, just started to study medicine and, uh, I started to hear about what was going on in, in, in these, uh, in this area, in the area of psychiatry at that time, uh, of course, the situation was, uh, completely split in Italy between the typical academic course where you are trained to, uh, learn about classical psychiatry, um, and, and the, well, at the time dominated by a psycho dynamics. Uh, so psychoanalysis, but also new therapies like family therapy, um, systemic therapy approach, um, and also, uh, relational approaches. And the important figure, as I learned, was, uh, Harry Sullivan from the US. Prominent figure with also with lived experience himself, uh wrote many important pieces about the kind of relationship that you establish with the patient. And I was, uh. Well, I started to to be part of the some training in psychiatry in the local university clinic and. Well, what I found very traditional kind of approach, including electroshock, uh, and use of restraints, uh, locked doors everywhere. This was a very typical, uh, condition of of a university clinic. And, and in this case, this was the, the door of entrance for, for the asylum or the nearer asylum, which was in the 4000 people there at that time, one of the biggest in Europe, um, private, privately run by a religious body. So the effort was to stop people going there. So there was some attempt to, uh, establish this clinic as a fortress to, to protect the patients somehow to go into the asylum. At the time, this was like a life sentence. Sometimes people were sent to the side of the can stay for the rest of their life. According to the log to to the to the law that was at the time operating initially. Anyway I, I started to to learn about the work of Franco Zelaya was the director introduced a couple of years before my my graduation medicine. Uh, and I started to be involved in some local, uh, meetings of the Democratic. And when I just finished my, my training and I did some training, uh, post post-graduation into the university clinic before deciding when to the prospect. Of course, I was also proposed to go and see some of these places. So I went to Trieste, I went to Aruba and also later to Arezzo, which were the three, uh, avant garde posts were at the time within their silos. So the work was done inside the mental hospitals and uh, trying to, uh, revert to condition of the patients, uh, which were only oppressed by this kind of institution and denied as human beings. So I was fascinated by the, um, either the humanistic and or the political side of this kind of work and the scientific challenge, because there was a completely different view of looking at the person rather than a patient with an illness, but a person within this whole, uh, um, aspect of human being. So including, uh, suffering, mental suffering, but not just mental suffering, but in framing mental suffering within a concept of personhood and personal, uh, life stories. Yeah. And I then finally, when I graduated, I decided to go to Trieste. I was, uh, proposed to, to go there. Uh, there was some sort of recruiting, some people which were interested, as some psychiatrists and psychiatrist were interested in joining the experience. That was already started for seven years. So it was in its full development when I joined, uh, just to the final part of the process of closing the asylum. And I went there in 1978. Um, and I stayed there for the rest of my career. Now I'm really a retired psychiatrist. My last, uh, work in, in the National Health Service in Italy was a director of the mental health department, which was also a still a W.H.O. was the tokenization Collaborating Center for Research and Training. So but I was, uh, in a complete, uh, I mean, let's say continuity, my, my career, all this through experience accompanying the evolution and somehow giving my own contribution, uh, within a group of people, there were some prominent leaders after Maceda, Franco Rotella, particularly, uh, eloqua. And so I was in that, in that kind of, uh, stream. My understanding is Franco Battaglia learned a lot of what he brought to Chester from America. That's right. Well, it was, you know, first of all, was a little bit different from the typical psychiatrist at the time. So he was staying a lot with the patient in the academic in this academic work, very traditional anyway. And Basil started to read a philosophy. At that time there was in Europe a full development of the the Anthropocene terminology was called the time is very important cause that started from our works on the, uh, or the, uh, existential, ethical, existential philosophy, uh, from Heidegger, uh, to our first of all, Husserl phenomenology of Husserl, and then, uh, Heidegger and his the say, scholars in psychiatry like beans Vanga or in French, Minkowski. These were some of the names that were at that time inspiring some of some of the streams in, in, in European, particularly in Italy, France and Germany. So Italy was very close to Germany. So. Kind of tradition. So these were some of the new things that Bazella started to study. And, uh, understanding what was the the kind of encounter that you should try to develop with the patient. So first of all, looking at the patient as a human being and in this existential course, uh, in a world, uh, so what was this world of the person, not just the inner world, but also the relationship with the outside world? So the, let's say, the acquisition of this, uh, human being, uh, within a his own experience, uh, in his life and its relationship with the, with the world. So, uh, um, and so the phenomenology was important because the investigation was to look at the person without putting the, uh, eyeglasses of, of psychiatry, uh, immediately using the diagnosis. But looking at the person as a person in his struggle in his life not to express himself as a human being. So. And Battaglia was very much in this there was a whole Italian course of, of a group of of of experts of, of phenomenology, uh, cardinal or later. Uh. There were other people, but Azania was again different. He when he he wrote some pieces. Very important. And you look at the person with this body and the kind of sight that psychiatry should impose of the on the person which are objectify as a, as a, as a thing, not just understanding the activity of this person. Um, and after then