What Would Basaglia Do?

This virus is the great equalizer, spreading through the earth with impunity and not discriminating as to wealth, class, ethnicity and even age.   We are humbled by our shared human condition now.     How we respond, however, differs based upon cultural, political and historical predispositions.    Continuing my communications with our friends in Trieste, I am focusing this blog on how even their special approach to serving people with mental illness may be compromised in this pandemic.

To set context, I was impacted by a blog posted by a professor at the American University of Rome.  My daughter attended the school for one semester in 2013 and that is how I became connected from afar with Dr. Lisa Colletta. 

This is the Italian version of “stay at home.”

Dr. Colletta offers a perspective on how Italians view a challenge like this different than Americans.  She points out that Americans may be struggling at this time with “disappointed ideals.”     She introduces the notion of “American exceptionalism,” in which we operate under the impression that “it can’t happen here and if it does we will handle it better than anyone else does.”  (Sound familiar?)

On the other hand, “Italians mostly believe ‘it will happen here and when it does, the response will be chaotic.’”   As a result, “a deep-down awareness of this historical truth has made Italians resilient in the face of calamity.”

She speaks about the “historical soul of Italy” that helps people live through problems.  Dr. Mario Colucci, a psychiatrist in the Trieste system, wrote to me describing this this social phenomenon that we’ve all seen played out on social media, “There are gestures of solidarity, it happens that young people help old people to avoid exposing themselves and to keep them at home. In the evening at 6:00 P.M. spontaneously from the balconies of the houses people start playing or singing to make the sense of community feel alive and to thank the medical and nursing staff who are sacrificing themselves in the hospital.”  (With thanks to Google Translate.)

But my friends in Trieste are concerned about the people they serve in the mental health system under the national mandate to shelter in place.  The very principles that the World Health Organization (WHO) has lauded, and we have admired – the hyper-attention to social connection and tending to the needs of the whole person – are strained in the wake of mandatory social isolation.    Dr. Francesca Bertossi says that her community mental health center remains open but “the activity is reduced.”   She adds, “many patients are disoriented, scared and lonely.”   And if this is happening in Trieste, one can only imagine how this has become so very much worse in the United States, where we struggle to address one’s sense of being disoriented, scared and lonely even in the best of times.

Last week, Dr. Roberto Mezzina copied me on a missive he sent to a number of  world mental health thought leaders where he reflected on the way in which mental health care is placed “at the bottom of health priorities,” even in Italy, which has a system we envy.    It was published also in Il Piccolo (as seen as the header to this blog.  The headline is translated as: “We defend and adapt services:  is mental health a priority?”).  With the absence of personal protective equipment and disinfectants, “the relationship, the main instrument of therapy and also of assistance in mental health, cannot be used freely and directly.” 

He also shared a review of the literature published by LANCET just last month called “ The psychological impact of quarantine and how to reduce it: rapid review of the evidence.”   This provides a glimpse into the longer term impacts we might expect to see as we continue in the quarantine state and gradually emerge therefrom.

The executive summary suggests:

Most reviewed studies reported negative psychological effects including post-traumatic stress symptoms, confusion, and anger. Stressors included . . .  infection fears, frustration, boredom, inadequate supplies, inadequate information, financial loss, and stigma. Some researchers have suggested long-lasting effects. In situations where quarantine is deemed necessary, officials should quarantine individuals for no longer than required, provide clear rationale for quarantine and information about protocols, and ensure sufficient supplies are provided. . .

Dr. Tommaso Bonavigo who works in the Domio Community Mental Health Center sent me a photo from last week.  This is a center where, during my visit last year, the sense of accoglienza or radical hospitality was so palpable that as one walked in the front door, it was hard to tell who were the users and who were the staff.  Yet now, because of the importance of controlling access, he found himself parked in the reception area signing people in, something not typically done.  Behind him was a poster with a phrase attributed to Dr. Franco Basaglia, Se un’istituzione viene gestita dal suo personale in maniera chiusa; mentalmente e praticamente l’istituzione  è chiusa; se fa l’opposto,  l’istituzione si apre.

Where Dr. Bonavigo sat as he logged in users at the community mental health center; not the usual practice. Then he noticed this poster directly behind him. The translation is: “If an institution is managed by its staff in a closed manner; mentally and practically the institution is closed; if it does the opposite, the institution opens up.” Franco Basaglia. Lessons/conversation with nurses on leave from Trieste. 1979

Tommaso texted me via What’s App, feeling as though he was betraying the vision of Dr. Franco Basaglia.  I counseled him back.  “Basaglia,” I texted,  “never could’ve anticipated a global pandemic.”  But it does beg the question:  What Would Basaglia Do?

And, now as the situation grows more dire in Italy, the community mental health centers are largely empty.  It is just hard to imagine how people are faring.  We will know more when we come out of this collective cave.   

Public information published by officials in Nigeria. How to stay mentally healthy in self isolation.

Dr. Duccio Papanti from Trieste sent me a link to an international Facebook page recently created that already has over 1,200 members, Mental Health During the Coronavirus.  There you will find people from all over the world collaborating on how to embark upon telepsychiatry to connect with their isolated patients, how to screen for depression and anxiety among hospital staff along with many other current topics.  A global network is being created that will likely outlast this crisis.

Finally, my friend Ms. B, whom I met last year at L’Una è L’Altra, the woman’s association that provides a daily source of connection and purposeful engagement for women in Trieste (which is sadly now shuttered), is feeling quite isolated and hindered from her aspirations to move on with her young life.    She writes, “I finished my studies last November getting the highest score in every exam,” but starting her career is now placed on hold.  She says, “The most common question – no matter who you are: young, old, man, woman, a popular singer, a famous football player or an ordinary person – is just ‘When will everything be normal again?’”

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