Mental illness haunts me in two different ways. The first surrounds me, living and working in Los Angeles, California, daily. When I see people half naked, lying on the hot sidewalk on the way to the trendy new coffee house. When I meet parents searching for their missing adult children and being turned away by agencies who can help—but will not—because it would be a “privacy violation.” When I hear of people with untreated mental illness finding themselves locked in claustrophobic jail cells and chained to furniture for the few hours a day that they are allowed out to ensure they do not harm themselves or someone else.
The other haunting also takes place here in Los Angeles, but is a product of my travel to Trieste, Italy, “the city that cares.” In Trieste, none of these tragedies exist—and that fact haunts me, in a good way. Recognized by the World Health Organization (WHO) as demonstrating a global best practice in community-based mental health care, grounded in accoglienza (the Italian word for hospitality), Trieste is a north star for the world.
Ever since I first witnessed the human-centered system in Trieste in 2017—and I have visited five times now, first on a fellowship and later as an observer for an entire month—I am more convinced than ever that my own city, Los Angeles, is capable of moving toward a true community-based system of care. That is, if we have the political will.
The current American mental health care system dates back to the 1960s, when the vision to close the mental institutions in the U.S. and build out a community system of care was gaining traction. From L.A. County, we can see clearly the through-line of the abandonment of this vision. After President John F. Kennedy called for a community-based system of care in the U.S. in his last major policy address in 1963, a gradual devolution of authority from the federal government to the state and now to the 58 counties followed, culminating in the 2011 elimination of the California State Department of Mental Health. This moment served as a capstone to the withdrawal of direct responsibility, or accountability for, mental health care from the state.
California is not alone in this downward slide. Today, America’s mental health system is fragmented, built upon clinical interventions, and tied to a reimbursement system that pays for some useful things but ignores all the life needs of a person in crisis.
In Italy, I discovered, this same story played out differently. Like the U.S., Italy was involved in the mid-20th-century movement to bring an end to the horrible conditions in asylums and institutions. But unlike the U.S., Italy had a visionary psychiatrist who started a revolution in his country around mental healthcare that persists to this day.
As a young psychiatrist, Dr. Franco Basaglia railed against institutional life, influenced by his World War II imprisonment as a member of the anti-fascist resistance. When he was assigned to head an asylum in the town of Gorizia (in the same province as Trieste) in 1961, he was horrified by the conditions he witnessed. As documented in the excellent book The Man Who Closed the Asylums, Basaglia initiated radical changes that flew in the face of conventional “treatment.”
Here are just a few measures he put in place: outlawing restraints, unlocking the wards, instituting meetings between patients and staff, and requiring that the doctors shun their white coats.
By the time Basaglia moved to Trieste’s asylum in 1971, his “democratic psychiatry” movement was gathering momentum. Basaglia and his supporters promised recovery for mental patients and pushed for measures to reintegrate people back into the community, where they could connect with family and friends and find meaning through work.
But he didn’t stop there. In 1977, Basaglia moved to close the asylum in Trieste, and the following year the Italian Parliament passed Law 180, known as Basaglia Law, which formally led to the dismantling of the asylum system throughout the country.
Italy’s community system of care—and the local mental health centers that anchor it—continues to focus upon treatment, recovery, and prevention today. But what struck me most about what I observed in Trieste was a culture that allows people to be treated with human kindness. I was particularly taken by the city’s emphasis on supporting a person’s life aspirations. Trieste’s community mental health program does not define people by their mental illness; they understand that a diagnosis is just one piece of information. Housing is integrated into the program, ranging from independent living to supportive family-style arrangements with 24/7 staff support. In a crisis response situation, community mental health center staff steer people away from the trauma of hospitalization, or worse, incarceration, through short-term housing in a home-like setting managed entirely by peers. Peers play a significant role in the entire system, offering support and the wisdom that can only come from lived experience. The community mental health team also connects people to clubs, associations, and social cooperatives that help them find employment appropriate to their skills and capabilities.
The current situation in California couldn’t provide a starker contrast.
I have yet to meet a person or a family member who can describe a successful story of moving from the onset of mental illness symptoms to treatment to diagnosis to sustained support to recovery. Instead, they find themselves stuck in a system (or rather, a non-system) built upon clinical interventions, tied to a financial model that emphasizes symptom management but ignores the longer-term life needs of a person in crisis.
Other solutions are available to us. In a podcast interview I conducted with Guyton Colantuono, executive director of Project Return Peer Support Network, we discussed the peer respite center, a cost-effective, trauma-informed alternative to hospitalization or jail. He explained that it costs $840,000 per year to run a 12-bed facility—which averages out to $295 to $368 per client, per day. By contrast, it costs $2,200 to spend a night in the emergency room of a typical hospital. Yet there are only two peer respite centers in all of L.A. County.
The guiding principles that are so evident in Trieste don’t require a secret handshake to unlock here. It will take the unwavering focus on the needs of the whole person—not just clinical interventions. A commitment to hold systems accountable to people and outcomes—instead of protecting the institutions. A culture shift to practice radical hospitality—as opposed to adhering to positional authority and power dynamics. A belief in every person’s ability to recover and the right to pursue a purposeful life—as opposed to writing off the hopes and dreams of a person with a mental health diagnosis. And a community ethos to foster social inclusion, and eschew marginalization and isolation.
This movement for change will require involvement at all levels of government—local, state, and federal. Some might say that is impossible to enact Trieste’s ethos of care here. But I would counter that it is immoral not to try.