he, he met the, the, the reality of the surgery was his career as an academic was, in a way failing because it was a too much difference. So it was a asked by his own professor to be promoted to be the director of a psychiatric hospital at the edge of the country, and Galicia, which was just on the border with the at the time, the Yugoslavia. Uh, and, uh, well, the rear wall of the, of the hospital was on the border. Precisely. So someone that was escaping in Yugoslavia, uh, when the overcome the the wall. Anyway, um, so I started through with this shock of looking how all these theories of the encounter with the human being were completely denied in a psychiatric hospital. So it's so people, uh, detained, people are confined there, people doing nothing, people restrained, people treated with shock therapies like insulin coma therapy, for instance, and electroshock. And so he started to stop all this. One of the first act was to deny, to sign the register of the, um, mechanical restraint. He said, I don't do that. So there was a shock for the or, you know, the typical, uh, kind of, uh, routine that there was in the hospital. And then he started to work alone. Then some of these, uh, friends came to work with him, like like Antonio Slavik, and then later other, like, uh, Agostino Perella and Domenico Casa Grande, etc., the whole group of psychiatric Democratica, uh, apart from surgery here in the South, was born in English Galicia became a case, also very famous in 68. Because it, in a way had a sort of political side, because this kind of rebellion against the oppression within an institution, the loss of freedom, were resonating with what was the student movement at that time, particularly the anti-authoritarian rebellion in many areas of the society and from school to factories? Anyway, so and this was typical 68 kind of movement and, and the psychiatry contributed in Italy and also in some other countries to be part of it. Uh, Azealia was in a way trying to overcome the authoritarian. But it was when it started to open the doors and adopting some of the of the techniques. But he used the techniques, but it just modified them very much because he didn't he didn't believe in using techniques as fixed tools, but in, in a process of allotment. Uh, so it started with the therapeutic community of Maxwell Jones. He also studied, which was developed in Scotland and used in the UK in many places in the UK by Tom main, David Clark and other people. And then he also look at the French sector where there was this, this correspondence between the community sector Secularized services and psychiatric hospitals, but the hospital was still dominating. And then you mention us. He went when he finished his first experiment in Galicia, where he was denied to set up the first community medical center that he was thinking about. He decided to go and he learned about by by reading what was going on in the US with the Carnegie Reform 63 for some years. And so he decided to spend six months in as a visiting professor, uh, in, uh, in New York. Uh, I think the Mount Sinai, if I remember. But also he looked at particularly the community mental health center, and he wrote a very nice, uh, letter from New York discussing critically what was going on, saying, this is an interesting new wave, but on the other hand, still is a is a in the register of psychiatry. So it's nothing beyond the old style psychiatry just, uh, approaching the people in their, in their living a areas or some problem, uh, in their, in their community areas, uh, close to their living environment. But. The kind of observation, the kind of approach really was not really so different, or just adapting to a new kind of social psychiatry that was still starting at that time. The other ideas of controlling the behavior of controlling this was the use of the psychiatric hospital in the Western World Series. So this was the Bazella, and then you came to Trista in 71 after this visit in the US, and then it was given like a green card from the local politician, the president of the province, which was anyway a managing hospital because it was a provincial hospital, as all other mental hospital at that time. And Basil was discussing not just the reforming but overcoming that kind of institution. And this happened in nine years, from 1971 to 1980. I came 78 by the end of all of this development in 78. Important reminds that there was the the Italian law, the first law that. In a way, uh, abolished, uh, the psychiatric hospitals saying that no new asylum should be built. Uh, and the new, uh, well, people in acute crisis should be treated in general hospital. Small units, no more than 15 beds. Uh, the kind of involuntary treatment must be limited to a week, not hampering any other human rights or civil rights as the previous law was doing. And it and the the norm was the rule was to treat people in the community by community mental health services. This was the law which the great law, uh, and also even even unprepared, the country was unprepared to apply on the large scale. But anyway, uh, Trieste was the forefront of this without some other, uh, experience, as I mentioned before. So I joined the death stage and I started to see what what is a community interest center, how the was this kind of blurring, the, uh, distinction between the patients and the staff. So was very much here and the relationship, uh, and how, uh, we can help the person, uh, not using the power, but using, uh, listening, staying with being with, uh, being in a way, uh. Concerned about the kind of life, the style of life, the quality of life that this person should have. So looking at where the people live. Visiting people in their own homes and wondering, uh, how to improve their housing, how to, uh, and people to get a job, etc.. Excellent. You mentioned at the beginning, you know, one of the principles of the trust model is seeing a patient as a whole person. And if I listen to that with sort of almost like a beginner's. Yeah, I think like, of course you should do that, of course. But actually knowing having gone going through psychiatric training, I know that doesn't always happen. Why do you think it is a problem? Why do you think many clinicians, or indeed many systems, are built to not actually take into account psychiatric patients as a whole, people with their