Critical AMHP Interview with Vincenzo Pasante on the Trieste Model and Statutory Practice in the UK.

By Greg Slay

Vincenzo has been a service user in Trieste as a teenager, before studying psychology and then gaining experience as a volunteer and as an intern in different services in the city. He moved to the UK in 2014 and has since worked in a number of roles, including in NHS mental health crisis services. In 2019 he started "A Place of Safety?" podcast and has been engaging in an ongoing uphill struggle to bring Basaglian ideas and practice to the UK

Alan Bristow (AB): Many thanks Vincenzo for taking the time to explore the Trieste model with us. And, especially, for bringing these ideas to an audience who might have a particularly keen interest in alternatives to our current MH system here in the UK.

Perhaps the best place for us to start is with the law itself. As you know, the AMHP role is, at root, a legal role undertaken at the precise moment whereby individuals, believed to be suffering from a mental disorder, are detained under certain sections of the MHA 1983. Can you help us to understand some of the key differences between ‘Basaglia’s law 180’ and the UK context? 

Vincenzo Pasante (VP):  First of all thank you for the opportunity Alan, there has been a lot of talk about the so-called "Trieste model" recently, but not always a lot of understanding of it, coming both from supporters and detractors. I hope this conversation will shed a bit of light on this complexity.

Law 180 technically no longer exists, as it became absorbed with minor changes within general health legislation shortly after it came into existence. Nevertheless, its principles are still the cornerstone of the Italian mental health system, in Trieste and elsewhere.

In my view, the main difference between the UK context and law 180 (to simplify) is the focus. UK mental healthcare at all levels is strongly focused on risk management. Problematic behaviours are understood and approached primarily in relation to their dangerousness. Basaglian practice frames these "risks" as the expression of a need and actively discourages "dangerousness" as the concept of reference to approach a mental health problem. Even forced treatment is not based on risk in Italy, but on urgent need and rejection of treatment.

In this way, a ward in UK mental health care will be primarily built to respond to dangerousness, whereas a mental health centre in Trieste will be built to respond to needs: locked vs open doors, no ligature points vs welcoming settings and so forth.

AB: Following our initial conversations, I understand there are some important inaccuracies, both historical and legal, often reported about the Law's implementation across Italy during the 1970’s. And that in fact, the majority of MH reform came under the previous 1904 law. 

VP: Yes, there are a number of inaccuracies that people believe. The majority of the reform in Italy as a whole happened indeed after the 1978 law, and it took until the 90's to close all general psychiatric hospitals.

This work however was based on what a number of teams and activists had been doing since much earlier around the country. In particular, Basaglia started opening up the Gorizia asylum in the early 1960's and started working at opening up/closing the psychiatric hospital in Trieste in the early 70's. The psychiatric hospital in Trieste eventually closed in 1980 but the vast majority of the work there was done before law 180 came into effect in 1978.

Basaglia's work in Gorizia, which by the way was strongly influenced by open door asylums in the UK, was done under the 1904 law. This led to some changes in legislation in 1968, still within the framework of asylum care (the Mariotti law) and eventually to law 180 ten years after that. It was therefore a change in practice that brought about a change in legislation, not vice-versa. In this respect, attempts to change UK practice by changing the law are somewhat misguided.

AB: It is clear that what constitutes the ‘Trieste model’ exceeds purely legal concerns and perhaps amounts more to a ‘philosophy’ or approach to mental health care in its entirety. With this in mind,  presumably the next question is, if it was not the law per se that resulted in such widespread reforms in Italy (and beyond) but started with practice itself, how can we incorporate such practice into the ethically complex and sensitive terrain of statutory mental health intervention today? What lessons are available to us to help negotiate the widespread ‘risk-management’ paradigm here in the UK?

VP: I think that your question hits the nail on the head. "Trieste model" is a pragmatic definition for what we are discussing, but the practice which stemmed from the experience in Trieste was a challenge to all fixed models, including itself. In a way it would be more accurate to talk about a "Trieste anti-model". In line with this, I would say that we CANNOT incorporate this approach within the current structure of statutory services in the UK. We need to look at their terrain, as your question suggests. One of my favourite quotes from The Negated Institution (1968) (the most famous book of the Basaglian movement) is, "The introduction of a new therapeutic technique within the old institutional context would be both destructive and self-defeating". Why? Because the old structure would turn everything into itself. This approach is therefore not a new technique to be applied to the old context but rather a path to a new context, which can give a different meaning to techniques.

