A psychiatrist with no office

Imagine a psychiatrist in a community mental health center who rarely sits down.  He doesn’t have an assigned office and he is always on the move. His day is “agenda free” so he can be available for whatever needs pop up in the neighborhood to which he is assigned.  This is what I observed in action today as I shadowed Dr. Tommaso Bonavigo — who was assigned the “on-call” accoglienza role at the Domio Community Mental Health Center in Trieste.

Tommaso seemed to wear several hats today – part lobby-greeter, part problem-solver, part consensus builder.  From the perspective of a lay-person, this is not what I imagine an American psychiatrist would do.  But, everything about what he did today seemed completely essential to ensuring quality care for the people in his neighborhood.

I drove to work with Tommaso this morning.  At 8:30 a.m., he debriefed with the nurses who have been there for the night. Who is in the Center?  What is on the docket for the day?  Today, Monday morning March 11, there are four guests.   In the lobby Tommaso greets several people and his warmth is infectious.

Dr. Tommaso Bonavigo available in the lobby of the mental health center on a Monday morning

We walk upstairs to visit the guest quarters.  One man is in his room, sitting all dressed on his made-up bed, with his shades still drawn.  Tommaso has a conversation with him and encourages him to come outside and participate in the community room.  An elderly woman, whose name is Maria, is there because she had a spat with her husband and ended up in the ER at the Ospedale Maggiore and then briefly in the pysch unit of the hospital (where I had been for three days last week).  A third is Franca, a long-time user, who is missing her front teeth because she was in a bike accident.  A fourth woman, Angelica, is brimming with  personality and we find her in her room standing at the window smoking a cigarette.    Tommaso has a long conversation with her and she shares a concern that the medication she is taking might be harming her memory.  

Our visit with Angelica is cut short as Tommaso is informed that there are people waiting downstairs to meet with him.  We enter a counseling room, and Tommaso introduces me as a colleague, and we all sit down.  Mr. and Mrs. Alfaro have shown up (without an appointment!) to meet with the psychiatrist-on-call that day to share their concerns about their daughter,  Stefania.   Still absorbing this language,  I can pick up words and emotions.   The parents are concerned (c’è  una problema) and I hear words that suggest their daughter is not socializing.  They both seem a bit defeated and given that they appeared to be in their late 70’s to early 80’s,  I could feel the burden of decades of care for their daughter weighing on their shoulders.

What I wrote in my notes as I listened with my heart was this:  how amazing that these parents could walk into the mental health center and talk to the doctor.  They needed Tommaso this morning – and they had his full attention!

I learned later that Stefania, who is 45 years old, only recently moved out of her parent’s home.  She has a job with a social cooperative four hours a day.  Her father drives her to her job, but they are concerned that she is not socializing with other people.   Tommaso assured them that he would have the social worker, Giulia, look into this and see what group activities she could be connected with.  There will also be a conversation with the social cooperative to see how she is doing, and Tommaso will meet with her in the following week when she comes in for her medication.

After Stefania’s parents, we drove to the Ospedale Maggiore to meet with someone who had been admitted to the psych ward from the neighborhood served by Domio.  Upon our return, Tommaso met with a young woman and her father who came in to see him (I was specifically not invited into that meeting by the woman who did not feel comfortable with the presence of a stranger, which I totally understand).

I left for lunch and upon my return, I was invited to participate in the 1:30 p.m. staff meeting where all gather to discuss the people they are collectively caring for and other common concerns.  The day was cut short by a meeting Tommaso and I had to attend at the Dipartimento di Salute Mentale (DSM) headquarters, a subject for another blog!

Daily 1:30 staff meeting at Domio Community Mental Health Center to compare notes on users they are serving in the system and problem-solve together

I was struck, today, by the seamless interaction between the Community Mental Health Center and families.  This is radically different from the custom in the American mental health system. There are benefits and drawbacks.  I believe the drawbacks can be managed because I see the benefits of family connection.    For example, today Tommaso had an email from a father, known to be somewhat controlling of his mid-40’s son, Franco.  He was upset that the staff person, assigned from the social cooperative to spend time with his son, had taken him to a bookstore, instead of on the two-hour walk that was originally planned! I was surprised that Tommaso felt compelled to respond to this complaint.

Dr. Bonavigo reading an email from the father of one of their adult users at Domio

Tommaso’s answer summed up so much about the uniqueness of this system. For the sake of the user, Franco, it was important to not sever any connections with the DSM.  The staff person who chose to take him to a bookstore needs to be supported in that decision and that relationship must be conserved, for the sake of Franco.  The father cannot be ignored, because he is such an imposing presence in the life of the son.  Tommaso set up a meeting for everyone to get into the room and discuss the situation. 

This struck me as such a brilliant, human solution.  More to follow.  I visit another Community Mental Health Center tomorrow.

Menu for a two-course lunch served at the Center for about 30 people who came to have lunch together

3 thoughts on “A psychiatrist with no office”

  1. I am loving your Trieste experience so much, Kerry! I am actually struck by the similarities in the Trieste care experience with those we have been trying to create in my public health safety net community in Contra Costa County. I have been fortunate to partner with amazing leaders who are dedicated to patient, family, and staff centered care in our psychiatric units, health centers, homeless shelters, and our detention health centers in Contra Costa. Maybe when you return to CA, we can find the time to invite you and Dr. Sherrin to Contra Costa to learn together and consider how we can spread the Trieste experience across our state. I believe it is possible.

    1. Teresa – so good to hear about the hope you have. And you should know that we are hoping to present these concepts to the oversight committee for the state Mental Health Services Act next month. It would be good for them to know that other counties are interested in a reform pilot. When our friends were here from Trieste in September, 2018, we had them introduce themselves during public comment to the OAC. I believe change is possible also and we have to build a stronger coalition and remain vigilant!

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