own sort of rich, complex worlds? Yes. Well, still, the domination of the medical model in the sense of biomedical model, particularly because, uh, to be a real doctor, you should look at the holistic analytic view. Uh, even on a patient, you can call it patient, but you must be very much holistic in the approach. Uh, the medical model, particularly the one that was denied by Bosnia, was the so-called that psychiatry organized so well, the effort was try to find where was the brain damage that this was the the effort of the research at that time, or, uh, of course, more more, you know, the more modern view, uh, what is about what's happening in your brain systems of neurotransmitters, uh, areas and connections between different areas, etc.? So, um, I think that this vision, uh, puts mental health on just on a, uh, very limited side. I don't deny the importance of biomedical research. It's very important. Uh, but it's never really resolved. People's problems in their in their lives can help to, uh. Uh, improve. Some of the symptoms can help to reduce the anguish and the suffering of people. Can help to establish better communication. Sometimes with the patient, which is very much disturbed and or severe in this condition. On the other hand, medication don't resolve really the problem. Uh, so they can open some window in some other possibilities like rehabilitation, social inclusion. So you must look at this holistic kind of approach. What we learned in the last years is also to listen better to what is the experience of the person. The the recovery movement, in my opinion, was, uh, probably the most important contribution, uh, to what I started to, to learn in the course of action experience, uh, where the in a way, um, uh, let's say the, the activity, the, uh, the initiative, the leadership was on the side of the professionals, particularly psychiatrists. Uh, but after one case or two, we started to, uh, understand better how important was to, uh, focus on the patient experience. What is, uh, what are the most important factors that are helping the person in the in the process of recovery as as identified by the person themselves? But just, uh, on the basis of the psychiatric knowledge that knows what is the best for you, but listening to the person in a, in a, in a biological, let's say, dialectical kind of relationship, where I say something, you say something and we find something new. Uh, in our relationship, that's what we try. Including the social elements, the social factors, social drivers, which are important, uh, in your life, uh, we call this like, uh, uh, the reality therapy. So talking about what is your real experience and trying to, uh, providing some advice, but also, uh, putting a lot of attention to what is, uh, working for you in a positive way, uh, helping what is helping you for a friend, uh, a pet, uh, a work, uh, uh, having a having got a house on your own and not anymore being dependent from a family, um, all these kind of things. What we started to say. The subjectivity of the person emerging from the illness and which was called in the American and an Anglo-Saxon, uh, a new, uh, wave recovery for us was emancipation was subjective ization. Was this kind of words autonomy, getting the autonomy, uh, as a, as a person and as a citizen. The social side still was politically intended, and I'm very pleased that in recent years we were confirmed by the audiences the convention on the Rights of Persons with disabilities, which is saying the same things that we were, uh, fostering, uh, in, in, in the, in the early, in the early days. But the person must be seen as a, as a whole person, as a citizen of a community, uh, must we must respect, uh, of the person and, and support the dignity of this person and all the rights in all the areas of his life. Uh, despite regardless, disability, uh, sometimes, uh, recovery also is defined by including others in life beyond the disability. That's so these are some of the points of convergence between the work done interest and in Italy within the old institution, try to set up new kind of services in the community that are related to a new kind of approach, mostly not just setting up structures and facilities, but kind of relationship which is slightly changing. Uh, and on the side of the patient movement, the recovery movement was saying, uh, hey, nothing about us without us. Uh, listen to what we are saying. You don't have the knowledge, uh, an exhaustive knowledge to to understand, uh, what I need, uh, to to improve the quality of my life. So this kind of sensitivity must be, uh, taken into consideration. Uh, the political side is becoming nowadays more and more important because, uh, of course, mental health patients are part of the international movement of people with disabilities. Uh, and so they advocate for their rights and they have what what is the difference is that we don't just, uh, push the person only as in isolation, but we say in order to allow the person to take the power to be empowered, we must modify. We must change the institution. We must change the practice of psychiatry, particularly community psychiatry, toward community mental health. And differences in psychiatry is the work done by psychiatric professionals in a community with a community, while community mental health is the work done by a number of other components, which includes social services, NGOs, third sector families, carers, caregivers, anything including the public opinion is delayed. People, uh, can contribute to a an overall change of the mentality, which is a campaigning and coming together with the change of the approach in psychiatry. Yeah, that makes a lot of sense. So it sounds like Franco Battaglia was the only person prepared for the new law, introduced in the early 1970s because of the work he had done before. And of course, we've seen a pattern of deinstitutionalization in many different countries in the UK included. But because Franco had done all of that work, he was almost prepared to go with that tide and actually create a realistic vision of what community mental healthcare could look like, whereas other places were probably court underprepared. Yes. Well, of course, if we look at the situation in Italy today, it's evident what the barzagli work and also the law as, as, as they reproduced. So on the one