Heart Forward Conversations from the Heart

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Season Five is a special treat: made in Italy!

This past year, with generous support from the Conrad N. Hilton Foundation, Heart Forward was afforded the opportunity to curate a study group to learn about a system in Trieste, Italy that the World Health Organization (WHO) has declared a global best practice for community-based mental health care.

As the Équipe met regularly via Zoom to prepare for their October 2024 study visit, they fashioned a mission statement define their purpose:

The Équipe is an intentionally curated and diverse learning community that is committed to advancing a more humane and holistic mental healthcare system. Rejecting the institutional status quo, which contributes to suffering, homelessness and incarceration in the US, we look abroad for bright spots that could inform sustainable change.

So about these conversations. During our week in Trieste, I snuck away to do interviews in the city. Who will you meet?

Claudia Battiston. Claudia is a Psychiatric Rehabilitation Technician – which is a role unique to Italy, but seems to complement what we know as occupational therapy.

Dr. Tomasso Bonavigo, interviewed alongside his colleague, Dr. Alessandra Oretti. Bonavigo works in a community mental health center and Dr. Oretti is the director of the psychiatric unit in the central hospital and is as the interim director of the mental health department.

Elena Cerkvenic. She is a service user in Trieste and just published a book this year called Sono Schizofrenica e amo la mia follia.

Dr. Mario Colucci. A psychiatrist and philosopher, who has worked in the community system for most of his career and has written extensively about the Basaglian vision.

Dr. Giovanna Del Guidice. Here’s a female psychiatrist who managed to work alongside Franco Basaglia and now is dedicated to keeping the flame alive as she travels to other countries to provide training.

Stefania Grimaldi. One of the cornerstones of the model in Trieste is the network of social cooperatives. We’ll learn about one such social cooperative, La Collina, and how this system works.

Michele Sipala. Michele, in a peer support role, is involved with a very innovative six-month residential program for young service users in the city’s mental health system, Recovery House.

Beatrice Stanig. She speaks about how the association – L’Una e L’Altra – has provided a place of purpose for her. She is now a peer support specialist and has written a book called, Sei Innocente.

Caterina Vicentini. Caterina is a service user who provides a glimpse into how valuable the services in Trieste have been to her recovery and her ability to continue her career as a teacher.

The episodes will be ready for release mid-January 2025. Subscribe so you will be alerted when the first episode is available.

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And thank you to my technical producer, Aaron Stern of Verdugo Sound for editing and production support.

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This interview will regale the history of a mental health pilot from the early 90’s that remains as relevant today as the day it was started. Back in the day, the Wright-Bronzan-McCorquodale Act of 1988 (known as AB 3777) funded – from the state’s general fund -- three Integrated Service Agency programs for mentally ill consumers. The most well-known of these was MHA’s The Village in Long Beach (Mental Health America) which became a model for the Mental Health Services Act (Prop 63) which would follow about ten years later.

This pilot featured two study groups. The Village coordinated and supported the 24/7 whole-person life needs of 120 consumers, randomly picked by the independent evaluator. The budget was based upon a per-capita allocation of $15,000 per person per year, paid quarterly in advance. Within this budget, Village staff (think “community integration managers” as opposed to case managers) had to cover all costs associated with inpatient care, outpatient care, vocational support, community engagement, whatever was required. By contrast, the control group was serviced through the usual and customary public mental health system; a clinical model.

Ragins and Pilon will talk about the remarkable staff culture that evolved and the stunning outcomes associated with the pilot. Higher levels of employment, lower levels of hospitalization and the like. The evaluation report is summarized here.

True payment reform is required if the public mental health system is going to make a difference in the lives of the people it services. Recovery is possible, but people need to be supported in all aspects of their life, not just with medication and clinical interventions.

The Guests:

Dave Pilon received his doctorate in Social Psychology from Harvard University in 1981. From 1989 until his retirement, he served in various roles at Mental Health America of Los Angeles (MHALA), including as its CEO from 2009 until 2017. For over 35 years he has consulted in the design and transformation of mental health programs and systems throughout the United States, New Zealand and Japan. Most recently he has served as the lead consultant to the L.A. County Department of Mental Health for the TRIESTE Pilot.

He is passionate about creating better ways to serve the most vulnerable among us, particularly people with serious mental illnesses.

Mark Ragins calls himself a recovery-based psychiatrist. He worked for 27 years as the medical director at the MHALA Village in Long Beach. Most recently, he’s been serving on campus as the only psychiatrist at CSU Long Beach

Dr. Ragins website features a number of resources and writings from the recovery mindset about which he is so passionate. He has recently published a new book, Journeys Beyond the Frontier: A Rebellious Guide to Psychosis and Other Extraordinary Experiences.

