Who. Is. This. Person?
The Trieste model emphasizes social recovery as a more critical element than viewing someone as a patient, in a medical sense. I have to say that in the two weeks that I have been here, any reference to a person’s diagnosis or medication regimen has come up in conversation as an afterthought, if at all. Invariably, I am told a quite complete story about a person – their upbringing, their family context, their education or work experience and the reason they have arrived at either the hospital or atthe community mental health center.
These are important details to set a context in which to chart a course forward to help someone regain a measure of equilibrium and return to a productive place in their home, or job or neighborhood. I cannot over-emphasize how different this plays out here in Trieste. By contrast, I have been in numerous meetings with mental health professionals in Hollywood, where we (as community members) are seeking to collaborate to find “a way forward” to help a homeless individual with a mental illness. We – who usually might be a team representing a nonprofit service provider, the police, the local church, the business community – want to paint a picture of who this person is. Because of rules, perhaps, to protect the privacy of mental health “patients” in America, the clinician in the room might say something like this: “Mr. M has had some involvement with our agency, and if he wants to return to the clinic, we will provide an assessment and update a plan of treatment, if warranted.”
This is the American way. The institutional staff, by rules and regulations (not of their making, or even of their preference, I might add), operate in a silo and the community is not seen as an equal partner. (Nor is the patient or user, for that matter.) This is not to cast blame; I am merely trying to shine a light on the pre-eminence placed upon the person’s story herein Trieste.
For example, during the last two days, visiting other service sites here in Trieste and a neighboring city, Udine, this is how I am introduced to two users:
The resident cat at the front gate to the REMS facility - an alternative to the state forensic psychiatric hospitals that were all closed in 2014. This is where Rafael currently lives. Notice that the gate is open. The front door is open. There are no bars on the windows or barbed wire. There is a video surveillance system. It is located in a residential neighborhood and in the summer, they hold outdoor movies in their garden for the community.
In the jail diversion program in Trieste, we meet Rafael, a man in his 50’s, who had been in the forensic hospital ten years ago, because of a tendency toward violent outbursts, sometimes directed to his family. He has been diverted now to a fairly new program in Italy, REMS, for therapeutic rehabilitation in a community-based, unlocked setting. (Law 81/2014, which created REMS throughout Italy, led to the permanent closure of six forensic hospitals in 2014.) As a member of the team tells me about Rafael, he says, “Rafael is the oldest of five children, but from a very young age, his father did not recognize him as the oldest son (il primogenito), thus contributing to a sense of failure and shame which has haunted him his whole life.” The family is very wealthy, and he desperately wants to return to be with them, but they have rejected him. The team is working to stabilize his circumstances, and ultimately find a different place to live.
The team at the community mental health center at Udine North
At the community mental health center in Udine, I am told about one of their longest residing guests (more than a year) and a particularly complicated situation. Antônia, in her early 20’s, is the daughter of a woman who arrived from Brazil many years ago to work as a prostitute. When Antônia was 14, her mother brought her to Udine to force her into prostitution to help make ends meet. The trauma of that experience may explain the “Lorena Bobbitt” crime she committed after meeting a young man at a disco. This put her on the wrong side of the law, and after serving time in jail, she has ended up in the community mental health center. Because it is not safe to return her to the mother, the staff team has been searching for family members in Brazil who might want to help. Serendipitously, on the day of my visit, one of the young psychiatrists was able to show her a letter which had just arrived from her brother, a priest in Brazil, who is willing to help arrange for her safe return.
“In other words, the active participation of users and their families, their role as real ‘players’ in the process, and the involvement of the community as a whole, can represent a fundamental resource in the search for alternative solutions to the problems of mental distress through the integration of formal and informal networks, and by making the ‘space’ of the mental health centre a place which produces resources and opportunities for recovery…”
Deinstitutionalization In Italy: Between Ethics And Politics
M. Colucci, B. Norcio, C. Sindici 2001
These are just two of a dozen stories I’ve heard – and any psychiatric intervention (which is occurring, don’t get me wrong) seems to be the least discussed item in a plan to help people move forward with their lives. Like a theme I described in an earlier blog, the psychiatrists and the entire team are working more as human problem-solvers to help restore the user of their system back to a place where they can live their life
If I maybe so bold as to suggest that we naturally were drawn to this type of human problem-solving as a small team of us approached the best way to help the Hollywood Top 14, back in 2013. We were not psychiatrists or clinicians. We were “lay-people” with a sincere desire to find the best path forward to gain the trust of someone and move them off the street. Because there were not community mental health centers, as in Trieste, sometimes the only and best option was hospitalization or a conservatorship, to save someone’s life.
By human instinct, we were drawn to find out as much as we could about the person: where they were born? What could they tell us about their family life. Were there relatives we could contact? When and why did they become homeless? How did they end up in Hollywood? What do they like to eat? To do? We would create our own set of crude “case notes” complete with a photo, so we could identify them when discussing a plan.
Watching this play out in front of my eyes here in Trieste, I feel somewhat vindicated that we stumbled upon an approach which was grounded in the simple fact that it is important to understand “Who. Is. This. Person?” This turns out to be a cornerstone of the Trieste model.
Grateful to psychiatric nurse coordinator Alesandro Norbedo who took me on a tour of REMS and answered all my questions!