hand, of course, a great respect of the, of the, of the rights of the, of people with mental health problems, uh, and attention to uh, reduce as much as possible the use of uh, involuntary treatments, involuntary care, coercion in general. But this doesn't mean that it has been overcome, particularly the use of mechanical restraint. In many places in Italy, particularly the the general hospital units, they even if they have a small number of beds, they use mechanical restraint very much and locked doors. So yeah, there was a big but anyway, there was a huge, uh, paradigm change. Let's say, uh, in the whole country, um, the idea of abandoning the old institution was completely, uh, received by also by the, by the public opinion, uh, even a few years later, there was a number of research. Marketing research. Doing what? What was. Trying to understand what was going on in the, in the, in the mentality of the public. Um, but today services are working in the community. There is a very limited use of, of institutions. Uh, the forensic, uh, for instance, small units are very limited in the there is a lot of discussion on it, but we have no enough anymore psychiatric hospitals for more than 20 years, because in 2000, in the year 1999, there was the closure of the last EDS or the just big institutions. So we don't have anymore. And this is this is interesting on all of it, all of Italy. Now the important is that rest is not rest is the forefront of this change. But this uh, uh, was addressed by the whole country. And this was very important. Despite the lack of policies, the lack of announcement, the resistance of the traditional psychiatrists, the resistance of the administrators. Because when you dismantle an institution, you touch a lot of interests around it, etc., etc.. So. But at the end of the day, this was done. This was done, uh, in 20 years. Uh, 21 years. Exactly. And more recently, also, the forensic hospitals were closed in this last decade. Uh, and substituted by small units? Uh, yes. Very temporary. Temporary you and a temporary, uh, of admission. So this is a big change, I can say, not just this day. I don't want to support the idea. That was. This was just an exceptional place. It was because of the kind of people and the kind of situation that was created there. But on the other hand, for instance, Brazil is a huge country that followed the Italian example and particularly the, uh, teachings. Uh, Brazilian wrote, uh, went around Brazil in 79 and he addressed a number of public conferences, publishing autistic book conferences, Brazilian translate in some languages. Other languages, I think also may be uh, is going to be published in the. You know English too. Uh, so Brazil today has completed a reform that started in the year 2000. Uh, there are few, uh, thousand people left in the whole institution, and the whole system of services operating in the community without being backed by institutions. So this is a huge country of 250 million people, which, uh, without the money of, uh, uh, you know, uh, high income country is undertaking substantial reform. So it's not impossible. Uh, the paradox is the more the I mean, the the richest the countries are, the more problem they have in changing. And because they invested a lot of money in psychiatric services. Sometimes these are, well, specialized, uh, they can do a good professional work, but usually they are fragmented. They don't change the overall system. They don't change the pathways of care of people for most of the times. Uh, look at the insistence of Pat McGorry, uh, on young people pathways. Uh, in these days, we see we saw the Lancet commission on, on on youth mental health, for instance. Uh, still, there is a case to try to promote the different use of mental health services across the world, across the globe, despite the increasing, uh, knowledge on many aspects of care, uh, and many aspects of the disorders. So, yes, this was Italy. Uh, Trieste is, uh, still is I say still because after 4 or 5 years we had a process of evolution due to political conditions. Uh, the support that was going on for 50 years is now reducing a lot because this is still, uh, challenging the privatization of mental health care. This is a pure public system where everyone can access, uh, it's easy, uh, access system, uh, with open doors, etc.. It's a public services. So this is a complete clash with what the privatization, the neoliberal kind of trends which are today. So there is a political backlash now. And also, uh, my colleagues which are working today, they're in a way they are not supported and they are facing a number of challenges, uh, reducing reduction, reduction of resources. Uh, but also, uh, not being supported in what they are doing. Uh, so lack of confidence and demoralization, uh, and at the end, lack of leadership. So because the leaders have been substituted and, and many of them don't have really the continuity of the history and the knowledge that came out from Bosnia and all this course of action across the years. So this is to frame the situation today, but regardless. Uh, this this aspect, I can say that three stars demonstrated it is possible to live for 50 years now without a mental hospital in a medium sized city or providing care, uh, in real time. Because we don't have we didn't have now the coming, uh, waiting lists for accessing the community services. People can just go to a community mental health center and be heard in real time, uh, receive a first contact, first assessment, etc., and start to develop a relationship with the continuity of care. It's another important aspect. Uh, that means that the same team is following you. Despite that, this team has to develop some particular functions or specialization. But we didn't divide and fragmented the teams. We are very much supporting a generic team working on the overall, um, Life was a whole life of that particular person that knows the person and establish a relationship based on trust between the person and the patient, the person with mental health problems and service, and some particular case manager, but also the services as a whole, because they know that they can go there whenever they want, whenever they need it. Uh, and they are supported in their own homes. So we just incorporated a number of these clinical aspects of community psychiatry