Hollywood to Test Radical Mental Health System Modeled After Trieste

A pilot study of a community-centered approach to mental health, modeled after Trieste, Italy, slated to begin in early 2021.

Gavin Crowell-Williamson
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A transformative care strategy imported from Trieste, Italy, will soon be implemented in Hollywood, according to journalist Rob Waters. Hollywood has the second-highest concentration of homeless people in Los Angeles, which itself is deeply affected by the twin pairing of homelessness and mental health neglect – 36,000 people are homeless in LA, three quarters of whom are unsheltered, and 30 percent have been diagnosed with a substance abuse disorder or “mental disorder.”

While the US system of care for mental health focuses on medical approaches, compliance, and documentation, Trieste has a more holistic approach, ensuring that all facets of life, from physical needs (for food, clothing, and shelter), to community connection and employment, are met. Roberto Mezzina, who was Trieste’s director of mental health until October of 2019, is quoted in Waters’ article as saying:

“American society has the most striking contradictions— especially Los Angeles. The system is very complicated—patchy and fragmented and existing in chaos. The jails became like hospitals, and the hospitals can become like jails. In this situation, to create a new experience and new pathway for care is not easy. It’s not enough to create a good community mental health center and then scale it up. You have to change the imbalance of power between service providers and service users.”

There have long been efforts to create access to better care for the most vulnerable and homeless. Recently, Kerry Morrison, the former director of the Hollywood Property Owners Alliance, pushed for the most vulnerable homeless residents of Hollywood, who she deemed the Hollywood Top 14, to receive better care. She hoped to create access to treatment and new shelters, which resulted in a search that unearthed Trieste.

Trieste, Italy, especially as compared to LA, had an inclusive, humane, and effective community mental health system. Hoping for the same for LA, Morrison brought many local leaders to check the city out for themselves, including LA District Attorney Jackie Lacey, Superior Court Judge James Bianco, and Jonathan Sherin, a psychiatrist and the director of mental health services for LA county for the past three years.

Whatever Morrison did in Trieste, it worked – California’s Mental Health Services Oversight and Accountability Commission voted in May of 2019 to allot $117 million over five years to finance a pilot study based on Trieste’s system of care. These funds are unrestricted, and as such, do not need to follow the federal rules that guide programs such as Medicaid. If the pilot shows success in Hollywood, Morrison and Sherin hope to expand the program across LA County.

“Our system has been driven almost entirely by medically oriented approaches and funded based on allowable services with cumbersome bureaucratic requirements,” Sherin said in Waters’ article. “We spend our time making sure that we’re compliant and that we’re taking care of the auditor, instead of engaging people as human beings, identifying what they need, and addressing the other issues in their lives.”

The proposal is not without empirical support – psychologist Dave Pilon, who helped develop the Hollywood pilot, led an experiment in the early ’90s that provided intensive case management as well as a full range of services for clients diagnosed with “severe mental illness.” Their funding, like the Hollywood pilot, was not earmarked solely for clinical services and could be spent on any service.

The results were positive – their clients spent less time in the hospital, were less likely to be institutionalized, were more likely to work at jobs and participate in leisure activities, were more likely to say they were satisfied with their services, were more connected to their therapists, and had more income, among other outcomes. The costs were higher (around $10,000 more per client), but Pilon believes that the pilot’s plan to shift funding priorities and invest in more social and rehabilitative services lends it a good chance to be at least revenue-neutral.

The pilot intends first to evaluate the needs and functional ability of each client in the Hollywood area on a tiered scale with proportionately higher funding allocated for higher tiers. Users would be re-evaluated each month. The program aims to reduce the time spent by staff members documenting their activities below five percent and to make clinical services’ ancillary‘ behind ‘primary’ psychosocial services.

Next, there will be outreach teams of nurses, social workers, and peer specialists to serve as 24/7 first responders to a crisis. There will also be new facilities, such as a respite center, a residential center, and an urgent care center, all of which aim to reduce the burden on emergency departments, paramedics, and police for psychiatric services. Finally, there will be a peer-support model of paid peer-support workers.

There are key differences between Italy and the US, of course. Specifically, Italy has very low levels of homelessness, a robust social safety net, a history of deinstitutionalization and community mental health, and very little reliance on involuntary treatment. The pilot is still subject to approval by the LA County Board of Supervisors, but Sherin is optimistic that the official approval will come soon. Their approval will open the doors for a year of planning and stakeholder engagement, with the program ideally beginning in early 2021.

“This kind of transformation will require broader efforts as well,” writes Waters. Quoting Keris Myrick, the county mental health department’s chief of peer services, he concludes:

“Creating change ‘is not incumbent on just the staff, the providers, and the peers that are doing all of this work in support of people. It’s incumbent on the community. When you come through the door of the Peer Resource Center, everybody who’s in this building has a responsibility to help that person. And I think that’s where we kind of miss the boat in America.”