When detractors of the Basaglia approach say that it would not be applicable to the current UK context I agree, but that is exactly why we need it in this country. I do not consider the UK context as acceptable.

We need radical change, this is what we are discussing. De-institutionalising the notice board of a psychiatric ward "Trieste-style" just won't cut it. In the UK this is particularly difficult as it is a country where change tends to be gradual, and powerful institutions tend to mask their violence very effectively. Then again, the mounting public frustration concerning the ongoing failings in the sector is a fertile ground for radical ideas, especially if the old ones keep offering the same mantras (more locked doors, more monitoring, better risk assessments) and continue to achieve uninspiring or tragic results.

The baby steps we can make at this stage involve getting informed, building networks and possibly unionise. Professionals, patients and families need to be allowed to believe that doors should not be locked, that risk management templates do not achieve safety and that there is not just one "best practice", defined by the UK mental health establishment. 

AB: I find this touches on the heart of the matter, how to practice differently or therapeutically, when the entire statutory MH system in the UK is one that is effectively underwritten by risk management. The Trieste ‘anti-model’, as you so aptly put it, is in direct contrast to the overriding ethos of MH care and treatment provided by the NHS or Local Authorities. 

But, I find it especially intriguing that the Basaglian movement and the Trieste ‘anti-model’ feel so far removed from the current British experience given that, historically speaking, Basaglia and the ‘Gorizia equipe’ drew inspiration from some of the first therapeutic communities established  here in the UK such as Dingleton, south Edinburgh and Villa 21 at Shenley hospital under David Copper, and later again Kingsley Hall, the radical therapeutic community established by R. D Laing in East London. For a country that has such a strong tradition of progressive ideas as well as alternative practices to mental health, it is curious that we seem so very far away from ‘Trieste’…  

VP: It is indeed curious. As you point out, Basaglia did not learn from some mysterious, far away culture on the other side of the planet. When you read the books edited by the Basaglian equipe in Gorizia, you go through page after page of praise for the openness of the British mental health approach of the time, compared to the abusive reality of locked asylums in Italy.

They wondered: how could Italy continue to tolerate this fascist, racist, neglectful, murderous system when Britain demonstrated that an open door/therapeutic community approach was not only feasible but so much better? Basaglians in the 60’s  were inspired by Britain, and maybe they even expected their work to be embraced by the UK. What happened instead was that British mental health care, for whatever reason, ended up almost totally disavowing what was arguably its best invention, the open door.

The divide between the Italian and British experience probably first showed when the Italian movement’s work started moving beyond the asylum and it became clear, both in theory and in practice, that the proposal was very different from merely opening the doors within psychiatric hospitals.

Sometimes this difference still gets lost in translation. Basaglia considered the open door asylum as a fundamentally patronising institution, which cared about dialectical engagement only insofar as doctors were ultimately in charge and mad people remained “safely” and benevolently ostracised from society, while still mainly being seen as a cluster of risks to be managed. Maybe that touched a nerve! Britain was immensely proud of its therapeutic communities and they were seen as a model to export, whereas the Basaglians saw them as a tool to highlight institutional contradictions and destroy the asylum model which had put them in place.

AB: Yes, exactly, there seems to be a tension here as ‘risk’ is still the overriding factor regardless of whether Asylum doors are ‘open’ or ‘closed’.

VP: Going back to (and paraphrasing) what you were saying in your first question, the AMHP intervenes in the precise moment when things get very dangerous, but the Basaglian approach doesn’t believe that a mental health professional should by default only suddenly become relevant based on risk. So what is an AMHP supposed to do?

Basaglian AMHPs and professionals more broadly may feel an almost intolerable pain in their position and need to be helped to work with it. This is what the meaning of a “negated institution” was from the start: working within rules and institutions we reject, negating them with practical actions. Basaglia had almost absolute power as director of an asylum, like every other director. This was of course beyond terrible, yet he stayed in his role and was able to use this power to undermine itself, build alliances and ultimately contribute to shape a new system. As a result, there are no longer any directors of psychiatric hospitals in Italy.