that you can find in parts of the world. But adding the social side, for instance, housing developed through personal budgets, personal plans into towards independent housing instead of providing residential, typical residential facilities, group homes, big sites, etc. but moving the person as much as possible toward individual supports that allows you to, uh, to, to uh, have your better. Better quality of life in your in your house or in the place where you can live with 1 or 2 other fellows. Um, trying to companions. Um, the the work was very important. The developing social cooperative movement started interest in the first cooperative work. Cooperative started in 1972 to provide a work, real work to the patient that were cleaning, that were cleaning the hospital for nothing, or for a pack of cigarettes. Recognizing the right for them to have a salary to be organized in a social cooperative, that means that they share the management of the cooperative, they are members, etc. and this there is now today a movement of 8000 cooperatives across the country which are entering the social kind of aspect of work, uh, contributing with the social value of integrating people with disabilities, not just mental health, but also other kind of physical, mental, intellectual disabilities, etc.. So yeah, these are the aspects of a holistic approach to care that looks at the person in a subjectivity. So favoring, uh, this kind of individual, individual approach based on trust, but also allowing the person to, uh, fulfill, uh. Uh, expectations about recovery, about social inclusion, etc., etc.. And so as a result, interest, as you said, a medium sized city, you don't require a mental health hospital, you don't require involuntary admission to a mental health hospital, involuntary treatment, mechanical restraint, all of these things which in the UK we've been accustomed to thinking of as kind of necessary evils of treating people with severe mental health conditions. These these are something that you don't use interest at all. Is that right? Uh, involuntary treatment. According to the new law that was established, 78 at limited rest was using one of the lowest ratio of involuntary treatment. These are intended as the last resort. So when the service tried and tried to establish a relationship and to engage the person in a, in a therapeutic, uh, program, and, and this has failed. So it's more a declaration of a service failure. Rather than the seriousness of the illness, let's say. So it's it's about so it's the responsibility of the service to do this. But saying that it's a very much reduced number of people. When I was, uh, director of the services, uh, one of the last few years, for instance, we had 18, 19 people per year in the city of Trieste, which were treated involuntarily for no more than ten days, so usually a week or, um, so that's still a little bit while increasing, but not that much. Uh, it's one of the most important results. Limitation of suicide. Reduction of suicide. Very important because the more you are embedded in the community, the easier is the kind of access you can promote to to the people in need. The lower threshold you have to access the care it's better for for preventing, of course, suicide and other things like that. Yeah. These are some of the things the typical well, the, the, the pillar of the, of this organization is the community mental health center opened 24 hours with beds or accommodating people in crisis, rather than using using the hospital beds for a typical admission, even if we have a small unit in General Hospital with six seven beds now, uh, which is used also by another city nearby. Security. Um, but the effort is to use the beds of the center rather than to rely on the typical end of a hospital admission. And also in the idea that your team is based in the center. So when you are in crisis, you must be followed by the same professionals that where you have established some relationship before, so vastly reduced inpatient stays, vastly reduced use of involuntary treatment, reduce suicide rate. What about the use of medication? Has that been looked at? Do you guys would you guys use medication and similar in amounts and similar doses or is there a difference there. Okay. We made a comparison in in Italy research with other about 12 sites. Uh, about the first episode of crisis, a crisis in the, in the whole of Italy. And the comparison was that well, showed that, uh, the community mental health center used a half of, um, daily dose of haloperidol equivalent than a typical hospital unit. So this was an example also in the in the follow up. And I'll be put into the follow up. So, uh, and another interesting data was that, uh, the proxy of overcoming the crisis was the establishment of a trusted relationship with the person, the the person people had within the first month of, of work, establish a trust relationship with the service. They overcome the crisis much quicker. This was a significant, statistically significant difference between the results of the sample. Um, and also another important learning that we had from that research was that the wider you have, your approach. So including the social components, as I mentioned, and not just the clinical intervention. Uh, also again, you have less uh, um, um, relapses and quicker resolution of a crisis. So this is an example. But medication are used. They are used. We did an active work to reduce, for instance, the depo injections uh, and to favor daily uh, use and self-medication as much as possible. So the self-administered medication or with the support of the family, sometimes, uh, instead of using a long and before injections and and leaving the patient, not, uh, supported the patient in its daily life, but the patient is treated by medication. That's that's it's that that's the typical kind of thinking. While we don't, we want to every patient engaged and also in a number of programs including socialization work as I mentioned, cultural programs provided by associations with work with us, uh, rather than having the patient managed by medication in its own place, in isolation, in his own home or family, etc.. So this is the first critical approach to the use of medication, with some attention to withdrawing medication when it's possible. Of course. And I guess one of the things the