What Los Angeles Can Learn From Trieste, Italy About Homelessness

Roberto Mezzina - Integrated University Health Service Trieste, Italy · Department of Mental Health / WHO Collaborating Center for Research and Training. Consultant psychiatrist, head of service
Roberto Mezzina - Integrated University Health Service Trieste, Italy · Department of Mental Health / WHO Collaborating Center for Research and Training. Consultant psychiatrist, head of service

As talked about previously, Los Angeles is grappling with a homeless crisis. The city has an increasing number of people sleeping in abandoned buildings, on the street, or other places not meant for living. 

At a time when many American cities struggle with just how to deal with homelessness, there is one Italian city that seems to have an answer. Trieste is a port city located in the Northeast region of Italy very close to the Slovenia border. This is a beautiful city that has virtually no homeless.

In the U.S., there are more people with severe untreated mental illness living on the street than receiving treatment in hospitals.

The reason why Trieste has hardly any people living on the streets is because of its mental health system. Trieste’s unique model of mental health has been recognized by the World Health Organization (WHO).

So, what does mental illness have to do with homelessness? The answer is — a lot. Mental illness is a major risk factor for homelessness. The largest survey on homelessness found that forty-five percent of those who are homeless are diagnosed with a mental illness of some kind. In fact, in the U.S., there are more people with severe untreated mental illness living on the street than receiving treatment in hospitals.

Trieste, Italy has a unique model of mental health treatment that helps support those with mental illness. This helps keep the rates of homelessness very low. Back in the 1970s, Italy passed a law targeting mental health reform. This legislation is called the Basaglia Law. This law paved the way for state mental hospitals to close and for residents to receive community-based mental health services instead.

In 1980, Trieste closed its 1,200-bed asylum. The city created a community-based system of mental health care to help integrate people back into the community. The goal of this move was to protect human dignity and give mutual respect to people who have a mental illness.

In Trieste, psychiatrists and other mental health workers provide community-based care to people with mental illness. They are the first to the scene when a mental health crisis takes place. Mental health workers leave the office to connect with clients.

There are no locked institutions in Trieste. There are only a handful of psychiatric hospital beds in Trieste and they are in unlocked wards. Involuntary hospitalization is rare.

Residents of Trieste who suffer from severe mental illness and need more support live in home-like group homes. They are treated with respect and encouraged to participate in the community. The focus is on social inclusion and support.

The mental health system in Los Angeles has been referred to as “broken” and “struggling.” The good news is that Los Angeles has recently begun collaborating with the Trieste system to see how the struggling mental health system in L.A. can be fixed.

A recent report on the Trieste Project in Los Angeles highlights several things that contribute to the difference in outcomes between Trieste and Los Angeles. There are major differences in reporting requirements, as well as how mental health care is financed.

Although there are community-based programs in Los Angeles and elsewhere in the U.S., they are riddled with bureaucratic requirements that interfere with efforts to provide recovery-based care. In L.A., Providers spend 25 percent of their time documenting services to meet medical necessity. Outcomes are not the main focus. While in Trieste, mental health staff providers are free to focus on delivering care instead of paying attention to an endless amount of paperwork. That is large because of the way services are funded in Trieste. 

In L.A., mental health funding is based on the quantity of services provided, while in Trieste, funding is driven by outcomes. This is a true recovery-oriented system of mental health care. It may be time for California to try something new and shift the focus to a recovery-informed model of reimbursement. This will help reduce the number of unhoused residents — just as it did in Trieste.


References:

  1. https://mentalillnesspolicy.org/consequences/homeless-mentally-ill.html
  2. https://www.ncbi.nlm.nih.gov/pubmed/30394406
  3. https://calmatters.org/explainers/breakdown-californias-mental-health-system-explained/
  4. http://file.lacounty.gov/SDSInter/dmh/1054552_TriesteConceptPaper-4-18-2019FINAL.pdf

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