Most tourists visiting the northeastern Italian region of Friuli-Venezia Giulia would never think to visit Monfalcone, a small town along the Gulf of Trieste just a few kilometers from the Slovenian border. The town is charming and quiet, and, having only become part of Italy in 1918 after more than a century under Austrian control, still does not feel entirely Italian.
But Monfalcone is home to something uniquely Italian: one of the many community mental health centers (CMHCs) that comprise a world-renowned, community-based mental health care system. This system, often referred to as the “Trieste model,” is considered a gold standard in the field of community mental health care, and has been praised in prestigious medical journals including The Lancet and The British Journal of Psychiatry. The Trieste model is unique in that unlike the mental health care systems of most countries, including the United States, it has rendered involuntary treatment—where patients are forcibly given psychiatric drugs, restrained, placed in locked wards, or otherwise stripped of their autonomy and ability to consent to treatment—almost completely nonexistent.
Monfalcone’s CMHC is located in an unassuming building not far from the local train station. There is a large yard behind the building where service users—those receiving services are never referred to as “patients”—can sit or walk beneath the shade of ancient towering pine trees. If you breathe deeply, you can smell the faint brine of the Adriatic Sea in the air.
Upon entering the building during my visit in April 2024, the first thing I noticed was the absence of the traditional markers of an institution. There are no uniformed security guards, no doctors in white coats, no locked doors. It felt more like a community center than a mental health facility. Service users walk around freely, coming and going as they please. No one was restrained, tied down, or locked up. When I first arrived, I found it difficult to tell service users from staff; as the CMHC’s director, a psychiatrist named Dr. Giovanni Austoni, later told me, this was intentional, a central part of the mental health care ethos in Trieste and the neighboring province of Gorizia.
I initially wanted to visit a Trieste-modeled CMHC because it seemed to represent a stark departure from the way many American states and cities have turned toward increasingly coercive and outright involuntary models of mental health care in recent years. In 2023, California passed draconian legislation to fundamentally overhaul its mental health care system, establishing a plan to bring back locked facilities while lowering the legal threshold for committing mentally ill individuals to involuntary care. Meanwhile, New York City Mayor Eric Adams and New York Governor Kathy Hochul, both Democrats, have advocated, albeit with less success, for the broadening of New York’s Mental Hygiene Law to allow the state to involuntarily hospitalize individuals deemed “unable to meet basic living needs.”
Often absent from these policy debates around involuntary treatment is the fact that alternatives do exist—that the human rights-based care that has long been a reality in Trieste and throughout the region of Friuli-Venezia Giulia, where more than one million people currently live, produces some of the best outcomes in the world for people with serious mental illness. Conversely, the evidence for the efficacy of involuntary mental health treatment is lacking: Most studies indicate that it results in fear, trauma, and distrust of the system for individuals subjected to it, and increases their future risk of suicide and psychiatric crises.
I wanted to understand why the Trieste model is so often ignored in U.S. policy debates around mental health care despite its nearly fifty-year history as a gold standard community mental health system, while coercion-centered treatment models backed by little or no evidence are being enthusiastically embraced. What I found was a promising alternative to the American mental health care model—one that views mentally ill people as individuals with rights and valuable perspectives on their own lives, rather than patients who lack insight into their illness.
At a meeting of staff at the CMHC in Monfalcone, I met psychiatrists, psychologists, nurses, and social workers. No one wore an official uniform. As we left the meeting, we passed a group of service users on their way to an art therapy class. Later, as Austoni was giving me a tour of the center, we were approached by a young man, an immigrant who spoke little English or Italian, who had arrived at the center after experiencing a first episode of psychosis. Austoni told him I was from the United States. We shook hands, and he introduced me to his mother, who was currently visiting him—service users staying overnight at a CMHC are allowed to have visitors, announced or unannounced.
As described in scientific literature and the media, the Trieste model can sometimes sound too good to be true. But visiting the CMHC in Monfalcone confirmed everything I had learned about the Trieste model. Service users walked around freely, socialized with each other, and talked to staff—there were no screams of people being restrained or treated against their will, no one tied to their bed or placed in a locked room. The reality was so far removed from my observations of mental health care in the United States that it seemed like another planet. Would this young man have been permitted to walk around, let alone speak with me or shake my hand, were he hospitalized in the United States? More likely, he would have been restrained and “stabilized” with high doses of an antipsychotic drug, which could be legally administered against his will as long as the psychiatrist deemed him a danger to himself or others. The psychiatrist supervising his treatment, along with the other staff, would have power over almost every aspect of his life while he was hospitalized.