chest model relies upon as well is the integration of mental health care services with social care services, which for those of you who for those of you who don't know, in the UK it's very different. So those agencies are separate. They communicate with each other. Of course they have to. But sometimes that communication can be very difficult and can take a long time. And importantly, social services in my experience, can be even more overstretched. And mental health services and the amount of care they can actually provide is very minimal. But interestingly, the two services are more or less integrated as. That's right. Yes. Well, of course, we have, um, mainstream welfare services which work for the general population, uh, that are accessed by the social centre of the municipality run by municipality. Also in some specific area, like, uh, teenagers, you know, adolescents, etc.. Um, they work for family, which are in some social hardship difficulties. Um, and we work together with them. But on the other side, when you start to have a different perspective from the beginning, from the start, looking at this person in his social context, what is happening, what are the components of the quality of life? Uh, you start from the beginning to widen the the view. Instead of saying, okay, I do my best. I'm a psychiatrist, I'm a psychiatric nurse, I'm a psychologist, I do my piece of work the best way I can, and the other things will be solved by someone else. That's the typical kind of fragmentation, not in the service, but in the approach itself as such, so that we try to overcome. So okay, let's have a typical, for instance, family session. Uh, we start and we have maybe four or 5 or 6 family sessions. Uh, looking at the person within the, the family context. But the family is engaged also as his own problems are concerned. So. The mother is not working because taking care of the son, which is very sick. So trying to help the mother to, uh, have a job or an occupation, at least the father is very distant. So working with the family, uh, try to, uh, to favor the cohesion of the family. Uh, looking at the subjective experience of the heavy burden that they they stand most of the times when the person with schizophrenia, for instance, there is living in the family, etc.. So looking this holistic view is more natural to engage the social services because you already know what are the problems on terms that you have to deal with, even if you do not have to deal with them directly. But you can. You have your knowledge and psychiatric community psychiatrists that you can engage the others, the other services to be part of an overall wider and more comprehensive package of care. That's that's the idea. Of course, some of the resources are run directly by the center, for instance, for grants, for people in training, for work that can be given by the center. Uh, you can approach a cafe or car repair shop where you have a good owner and you can ask the owner, you can take this guy and they don't have to pay. But taking four for training and you provide to the guy. Uh, this kind of work grants some small amount of money, but it's significant also to recognize the effort is doing. And this is very important for young people. For instance. First episode psychosis. They maybe are withdrawing the studies they are not going to do. And we can propose. Okay, let's stop for a while. There is the bar, the cafeteria run by the cooperative. We want to have an experience in this group, people, etc.. So this kind of instrument they have, there are some personal budgets we can manage for fixing the personal situation of people with more complex needs according to housing, work, uh, social relationship, etc. that is an add on the standard of care, let's say the clinical care. So the service must be, in a way, as much as possible, equipped with a number of instruments and tools that can help to widen this view. Also in intervention on the other side, of course, you must, uh, engage the other services working in the community and try to propose what we call joint care. I've seen. I noticed in my small experience in UK, uh, that it's very hard sometimes to have people at the same table discussing kind of how to join the forces and share responsibilities and working together for a more, uh, let's say, comprehensive plan for the particular person, rather than saying, I did my my best. Then I passed the k the past the back, you see to someone else because I've done what I have to do it. But in this way we use a lot of meanings. We do lose a lot of understanding of of what is going on in the person interior condition. Yes, that's one of the biggest problems I've seen in the UK as well. And a lot of the principles of the trust model sound very similar to the open dialogue model, which has come out of Finland. And is is that a coincidence? Is there historical other common historical roots there, or is it a case of separate groups, uh, arriving at similar conclusions as to how best to run community mental health care? Yeah, I think I think the second you you said probably also well, you know, the conditions in Finland were completely different than, uh, in Italy where you have such kind of density of the population density of social relationships, uh, etc., while in Finland it's completely different situation. But it's interesting to say that these are two groups that warped separately without any connection. The only connection can be somehow the relation of kind of therapy. They share family therapy as some sort. Some of the, uh, the roots. But uh, uh, Trieste was looking at the community, uh, as a resource, not just, uh, as a source of problems or source of referral, uh, as well as the open dialogue is using the family, uh, listen to the family as a whole and having this dialogue within, within a social group. Uh, I think this is very similar. Um, probably we have some differences that I don't want to emphasize, but of course, probably we are. We were more, uh, active in taking decisions and sometimes sometimes also taking the responsibility to do, uh, uh, involuntary care in a different way. Uh, while the open dialogue is more traditional kind of stuff. So you enter into the dialogue, otherwise you are out and you are, in a way, hospitalizing the traditional way. We try to find more, probably a sort of