Trieste Model – ‘Open Door—No Restraint System of Care for Recovery and Citizenship’ – Italy

The Trieste Model is described as an ‘open door... no restraint system of care for recovery and citizenship' in the city of Trieste, Italy (Mezzina, 2014, p.440). Trieste is a city of approximately 236,000 people in the north-eastern region, Friuli Venezia Giulia. In the mid-late 20th century, policymakers in Trieste sought to transition mental health services from a clinical model based on treating illness (for example, with a focus on clinical symptom reduction), to a wider approach that focuses on aspects of their social context that can be altered to foster belonging, safety, and social inclusion.

According to Roberto Mezzina, ‘[t]he core of the organization is a network of Community Mental Health Centers active 24 hours a day, 7 days a week... with relatively few beds in each of them. The system coordinated by the [Department of Mental Health] also comprises one general hospital psychiatric unit, a network of supported housing facilities and several social enterprises. (Mezzina, 2014, p.440) The Trieste Model has been the subject of considerable research (Portacolone et al., 2015). The WHO cite the approach to public psychiatry as one of the most progressive in the world, and Trieste has been the site of a collaborating centre of the WHO for over four decades with the goal of disseminating its practices across the world (Portacolone et al., 2015).

One challenge for evaluating the evidence for specific practices within the overall Trieste Model, according to Mezzina, is that 'it has not been possible to evaluate the effectiveness of single interventions (i.e. psychoeducational, rehabilitative, psychotherapeutic) because these are interwoven in its "whole system" approach' (Mezzina, 2014, p.440). Nevertheless, there have been several 'cohort studies on patients with psychosis, family burden studies, research on crisis intervention, user and family member satisfaction, and attitude toward community care', according to Mezzina (2014, p.440). Most appear to be Italian-language studies.

Mezzina reports that '[f]ewer than 10 people per 100,000 of the population receive a [compulsory psychiatric treatment order], usually for approximately 7 to 10 days', which is 'approximately 1% of all episodes of residential care' (Mezzina, 2014, p.442). In addition, 'most of them are handled by the [Community Mental Health Centres], which have come to take over most [general hospital psychiatric unit] admissions'. In 2014, Mezzina summarised the largely Italian-language evidence base as follows:

Crisis management at [Community Mental Health Centers] also proved effective in preventing relapses and chronic courses. A national survey carried out in 13 centers showed that crisis care provided by 24/7 [Community Mental Health Centers] is more effective in crisis resolution and at 2-year follow-up, particularly when related to trusting therapeutic relationships, continuity and flexibility of care, and service comprehensiveness. A 50% reduction occurred in emergency presentation of general hospital casualty for approximately 20 years... Qualitative research particularly highlighted some major social factors connected to services and the connection between recovery, social inclusion, and participatory citizenship. Recent data suggest 75% compliance with antipsychotic medication (n = 587), a situation related to the quality of therapeutic relationship and social network enhancement. User satisfaction with services has been high right from the early years and, more recently, recorded 83% in two [Community Mental Health Centers].

Reportedly, some forensic psychiatric services 'are managed de facto with an open door policy' (Mezzina, 2018, p.340), though English-language evidence on the outcomes and precise nature of such interventions appears to be limited.

Several caveats are noteworthy. Portacolone and colleagues reviewed the implementation of the Trieste Model in the US city of San Francisco, and concluded that the success of the Trieste model appears to require a low youth population, low rates of drug use, and adequate housing with high social inclusion (Portacolone et al., 2015). Without such conditions, according to Portacolone and colleagues, it can be difficult for community-focused, de-hospitalised systems to work. Some psychiatrists have argued that it is therefore misleading to cite Trieste as an exemplar, when different cultural, social, economic and political circumstances might require alternative arrangements (Allison et al., 2020). Even within Italy, according to Carta and colleagues (2020), the principles and ideas behind the Trieste Model have been applied to varying degrees in different regions, and with extremely varying levels of success. Nevertheless, Trieste remains an important site in global efforts to reduce and prevent coercive mental health practices.