We’ll catch you if you fall

As the theme song opens for Mad Men, there is that silhouette of the man in a free-fall.   Who is there to catch him?  To rescue him?  It is a haunting image of being alone in the world.

Its 2 p.m. at at each of the community mental health centers throughout the Friuli-Venezia Giulia region of Italy, and all the staff gather to talk about how to serve the users of their system. Every day. This may not be the case in the rest of Italy, but this team approach is critical to the success of the system in this region.

I’ve witnessed now, four different times, a human safety net that exists here in Italy that is intended to catch that silhouette in a free-fall; or prevent that free-fall from happening in the first place.  It is the meeting that happens in every Community Mental Health Center in this region at around 2 p.m. every day of the week.  All the workers in the center gather to discuss what is going on with not only the guests who are temporarily staying in the Center, but also those users who have surfaced as current concerns. 

At the 2 p.m. team meeting, even the person responsible for answering the phone is included – because no one is excluded from knowing the users or having a suggestion

I used to wonder, in the American mental health system, “who feels accountable?”  Who feels accountable for that person who is lonely and abandoned by their family in a board & care home, or the anonymous person we see wandering the street, or for the family who cannot find their mentally ill loved one?   In America, it appears that the answer is:   no one.  Here in Trieste, and in this region of Italy, the accountability is felt by the staff of the community mental health center – from the psychiatrist to the person answering the phone.

I am becoming aware that the citizens of Trieste and the neighboring cities may not fully appreciate how significant is this safety net.  (As Joni Mitchell sang in her song Big Yellow Taxi, “you don’t know what you got till it’s gone.”) I also suggest that we in America can make a greater effort to embrace this accountability.  There are three key ingredients that need to be cobbled together to try this in America:

  • First, it must be a team effort.   Here, one single person has not been relegated to carry the weight of the world on their shoulders because of a particularly difficult case.    A name is offered up at a meeting, and everyone who has something to offer is free to speak. The human response is una responsabilità condivisa – a shared responsibility.
  • Second, the staff at the Center has access to (and has cultivated) a vast array of external resources in the community that can be called upon to help.  Those resources could be family, neighbors, friends, co-workers, the social cooperatives, the non-profit associations,  the police – whoever has a relationship with that person.
  • Third, there is no burden to draft meeting minutes, or case-notes to accompany every person that is discussed.  It is a conversation and if an agreed-upon strategy, once executed, doesn’t work,  they will try again at a future meeting.  Case notes are kept for appointments and particularly significant contacts with a user, but otherwise, the paperwork burden is exceedingly light.

So, for example, yesterday I spent the day at the Maddalena Community Mental Health Center.  It is a beautifully remodeled four-story center located in a historical brick building, built in the 1800’s.   I spent a few hours with Dr. Francesca Bertossi and a young university student studying to be a psychiatrist, Francesco Aretusi.   

Dr. Francesca Bertossi and medical student Francesco Aretusi at Maddalena Community Mental Health Center in Trieste

I met a man staying there temporarily as a guest – Fabio.  At 70 years of age, his participation in the mental health system in Trieste dates back to the time of Dr. Franco Basaglia.  His mother was severely mentally ill, and his father took his life when Fabio was about 30.  This may have contributed to the original onset of his psychosis.  He was a current guest of the Center for a short time because of recent manic-related crisis and conflict with his wife, who is also a user of the system.  He gave me a flower

In keeping with this “know-the-whole person” approach toward psychiatry, Dr. Bertossi told me a story about a user of their Center who has grown increasingly withdrawn and isolated.  In America, there would be little attempt to reach out and figure out what is going on – arguably, the pressures of American caseloads, the way they are currently configured, may preclude this. But, in this case, it exemplified how being proactive with the “falling man” may prevent a crisis down the road.

This particular man, Marco, who has been a user of the Center for 25 years, lives alone and comes to the Center twice a month for an anti-psychotic injection.  However, for the last three years, he has grown more isolated, stubborn and lax in his self-care.   He will not allow anyone to touch him, so this makes it impossible to provide even the most basic medical treatment, such as a lab test or blood pressure reading.  He lives in government housing, and though he has access to funds, he has for three years refused to pay for heat or hot water (even during the cold Trieste winter) and his nutrition is poor, so his health is deteriorating, and he has lost his teeth.   

At Maddalena, they have had a long history with him.   If he stops taking his medications, he may resort to experiencing delusions of persecution and this has resulted in several brushes with the law, especially during the 1990’s.    They have had to result to compulsory treatment on a couple of occasions.

As Dr. Bertossi suggested, “he is our most difficult story.”  So, in the spirit of relentless problem-solving, which is what the psychiatrists and their team do in Trieste, they decided to make a specific effort to have him meet with two psychiatrists every two weeks when he comes for his injection.  The end game is to bring him into the Center to stay as a guest for awhile, in order to re-engage with him and reduce his social isolation.  In the meantime, the short-term strategy involves encouraging him to take a shower.

As is the case in other stories I have shared, they will not give up on Marco.  It is not an option.

In the afternoon group meeting, nearly 30 minutes was devoted to problem-solving around two current situations that have captured the attention of the staff.  One involved a 23-year old man who has, in a sense, been left to his own devices by his parents who have divorced.  He and his sister, who also suffers from schizophrenia, live alone.  The plan is to help the young man find a supported-work opportunity, but the group also felt it was important to attempt to re-engage the parents to accept some responsibility for helping in this situation.

The 2 p.m. meeting with full participation, including that of Dr. Matteo Impagnatiello, who leads the Maddalena Center. It is a multi-generational and multi-disciplinary huddle.

In another case, the parents of another young twenty-something man are calling the Center every day because they are concerned that their son is using drugs.  It is a complicated family dynamic (as most seem to be) and what the staff notices is that the parents would prefer to shift the responsibility for parenting to the Center, to remove the burden from their shoulders. 

I will write more about this family angle in another blog – as I see many instances where the staff of the Community Mental Health Center finds themselves engaging with the family as a system.

But in the case of each of these stories from one day at Maddalena – Fabio, Marco and the two young men in their twenties – I saw evidence that there is a group of people stubbornly persistent in their collaborative commitment to prevent a free fall into crisis.  If I lived in Trieste, I would find that enormously comforting.

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