The Trieste model: deinstitutionalisation done differently

In 1971, a young Italian psychiatrist named Franco Basaglia took charge of the psychiatric hospital in Trieste, a port city on the Adriatic. The hospital, San Giovanni, housed roughly 1,200 patients, many of whom had been there for decades. Basaglia did something unusual for his time: he believed that almost none of them needed to be there at all.

Over the following decade, he and his team gradually closed the hospital, transferred patients to small community residences, and built a network of 24-hour community mental health centres across the city. By 1980 the asylum was effectively shut. The Trieste experiment became the model for Italy's Law 180 (the Basaglia Law) of 1978, which closed all of Italy's public psychiatric hospitals and required regions to build community-based services in their place.

What the model actually looks like

Today, Trieste is a city of about 200,000 people and operates four Community Mental Health Centres (CMHCs), each covering a defined catchment area. Each centre is open 24 hours a day, every day of the year. They serve as the first point of contact, the place where most psychiatric care happens, and a residence where people in crisis can stay for short periods without being transferred to a hospital ward.

Other elements of the system include:

• A small Psychiatric Diagnosis and Care Service in the general hospital (about six beds for the whole city)
• Roughly 25 small group homes for residential support
• Active outreach into people's homes and neighbourhoods
• Strong links with cooperatives that provide work for service users — a hallmark of the Italian "social enterprise" approach

The combination means most acute crises in Trieste are managed in the open, 24-hour CMHC rather than in a locked ward. Compulsory hospital admissions per capita are among the lowest in the developed world.

The philosophy

Basaglia's view, drawing on phenomenology and political philosophy, was that institutions did damage in their own right. The longer someone stayed in a psychiatric hospital, the more they lost the social skills, relationships, and identity that allowed for life outside. Closing the hospital was not just a clinical reform; it was a re-claiming of personhood.

The phrase often associated with the model is "The patient is not the illness." The clinical job, in the Trieste view, is to support the whole person to live a meaningful life — in their own home, with their own work, with their own relationships — even while psychotic symptoms are present.

Does it work?

Studies of the Trieste system, including work by Roberto Mezzina (former director of the WHO Collaborating Centre for Research and Training in Mental Health in Trieste), have documented:

• Compulsory admission rates roughly a tenth of those in much of Europe
• No public psychiatric hospital — over 40 years now
• Suicide rates among service users that are not higher than in other comparable European systems
• High levels of community integration and employment for people with severe mental illness

The World Health Organization recognised Trieste as a Collaborating Centre for community mental health and has used it as a global reference site.

What it depends on

Trieste's success rests on conditions that are not easy to replicate:

• A relatively small, geographically compact catchment area
• Stable public funding through the Italian National Health Service
• A strong social cooperative tradition that creates employment for service users
• Decades of cultural acceptance of the open-door model
• Strong professional leadership and continuity over generations

Other Italian regions have implemented Law 180 with varying success. Some have built robust community systems; others have struggled with under-funding and a vacuum where the asylums used to be. The Italian experience is a reminder that closing institutions without building genuine alternatives can leave people worse off — a lesson the United States learned painfully during its own deinstitutionalisation in the 1960s and 70s.

What other systems have borrowed

The 24-hour community mental health centre model has influenced services worldwide:

• The UK's Crisis Resolution Home Treatment Teams owe a debt to Trieste's outreach approach
• Open Dialogue in Finland shares the principle of meeting psychosis in the community rather than the hospital
• Some US peer respite and crisis stabilisation models echo Trieste's residential CMHC concept
• WHO's Mental Health Action Plan 2013–2030 explicitly calls for the kind of community-based system Trieste pioneered

Honest limits

Trieste does still use medication. People are still admitted to hospital occasionally. Treatment-resistant illness, severe agitation, and dangerous behaviour are still encountered. The model is not anti-psychiatric in any meaningful sense — it is anti-institutional, which is a different thing.

For families and clinicians studying Trieste from elsewhere, the lesson isn't to abolish hospital beds but to invest in 24-hour community alternatives that can absorb most of what would otherwise become an admission.

What it means for someone with schizophrenia today

Even if you live somewhere with no Trieste-style service, the underlying principles are worth carrying with you:

• Community settings are usually preferable to hospital settings when safe
• Continuity with the same team matters more than admission to any particular building
• Work, relationships, and ordinary life are not luxuries that come after recovery — they often are the recovery

This article is for educational purposes only and is not medical advice, diagnosis, or treatment. Always consult a qualified mental health professional. If you or someone you know is in crisis, call or text 988 in the US, or your local emergency number.