 

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Waters, R. (2020). A New Approach To Mental Health Care, Imported From Abroad. Health Affairs, 39(3). DOI: 10.1377/hlthaff.2020.00047 (Link)

9 COMMENTS

  1. Move over psychiatry, to the left.
    Wait your turn.
    Obviously this is headed in the right direction and success will depend on the implementation, not the clients.

    So if we are pulling the MI believers from MI service and sticking them into a new program, in an MI saturated cult, it’s bound to be a flop.
    Unless of course there are informed “providers”.

    Why is it that I fear common sense approaches can’t be utilized by those who don’t have experiences with common sense?

    Age is another problem. The enthusiastic MI worker who is 22, the enthusiastic MI worker who is 50 can both be problematic. I personally don’t think a 22 year old knows quite as much as I do, combined with where they come from.

    How can one possibly “know”, from education, from the slanted formal education, from life’s environmental education, what can they possibly offer a user who has a life, had a life with such a completely different experience?
    After all, it is experiences that psychiatry likes to treat and label.

    • Sam- I agree with you that without input from people with lived experience–it will be a flop. Moreover–survivors need to be involved not just in the design but also in the leadership and delivery. Why not issue a call to action for survivors/leaders/peers nationwide to flood this program with resumes and stimulate a massive migration of the most experienced and talented survivors to travel to Hollywood to ensure success?

  2. “The system is very complicated—patchy and fragmented and existing in chaos. The jails became like hospitals, and the hospitals” became jails. It’s not that complicated, however, if you look to the common sense reality of “cui bono.”

    The “mental health” industry financially benefits from defaming as many people as possible with their make believe and “invalid” diseases. The systems are all about controlling people, via the worship of money, by those working within the “invalid” systems.

    https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/transforming-diagnosis.shtml

    The “mental health” workers do need to be educated about psychopharmacology, however. Since they’re given “intensive case management as well as a full range of services for clients diagnosed with ‘severe mental illness.'”

    The “mental health” workers do need to be educated as to the reality that the ADHD drugs and antidepressants can created the “bipolar” symptoms.

    https://www.alternet.org/2010/04/are_prozac_and_other_psychiatric_drugs_causing_the_astonishing_rise_of_mental_illness_in_america/

    And that the antipsychotics/neuroleptics can create both the positive and negative symptoms of “schizophrenia,” via anticholinergic toxidrome and neuroleptic induced deficit syndrome.

    https://en.wikipedia.org/wiki/Toxidrome
    https://en.wikipedia.org/wiki/Neuroleptic-induced_deficit_syndrome

    Meaning that the two “most serious mental illnesses” are, in fact, created with the psychiatric drugs. So the reality is that the “serious mental illnesses” are not actually “lifelong, incurable, genetic” illnesses. They are iatrogenic illnesses, created with the psych drugs.

    Since the psychologists, and all non-psychiatric “mental health” workers, are not informed about the common adverse effects of the psychiatric drugs in their education. And because the common adverse and withdrawal effects of the psych drugs are missing from their DSM. They do regularly misdiagnose all people who are suffering from the common adverse effects of the psych drugs.

    Why in the universe are non-medically trained “professionals,” who’ve been misinformed by the psychiatrists, the pharmaceutical industry, and their “invalid” DSM “bible,” able to “diagnose” anyone anyway? The social workers, CPS workers, psychologists … None of the non-medically trained, so called “professionals,” should have any right to diagnose anyone with anything. They are not medical doctors.

    Teams of miseducated “nurses, social workers, and peer specialists to serve as 24/7 first responders to a crisis” will not help. Unless, all these people are properly educated regarding the adverse effects of the psychiatric drugs, as well as regarding the invalidity of the DSM disorders.

    “When you come through the door of the Peer Resource Center, everybody who’s in this building has a responsibility to help that person. And I think that’s where we kind of miss the boat in America.” And as one who went through “peer training,” but couldn’t actually buy in. Because they’re still teaching the debunked “chemical imbalance” theory in peer training.

    I know real help won’t exist, until the truth about the psych drugs, and the fraud of the DSM disorders, is being told to both the clients, and the “teams of nurses, social workers, and peer specialists,” … as well as to the public at large.

  3. It seems to be in the right direction…what I seem to understand as “harm reduction.”

    Making sure that folks have a safe place to sleep. Food to eat. Companionship. The basics of being HUMAN.

    If it costs $10k more per person to use this model – perhaps those with “lived experience” can help, as they go through the process and get better.

    I’m reminded of the old Mission model, where, you’re given a bed, helped off the street drugs or alcohol, and then given work around the Mission to help them get on their feet again…

    it’s not the answer, but it’s a start. My concern for this is that it is crying for “privatisation” if someone can make a buck doing it. . . Sigh.

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