negotiation, a compromise, mediation, uh, in the way that we also represent to the patient sometimes the risk of entering into a typical coercive kind of response. Uh, and we have we are on the same shape saying, uh, let's try to find a solution together. There is this emphasis on trying to achieve a result which is avoiding the use of coercion, while the open dialogue is probably more liberal, more democratic, let's say in the in the approach, but can risk to split the patient into groups, while for us, everyone, even the most difficult one is completely the same that you and me, if we have a problem of sleep going to the center. So that's the difference. I don't know if I gave the idea, but uh, because we worked the initial, the initial idea was to demonstrate that you can do without the asylum. If you want to do that. Of course, you must have tried to find sometimes compromises, negotiation, uh, contractual relationships other than just listening and developing a dialogue, but taking more into the action side of the of the other thing. When we talked originally a few weeks ago, you told me a lot of clinicians come to Chester to visit to see how it works when people do visit. What surprises them the most about the system or what impresses them the most about the system? Well, okay, again, I have to say the situation now is a bit more difficult. But anyway, I think services are still there. They are operating with the open door. Uh, they are welcoming people. Sometimes they can be more exclusive, exclusive, inclusionary, saying that they are not so open arms for everyone because of the kind of pressure they have. But anyway, uh, people are, in my opinion, they are mostly, uh, impressed by the kind of relationship, the kind of situation they find in the center, where it's a very natural kind of social interactions. So it's not the typical bureaucratic place where you have a typical, uh, reception and you, uh, they ask you if you have an appointment. If you don't have an appointment, you are to take an appointment. Otherwise you cannot access the place. It's an open place where you find the clinicians and the patients in the same place together. Some of the patients come every day to use the place as a social resource, but to meet others and to have small groups or informal catch up, etc., etc.. Uh, so the atmosphere is very different. The open door is is very different, of course. Uh, and uh, not no use of uh, coercion is another important issue. This makes a particularly difference from other experiences across the world, but also the social cooperatives, all the social engineering around mental health. So the engagement of other people with the good ideas, or for instance, the guys that work at the radio station or the social cooperative, they engage the patient in running. So this is some of the solutions that were found creatively in a way when when you don't think to this person just as a. Someone bearing problems, you know, bringing problems to the society, to the service, but also someone with talents, someone with some competence, with human skills, etc.. So this is can be helped by this wider vision, not just the patient and the treatment, but the person and the quality of life and the kind of social inclusion you can promote. And presumably, even if you looked at the model economically and I don't know if it has been studied economically, but I imagine it to be quite cost effective because at the end of the day, in-patient hospital treatment is the most expensive. It has that kind of economic analysis been done? Yes. Of course. Uh, well, we were surprised in the first years we, uh, made the first study where, uh, the demonstration was that the new services didn't cost more than the former hospital. Uh, then we had some demonstration that they cost, uh, about 60% of the psychiatric hospital. But across the years, I have to say, regrettably, but the kind of proportion is increasing in favor of our services. But it's not a good, a good, uh, outcome somehow, because this demonstrates that it's possible to reduce investment in mental health too much. Anyway. Now, last calculation was that it's about 35, 36% of the cost of the psychiatric hospital. So what if that's the case? And what what are the obstacles to introducing this kind of model more widely in Italy or in other places in the world, changing the minds of psychiatrists? That's the point. Number one, there was a psychiatrist with a huge reputation, uh, academic reputation. But he was really wondering if what he was doing was in favor of the patient as a person, or just applying a preferred method knowledge to, to to the case. So I think if you have an open minded, uh, where I know if you are an open minded professional psychiatrist, uh, and you want to use all the resources that can be helpful to a person in his process of recovery and social inclusion, social integration, etc.. I think this is this is an ideal kind of approach. Uh, it's it's somehow sound because you use the. Someone said the Twin Boys Institute of the Netherlands during a research called Freedom First about race. They, they they said that one of the most important aspect is that is in an ecological approach. It uses the resources existing in a particular context, resources of the person or the family or the neighborhoods, uh, or the service, of course, of the service. And putting this in a, in a, in a, in a mix, which is a powerful somehow. Uh, rather than, uh, uh, spending money into setting up some boxes where to put the person because this person is not manageable, is disturbing, etc., etc.. So it's sound. Well, anyway, you know, probably that, uh, because I mentioned to you that I'm somehow sometimes well, these days I'm engaged. Just today, as I talk with the, um, people at NHS England, which are, uh, supporting this pilot, uh, um, this pilot program for, uh, 24 over seven community services of new kind somehow, which incorporates many aspects of what was our approach. Uh, it's not an application of the best model, which is can be very, very naive to think in the nowadays British context. But, uh, it takes the some of the principles, uh, adapting to different situation. And, uh, some of the pilots, uh, will be developed in big cities like London. Some of the pilots otherwise that will be developed in a rural area in the north of England. Uh, it