Laws governing involuntary treatment in the United States vary from state to state. New York, for example, allows initial involuntary hospitalizations of sixty days, with the possibility of extension, pending a judge’s order. In 2020, a study published in the journal Psychiatric Services and based on data from twenty-five states found an average rate of 357 involuntary psychiatric detentions per 100,000 people between 2011 and 2018, ranging from a low of twenty-nine in Connecticut to a high of 966 in Florida. In the twenty-two states with continuous data between 2012 and 2016, the average rate increased from 273 to 309. In Trieste and Gorizia, the rate of involuntary treatment is among the lowest in the world—only eight people per 100,000 are treated involuntarily every year, and restraint is never used.
Pamela Fragnoli
Graffiti on the former mental asylum in Parco San Giovanni in Trieste, Italy, reads “Freedom is Therapeutic.” This image originally appeared in the 2023 paper “A Walk to the Narrenturm in Vienna: Remarks on the Heritagization of Psychiatric Institutions” by Maria Bianca D’Anna and Pamela Fragnoli.
Advocates for involuntary mental health treatment do not seem to believe that a mental health care system with such low rates of involuntary treatment can produce desired outcomes, such as higher psychosocial functioning, faster crisis resolution, lower rates of crisis relapse, and lower rates of hospitalization and suicide. But evidence suggests otherwise. The suicide rate in Trieste and Gorizia has dropped since the implementation of the Trieste model, psychosocial outcomes and functioning are better, and a study of the region’s CMHCs from 2005 found that the crisis care provided there resulted in faster crisis resolution, better relapse prevention, and better clinical and social outcomes at the two-year follow-up. Between 1984 and 2005, there was a 50 percent reduction in emergency psychiatric presentations at Trieste’s general hospital, which has a small number of psychiatric-crisis beds, an open-door policy, and staff trained in avoiding coercion. Other studies have underlined service users’ high satisfaction in the quality and flexibility of available services.
Unlike the United States, Italy has a universal health care system that covers all Italians regardless of employment, citizenship status, or ability to pay. The health care system is publicly funded through a progressive tax model and administered by a network of regional health authorities. Mental health services are considered a part of health care and are covered by this system, with each regional health authority responsible for planning, implementation, and service delivery. The Trieste model is also far more cost effective than the inpatient system that preceded it. A 2018 study estimated that, adjusting for current expenditure levels, the Trieste model’s costs amount to just 37 percent of the cost of the asylum system that preceded it.
But the success of the Trieste model is rooted in more than just universal access to health care. While universal health care is necessary to streamline access to services, the Trieste model is also built around the idea that people with mental illness are individuals with rights and that protecting and respecting these rights is integral to better care and better outcomes.
In both Italy and the United States, the history of mental health care for those with serious mental illness is rife with abuse and abandonment. Throughout the first half of the twentieth century, psychiatric patients in both countries were housed in large asylums, where they faced horrific conditions, severe neglect, and even torture.
In the United States, a confluence of factors led to the gradual clearing out of asylums beginning in the late 1950s. Shortly before his death in 1963, President John F. Kennedy ushered in the era of deinstitutionalization when he signed the Community Mental Health Act, which promised to establish a new mental health care system centered around community-based care. But the kind of investment that was needed in community-based care never materialized, leading to a fragmented and overburdened public system with long waitlists. The United States now has some of the worst mental health care outcomes in the world: People with serious mental illness can wait more than a year to access care, many individuals can only access care while in the midst of a psychiatric crisis, and the largest providers of mental health care services are prisons and jails. What’s more, so-called care in the United States too often involves coercion or forced treatment with psychotropic medications, which frequently leaves patients traumatized and reluctant to voluntarily engage with mental health care services.
In Italy, the asylum era came to an end under starkly different circumstances, owing in large part to the work of a psychiatrist named Franco Basaglia. The son of a wealthy Venetian family, Basaglia was imprisoned during World War II for anti-fascist activities, and later became the director of an asylum in Gorizia in 1961. Basaglia saw the asylum as a place where the poor and the underclasses of society were locked away and forgotten about. Upon arriving in Gorizia, Basaglia refused to sign orders to restrain patients. Little by little, the wards were opened, doors unlocked, and walls knocked down. Patients were allowed to do things like wear their own clothes, grow their hair, and use mirrors, and, as a result, were able to reclaim a sense of self. A patient-run periodical was established, as were general assemblies run by the patients. Basaglia believed that these acts in themselves were therapeutic, a necessary step on the road to recovery.
