I have previously written that the United States is the worst place in the world to have a mental illness, while Trieste is the best.
We are the worst because we so badly underfund treatment, recovery, and housing programs for people with severe mental illness.
The result: 350,000 in prison; 250,000 homeless. Life in prison when you are mentally ill is unimaginably horrible—long and repeated stays, high risk of solitary, physical and sexual abuse. Usually the "crimes" are nuisance and avoidable—our mentally ill patients wouldn't be prisoners but for neglect.
Trieste is the best because it cares about people with mental illness and treats them like people. The emphasis is on social inclusion, providing decent housing, a job, friends, dignity—a secure place in society.
Trieste sounds too good to be true, but it is true. I didn't believe its reputation until I twice visited Trieste and absorbed its lessons. And I have also seen the same model working well in many other parts of the world, where society treats the severely ill like people, not outcasts.
Everyone I know who has visited Trieste leaves with the same uplifting feeling about it and the same deep sadness that we are so terrible.
We are fortunate to have an especially eloquent description of the U.S./Trieste comparison made by a recent observer who brings her fresh eyes to it. Kerry Morrison manages a business improvement district (BID) on Hollywood Boulevard, a position she has held for 20 years. Los Angeles is the homeless capital of America, and years ago, Morrison formed a coalition of private and public sector partners to work together to help get people off the street. About four years ago, it became evident that there was a very small cohort of the homeless population that remained living on the streets, despite everyone's best efforts. These individuals were severely mentally ill, and some had not moved from the general vicinity for decades.
That led her to the creation of the Hollywood "Top 14" list in 2013, and the tracking of case studies to document what it takes to help people with severe mental illness. Kerry was chosen as a 2016-17 Stanton Fellow by the Durfee Foundation, which supports her inquiry into this issue. Hence, her trip to Trieste and Geel, Belgium to bring home ideas on how we can do better in Los Angeles and all around the country.
Kerry writes: "In the space of one week’s time, my feet were planted in two places on earth where people with severe mental illness are treated radically differently.
On Friday June 16, I had an opportunity to tour LA County Twin Towers jail, where approximately 4,000 mentally ill inmates are incarcerated. One week later, I arrived in Trieste Italy. My intention was to learn about the Trieste Way; reforms initiated by Dr. Franco Basaglia in the 1970s. The contrasts between Italy and America are stunning.
As I explored the streets of this beautiful city, I did not see homeless mentally ill people huddled in doorways or walking down the streets barefoot, in ragged clothes, talking to the wind.
At home, every day, I see tourists who have traveled a long way to see our Walk of Fame and they are confused by the inhumane way vulnerable people are left to fend for themselves, homeless on our streets.
My heart breaks and I am humbled and embarrassed for our country.
Trieste closed its mental hospital in the 1970s and built a robust network of community clinics. No such safety net of community support exists in Los Angeles.
At the community center in Domio, where Dr. Tommaso Bonavigo works, they are responsible for an area that includes about 1,300 patients and they have six emergency beds available 24/7.
It is apparent that the staff in this system have been acculturated to serve the whole-person, a Basaglian tenet. Bonavigo explained that to truly help a person, you must know about their background, their family, their likes and dislikes.
Perhaps the people in Trieste are not as sick as those we see in LA? To test this, I asked the doctor to tell me the story of a “difficult” patient. As he told me the story of Bianco, a mentally ill, illiterate man in his in his early 60’s, I kept inventory of the contrasts between the Trieste model versus Los Angeles.
Bianco was living alone in a house he had shared with his mother, who passed two years ago. Due to the malodorous condition emanating from the house, neighborhood complaints reached Bonavigo at the center. First difference: The police were not the first responders.
Bonavigo described a relentless process he undertook to connect with Bianco, who had a routine of leaving the house all day and wandering the town. He made at least 15 visits to the house. Second difference: The psychiatrist actually leaves the office to meet the client where they are.
Eventually, he resorted to an official authorization for an “involuntary visit” which would require the presence of a magistrate. Third difference: He does not give up, and even in this place which most defends patient freedom, common sense allows infringing on it when patient welfare comes first.
Bianco was offered a temporary room at the center and the staff began to engage with him. Fourth difference: There is no temporary place to house someone like Bianco in Hollywood.