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John Foot is a professor of Modern Italian History at the University of Bristol in the U.K. He is an expert on the life of Dr. Franco Basaglia, the visionary psychiatrist whose lasting impact on the Italian mental health system continues to inspire the world.

We will explore Professor Foot’s journey into this avocation, which was sparked by the chance viewing the film San Clemente (1982) while on a trip to Trieste.

Professor Foot is author of Franco Basaglia: the Man who Closed the Asylums. He is a co-editor of compendium of essays about the impact of Trieste in other counties that emanated from a symposium held in Oxford in 2018. It is titled Basaglia’s International Legacy: From Asylum to Community.

We also explore in this interview the plan to translate into English a book that was originally published in 1968, L’istituzione negata (The Negated Institution), which had seminal impact on advancing the Basaglian revolutionary school of thought in Europe and South America.

That one man could have such profound impact on advancing a human-centered, community-based system of care for people living with mental illness is astounding. This interview will provide some insights into Basaglia, who is relatively unknown in the English-speaking world.

Other resources associated with the interview:

Documentary (1968) I giardini di Abele

Book (1969) Morire di classe

Documentary (2013) Dentro le proprie mura

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Guyton Colantuono is the executive director of Project Return Peer Support Network, a position he has held since 2014. He has spent more than 25 years working in the field of mental health and has led a multitude of programs including those addressing homeless outreach and shelter, transition-aged youth and employment development.

He has an unwavering belief that “people are people first” and a label is not a destiny. His lived experience as a survivor of homelessness, drug addiction and mental illness has fueled his passion for a whole-person approach throughout his career.

Particular emphasis will be placed on the unique offerings of a Peer Respite Home, to which he applies the metaphor of a “bed and breakfast for someone experiencing a mental health crisis.” He and his team of peers oversee Hacienda of Hope in Long Beach, one of two peer respites in all of Los Angeles County, and one of five in the state of California.

We’ll talk about how peer respites naturally adopt a posture of radical hospitality in welcoming guests, and how this is a stunningly less expensive bed to provide than those associated with psychiatric hospitalization or the county jail. Peer respite is the ultimate in trauma-informed care, and we’ll make a case for increasing the availability of these beds as a resource for providing care for people living with a mental illness not only in Los Angeles County, but throughout the state.

Resources

Definition - Peer Respite

'Peer respite' homes aim to be alternative to psychiatric wards - Los Angeles Times (latimes.com)

The Effectiveness of a Peer-Staffed Crisis Respite Program as an Alternative to Hospitalization | Psychiatric Services (psychiatryonline.org)

Impact of the 2nd Story Peer Respite Program on Use of Inpatient and Emergency Services | Psychiatric Services (psychiatryonline.org)

Report from the Auditor of the State of California. Lanterman-Petris-Short Act. California Has Not Ensured That Individuals with Serious Mental Illness Receive Adequate Ongoing Care. July 2020

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Dr. Tom Insel is a psychiatrist, a neuroscientist and an influential voice in the national conversation that is gaining momentum around the failures of the American mental health system and the need to do better for the humans that are suffering as a result. His new book, released in February 2022, is a worthy read, Healing: Our Path from Mental Illness to Mental Health.

In this episode we talk about how his life journey informs his current work and advocacy as he enters this chapter in his life. He speaks with a certain humility about how assumptions he made early in his career, or even while head of the National Institute for Mental Health, have changed as he has spent time with families and people with lived experience. His eyes were further opened to the challenges in our communities as he toured the state on a listening tour in behalf of California’s new governor, Gavin Newsom.

He speaks with eloquence about the profoundly simple idea (yet hard to implement or fund in our current system) to focus on People, Place and Purpose to support an individual’s recovery from their mental illness.

Dr. Insel joined our delegation in September 2019 when we attended the international mental health conference in Trieste Italy and he shares some memories from that experience.

Additional links and resources:

Thomas Insel, the ‘Nation’s Psychiatrist,’ Takes Stock, With Frustration - The New York Times (nytimes.com)

https://www.theatlantic.com/ideas/archive/2022/02/american-mental-health-crisis-healing/622052/

Additional articles from his website:

Press — Thomas Insel, MD (thomasinselmd.com)

Finally, Dr. Insel is part of a team that has created a new information source MindSite News.
From their Mission Statement:

MindSite News is a new nonprofit, nonpartisan digital journalism organization dedicated to reporting on mental health in America, exposing rampant policy failures and spotlighting efforts to solve them. We seek to create and sustain a sense of national urgency about the workings and failings of the U.S. mental health system and to impact that system through our reporting, making it more equitable, effective, transparent and humane in its care for individuals and families struggling with mental illness.