Basaglia eventually became the director of the asylum in Trieste, which he helped to dismantle from the inside. Across Italy, the anti-asylum movement gained ground after Basaglia’s work in Gorizia became internationally recognized. During the mid-1960s to early-1970s, leftist filmmakers, photographers, and journalists visited asylums across Italy to show the country the immense human suffering, the filth and neglect, and the dehumanization happening in those institutions. Italians were shocked and disgusted at what they saw, and drew parallels to the then-recent horrors of Nazi concentration camps. A coalition of reformers and leftist politicians worked to transform institutions that they believed had no place in a modern, post-war society. In 1978, not long before Basaglia’s death, Italy passed Law 180, known as “Basaglia’s Law,” which mandated the closure of all mental asylums and replaced them with community-based care. As Enzo Quai, a nurse who worked alongside Basaglia, noted of his reforms, “It was a class revolution.”
Currently, the system in Trieste and Gorizia serves roughly 375,000 people, and is composed of six CMHCs with six to eight beds each, one small psychiatric emergency unit in the general hospital with seven emergency beds, two integrated services for eating disorders, a university clinic, rehabilitation and residential services, a residential facility for security measures, and a World Health Organization Collaborating Center for research and training. The CMHCs are open twenty-four hours a day, seven days a week. Service users can walk in at any time; there is no waitlist. If someone does require hospitalization, they are moved from the hospital to their local CMHC as soon as they are stabilized. CMHCs can also connect service users to rehabilitative community programs that focus on social inclusion, employment, and educational opportunities. The entire system is centered on moving the site of care out of the hospital and into the community.
In this sense, the Trieste model is the opposite of the asylum model that preceded it: While the asylum system removed people from society because they were perceived as a danger to themselves or others, the community-based system enables mentally ill people to live meaningful lives as part of the larger community. When I asked Austoni how the Basaglian movement was able to convince Italian society that people with serious mental illness were not dangerous or violent, he said that it was—and still is—a constant battle, requiring both immense patience and the support of a political movement.
The Trieste model embodies what Basaglia called “putting illness in brackets”—of centering the role that the service user’s social and economic circumstances and the surrounding society play in their illness and recovery. This philosophy is a stark departure from the biomedical model of mental health care that is typically practiced in the United States. While the biomedical model relies on an understanding of mental illness as a brain disease and consequently equates the person with their diagnosis, the Trieste model views the patient as a whole person, and focuses on developing a holistic plan around the needs and desires of the service user that will ultimately lead to recovery. These might include finding a job, reconnecting with family, continuing education, or pursuing a hobby. In this sense, the Trieste model views mental health care and psychiatric problems in a far more expansive way.
The Trieste model is radical in its efforts to do away with the power imbalance between doctor and patient, eschewing coercion and force for a therapeutic relationship built on rapport and connection. Austoni had come to Monfalcone from a region of Italy where restraints were still used, and he told me that in his experience, these only increased a service user’s agitation and aggression, rather than helping to calm it. “Simply by not restraining an agitated person,” he said as we walked the halls of the center, “you help to calm them, to build trust.”
While many politicians in cities and states across the United States may believe that involuntary treatment can solve our mental health care crisis, the reality is that American mental health care reformers have much to learn from the legacy of Basaglia and the Italian reform movement: When it comes to global outcomes for people with serious mental illness, the United States performs especially poorly, while the Trieste model produces some of the best in the world. Decades after deinstitutionalization, the United States continues to operate from the same paradigm of care that defined that abhorrent system.
By contrast, service users under the Trieste model can access care without barriers, referrals, or waitlists. Perhaps even more importantly, the system is based on the idea that in order to recover and lead fulfilling lives, people with serious mental illness must be treated like human beings with agency. While involuntary treatment advocates in the United States view widespread coercion of mentally ill people as a social necessity, the Trieste model proves that there is another way—that it is possible to create a mental health care system that is both effective and compassionate, that protects the humanity and dignity of individuals rather than chipping away at them. But as the Italian reform movement’s history demonstrates, this type of transformation requires both a grassroots movement and reformers working inside institutions to change them while being critical of their power.
Near the entrance to the shuttered asylum in Trieste, a painted slogan reads “LA LIBERTÀ È TERAPEUTICA”—“freedom is therapeutic.” It was a defining slogan for the Basaglian movement, one which conveyed the radical idea that freedom itself is healing—freedom from abuse, forced treatment, locked wards, and restraints, but also freedom to be a full citizen with rights, aspirations, and dreams, to live a life that is valued.