What day to day actions can an AMHP undertake which can make use of coercive institutions, rules and powers to move in a direction where they are less needed?

Sometimes I wonder if some of the most ferocious attacks by professionals on Basaglia/Trieste are a rejection of the pain that this ongoing cognitive dissonance work would involve, especially in the beginning. It’s very difficult to work in a system that one considers fundamentally and unnecessarily violent.

It’s also possible that some look at Trieste and fear that the pupils have eventually mastered their tools better than the teachers, that this is what the UK had started, should have developed further but didn’t. Perhaps this contributed to an instinctive rejection, who knows, but it is telling that whereas elsewhere in the world the Italian revolution was seen with interest and curiosity, if not enthusiasm, the UK was an outlier (only Germany went close) in being hell-bent on categorically rejecting what it had significantly inspired.

AB: With that in mind, for those of us who may want to further any interest in the Trieste Model here in the UK, where would you advise they go? Given what you say about the divergent paths between the British and Italian experience, perhaps no surprise then that the Negated Institution (1968) is still unavailable In English. Aside from these isolated experiments to ‘adopt’ Trieste models in the UK, other than your podcast, where else might we find support for such a philosophy?

VP: Currently we are at an interesting crossroads. There are 6 pilot projects based on this approach, at least nominally, in the country. I have also been involved in the “Joshi Project”, which aims at bringing the approach to Inverness, but it is struggling to get backing from the NHS.

When I started my podcast in 2019, I considered myself lucky that someone in the country had some vague knowledge of this approach. I remember my first days working in crisis care in the UK, and a colleague asking me from where in Italy I was from. When I said Trieste, they had never heard of the city, and the fact that I was from there did not strike them as meaning anything in particular.

Being a Basaglian in the UK was a very lonely experience. However, with time one action leads to another and we now have an opportunity to achieve something important. Will the current system try to co-opt these projects into itself? Of course. Will this be achieved? It will depend on a range of factors, including the training that staff get and their ability to use power against itself constructively.

The best person to speak to in the UK right now is probably Prof. Sashi Sashidharan, who has in depth knowledge of both the UK and Trieste approach, is involved in setting things up and has ongoing contacts with the Trieste environment.

Time will tell!

AB: And lastly, perhaps a predictable question looking to the future of the Trieste (anti-)model more generally. The turbulent political climates in which we are all immersed are having clear ramifications for health and social care. Trump's slashing of funds for State Health departments and his administration's vocal attacks on Autistic people, as well as Italian Prime Minister, Giorgia Meloni's direct attack on the Trieste model itself would seem to suggest that progressive, therapeutic approaches towards mental health care are definitely in the crosshairs of the populist right. I wonder what this spells for the Trieste ‘anti-model’?

VP: There is indeed an ongoing offensive against services in Trieste by the political right. This is not however a direct offensive by the national Meloni government (not yet!), it’s an attack by the “Friuli Venezia Giulia” regional government which is still right wing but another party (Lega) and has Fedriga as its president.

The right is generally quite sympathetic to psychiatric hospital systems, because the institution’s function is primarily to repress and control the danger that illness or deviance more broadly represents to the overarching societal structure. Typically, any such system tends to drift towards a mixture of brutal or benevolent repression when “the risks are high”, or neglect when a patient is “low risk”. “Therapeutic” interventions tend to be seen as the ones which control or repress symptoms as quickly and bluntly as possible. While cuts in funding are always more or less threatened in the UK system, coercion has been rising for decades, no cuts there!

The recent cuts in disability benefits by the UK (right wing?) government are an example of how the real “risk” to society is not represented by illness in itself, but by the threat that people not fitting societal standards of productivity represent to the sustainability of a system which is a significant cause of illness.

We have a fight on our hands, and it’s up to us to decide what the future will look like.

AB: Inspiring words Vincenzo. Solidarity from the Critical AMHP blog! 

Picture: <a href="https://www.vecteezy.com/free-photos/hiking-trails">Hiking Trails Stock photos by Vecteezy</a>