The staff found family members; a surviving brother and nephew willing to come back into the picture. They engaged the services of an intermediary who will help to manage his money—and pay off the considerable debt he has incurred to local utilities and various pubs in town. The house will be cleaned so he can move back in, but the team is talking to the family about the wisdom of moving Bianco into a smaller house. Fifth difference: Families are welcomed in case conferencing, if they are willing to engage. If not families, the mental health system in Trieste will turn to caring friends. There does not appear to be a HIPAA firewall here.
Finally, when Bianco moves home, he will be encouraged to come to the center daily—and he is building relationships there now. Sixth difference: There is no regular place of engagement or community support for mentally ill people in our city. They remain isolated and alone.
In Los Angeles, Bianco’s situation would likely place him on the downward spiral to homelessness. I know this because I’ve seen elderly people left to their own devices on our mean streets. I remember one man, Helmut, 79 years old, living on a bus bench in front of Hollywood High School. He had been evicted from an apartment he lived in for over 40 years. He was a hoarder and suffered from some type of mental disorder. If only the landlady could’ve called a place like the center before evicting him.
Los Angeles and Trieste may be separated by thousands of miles and political and cultural differences, but we share the obligation to care for those who are vulnerable in our communities. In the U.S., let’s shift responsibility from our police to mental health professionals, stop hiding behind HIPAA, and invite family and community into planning for a better quality of life for those who suffer from severe mental illness.
Thanks so much Kerry for your detailed and distressing comparison.
The title of our piece, "Shame Of The Cities," is borrowed from Lincoln Steffens' muckraking book written in 1904. He was describing big city corruption promoted by "big business men" and tolerated by ordinary citizens who were passively allowing it to continue. His goal was "to sound for the civic pride of an apparently shameless citizenship," to make people aware of the problem, and to stimulate a public sense of responsibility for solving it.
The fight to provide adequate care and housing for the mentally ill needs a similar push back against complacency. It has many fronts. While Kerry Morrison is leading the charge on the streets of LA, advocates for the severely ill are actively trying to shame us into correcting their plight on the national level—continuing in Lincoln Steffens' muckraking tradition.
Housing First is a crucial effort to end the back-alley life suffered by many with mental illness.
The correctional system has become a strong advocate for better mental health services. It makes no sense for cops to be first responders and prisons to be our nation's biggest providers of psychiatric services.
Everyone should follow the website of the Treatment Advocacy Center led by Fuller Torrey.
Everyone should read "Insane Consequences" by DJ Jaffe.
The American Psychiatric Association and the American Psychological Association have been late in making the plight of the severely ill their first priority, but have been more active in recent years and will hopefully be even more committed in the future.
The National Alliance On Mental Illness, a valuable grass roots organization started by families, would be even more effective if laser focused on getting patients out of prison and off the streets.
The advocacy movement has recently achieved a great success with the passage of the "21st Century Cures Act" which contains many provisions to end the federal neglect of the severely ill.
And the appointment of a new Assistant Secretary of Mental Health promises to coordinate efforts that were previously poorly targeted and very disorganized.
But all this is gravely threatened by the greedy and cruel Trumpcare bills being rushed cynically through Congress. Their goal could not be more wrongheaded- to drastically cut Medicaid, essential to the mentally ill, in order to provide a massive tax cut for the rich.
Trumpcare would further shame America, not make it great again. Everyone who cares about the mentally ill must make themselves heard before it is too late.
Franklin Delano Roosevelt said it eloquently 80 years ago when our country was much poorer and in a deep economic depression: "The test of our progress is not whether we add more to the abundance of those who have much, it is whether we provide enough for those who have too little."
He was following the tenets of Jesus Christ, who preached: "Blessed are you who are poor, for yours is the kingdom of God." And Jesus warned people like Trump, the Koch brothers, and their flunkies in Congress: "I tell you the truth, it is hard for a rich man to enter the kingdom of heaven. Again I tell you, it is easier for a camel to go through the eye of a needle than for a rich man to enter the kingdom of God."
Blessed are those who care about the mentally ill. Cursed are those who neglect and consign them to dungeons and back alleys.