will be very interesting to see how this concept of having your own service, uh, near to the place where you leave, which is easy, accessible and provides immediate response in a wider view that is not just, uh, focusing on your symptoms and better health and development of community mental health care, I think so, I think it's possible. Well, you've seen it. You've seen it first hand. Well, yes. But of course, when you have an institutional. Very established institutional system. It's hard to say we will overcome this in a quick, well, quick time and etc. but on the other hand, let's start with doing kind of the right things. Uh, when when developing a community services, uh, look at this can be increased in the capacity of taking care of the more serious people. Uh, look, to what extent you really need to have hospital beds or better address to address the crisis in a different way and and try to provide responses to the overall needs. Because when you have a mental health problem, you know very well as a psychiatrist that the stressors in your life, they can impact even more than that person with more established defenses and resources. Uh, so of course you are more sensitive. You are more vulnerable when you have a mental health problem. So the more you establish kind of. A condition of of life which are helping you to have your your balance in your mind. You're kind of, uh, recovery, uh, faster the less you need to be anyway, dependent on a mental health service or a mental health system. So that's the idea. Yes. I look forward to seeing what the results of the pilot treatment are. And I also think it's just so important to know that something is possible. Like, again, the consensus when I was training amongst myself and my colleagues was largely that a lot of the problems we've talked about when necessary evils, involuntary treatment, sectioning, people using sometimes quite large amounts of medication, extended hospital stays. And so just knowing that it's possible, I think opens up a lot of doors, even in someone's mind and in the minds of different psychiatrists. And then I think somehow then arriving at it step by step, you know, I'm sure it can take a long time and have bureaucratic challenges, but at least, you know there's a path. So hopefully, if people who are listening to this, uh, work in mental health care or training. Mental health care. Certainly. I'd encourage them to learn more about the trust model. Where can people go if they'd like to learn a bit more about it? Okay. We are we are doing a lot of effort to try to establish, uh, sort of school. Uh, of course I did. Uh, for when I was director, uh, for about ten years. Nine years. I did a yearly, uh, school and meeting for the school, also presenting some of the best experiences in community mental health across the globe. Uh, interest. And this was also used by World Health Organization to set up this guidance, uh, that you can that has been published in 2021 for a good practice services, uh, cognitive human rights and and recovery. Uh, uh, it's still difficult. Well, our dream is tried to be supported in this idea of establishing something like a school. Of course, the and the our friends from the from the from Finland, the open dialogue. They they were very able to. First a transformed data protein in a very. Let's say, simple list of points that can be implemented. Some of these points are more difficult, of course, like the the allergies is not that easy to understand, end to end to operationalize needs, training, etc. but what we should try to do now, today is try to abandon the idea that we had an experience, which is a changing over time. That was the reality. But uh, to, uh, try to, uh, extract from this the most important points that can be generalized. Uh, what are the lessons we learned? Uh, what are the solutions that can be modified? But in a way, uh, applied to a I don't say, uh, um, without taking, uh, consideration of the take into consideration the context where they then apply. But on the other hand, to be such a kind of generalized solution that you can have in your, in your, uh, in your knowledge that you can adopt and I, I very much think that the work that should be done in the UK will be very important in the, in the next years. We have also another interesting, uh, uh, collaboration in Los Angeles. Which started a few years ago then or stopped by the Covid now is restarted again to have an idea which is even more difficult than UK because USA don't have doesn't have a system on mental health is very much depending on local uh conditions and different sources of financement to be integrated in an overall offer. So it's even more difficult also for the social context of cities like Los Angeles with the homeless, etc.. But I think that's, uh, demonstration of Brazil. I mentioned there are countries like Poland, uh, which are developed, which have developed already, community mental health centers joining open dialogue and rest approach. Interesting. And now they are scaling up this to, uh, the rest of the country. Um, there are countries like Czech Republic which are reforming psychiatric care in, in a, in a, in the, in the middle of Europe adopting principles. So I think it's a, it's an, it's an international movement. And we don't have a place specific place where to learn this, uh, interest. Unfortunately, as a, uh, vast majority of people just speak Italian. So it's very difficult to, to have an experience as a trainee and. Uh, but we hope that in the future we will have more. I will be more successful in setting up a number of, uh, uh, well, let's say, uh, that is cool. Let's say. Anyway, I'm finishing a book in these days with my colleagues such as Darren from UK, who is a great companion, work for many years in Birmingham. As you and I were editing a book with more than 60 authors, authors about not just, uh, the component of the rest, but the use and the adoption of the principles and, and models, uh, in many parts of the world. And, and you need to have it. Uh, when is the book coming out? Well, I think by the end of the year, for sure, by Oxford University Press, uh, the title would be probably. Well, uh, Utopia and reality. So wonderful. So we'll be on the lookout for that book, doctor medicine. I thank you for spending some time with me today. Thank you. Alex.