Democratic psychiatry and the Trieste model

1. Introduction

Version followed: the Trieste Department of Mental Health (DSM) system as its directors describe it. The main sources are Roberto Mezzina's chapter "Community Mental Health Services with open doors and without restraint: Trieste, Italy" (2017), his presentations (2014, and undated slides on the Czech Ministry of Health site with 2010–11 figures), the DSM/IDEASS brochure introduced by Peppe Dell'Acqua (c. 2011, Italian and English editions), and Sade, Goljevscek and Corradi-Webster's 2020 report on the Trieste home crisis team. Its Basaglian roots (Gorizia, 1961–68) follow Psichiatria Democratica's own account (Lattanzi, c. 2020). Figures differ between these sources, and each difference is flagged where it comes up.

Bed numbers, staffing, budget shares, the Trieste timeline and the legal steps of compulsory treatment (TSO) are cited to the sources above and a 2025 legal commentary (Morra). The Trieste sources describe a stance, not a step-by-step de-escalation procedure; they do not say how staff handle physical aggression or how a TSO is ended or converted to voluntary care in a CMHC. Those steps stay marked [synthesis] or [uncertain]; the organisational safeguards of Italian no-restraint hospital units are cited from a 2024 survey (Pocobello et al.), and individual crisis plans from WHO/Europe (2025).

What it is. Democratic psychiatry is not a single therapy. It is a movement and a whole service system that grew out of Franco Basaglia's work. Basaglia directed Gorizia asylum from 1961, Colorno until 1971, and Trieste's provincial psychiatric hospital from August 1971 [source: DSM brochure (English) p. 2]. The movement led to Italy's Law 180 of 13 May 1978, which made psychiatric treatment voluntary as the norm, moved it into community services, and limited acute admission to small general-hospital units [source: Schochow et al. 2024; DSM brochure p. 6]. Basaglia founded Psichiatria Democratica in 1974 according to Schochow et al.; other accounts give 1973 [uncertain].

Today Trieste runs a network of community mental health centres (CMHCs, Centri di Salute Mentale), each open 24 hours, 7 days a week. Each has a few "hospitality" beds and an open door, and none of the services use mechanical restraint or ECT. Around them sit a small general-hospital unit, supported housing, social cooperatives and personal health budgets [source: Mezzina 2014 presentation; Mezzina 2017; Sashidharan 2022]. Timeline: the first CMHCs opened in the health districts in 1975–76 and were later organised to run 24 hours a day (the year they went 24-hour is not given [uncertain]); the provincial administration's resolution closing the hospital is dated 21 April 1980; the DSM was instituted by law in 1981 [source: DSM brochure (English) pp. 8–9; Mezzina Czech presentation: "started 1971, PH closed 1980"]. Trieste has been a WHO Collaborating Centre since 1987 (reconfirmed 2010); Mezzina also says it began as a WHO pilot centre in 1973 [source: DSM brochure pp. 3, 13; 2019 meeting programme; Mezzina 2017 p. 34]. It hosts study visits and training, about 1,000 visitors a year [source: DSM brochure].

No certification or licence is needed to work "in the Trieste model". There is no manual and no fidelity scale. The DSM itself says no universal model can be defined, and lists conditions that carry it instead (see §2) [source: DSM brochure; Mezzina 2017 p. 36].

How change happens. The core idea: if you change where and how care happens, you change what care can achieve. Mezzina 2017 calls this the shift "from hospitalisation to hospitality". Change follows from:

meeting the person rather than the diagnosis ("bracketing" the illness);
freedom, summed up in the motto "only freedom is therapeutic";
continuous relationships with one team that takes responsibility before, during and after a crisis;
restoring citizenship: rights, a home, work and social ties.

The crisis is treated as part of the person's life story and is "dissolved" into everyday life instead of being contained in a ward [source: Lattanzi c. 2020; DSM brochure; Mezzina 2017 pp. 19–20].

Who this guide is for. A clinician working in, setting up or adapting a 24/7 open-door community service, or bringing its stance into ordinary community mental health work. Wherever something is an adaptation for a non-Italian service, it is marked [synthesis].

2. Framework

This is a system of care, not a sequence of therapy phases. Below, the pathway a person takes through a Trieste CMHC is set out as stages. Mezzina's chapter does not name these stages formally; the ordering is my synthesis of the practices he describes [source: Mezzina 2017 pp. 13–24; IMHCN CMHC page; DSM brochure; ordering = synthesis].

Service structure (figures differ between sources, flagged below):

CMHCs. Four, each serving a district of about 60,000 people.
- Beds per centre: 6 in Mezzina 2017 (p. 13), Sade et al. 2020 and Sashidharan 2022; "6–8" in Mezzina's presentations; 8 in the c. 2011 brochure. Treat 6 as the current figure.
- Staff per centre: about 30 nurses, 4–5 psychiatrists, 2 psychologists, 1–2 social workers and 1–2 rehabilitation workers, with two night staff for overnight guests (Mezzina 2017 p. 13). Department total: about 210 (Mezzina 2017 p. 14) or 215, about 1 per 1,000 inhabitants: 26 psychiatrists, 9 psychologists, 130 nurses, 10 social workers and 6 psychosocial rehabilitation workers (Czech presentation). The brochure gives 524 staff in 1971 and 225 in 2010.
General-hospital unit (SPDC). One unit, open 24/7, with 6 beds in Sade et al. 2020 and the Czech presentation and 8 in Mezzina 2017 (p. 14); the brochure gives both [uncertain; the number has probably changed over time]. It acts as an emergency filter and normally keeps people under 24 hours (Mezzina 2017 pp. 14–15). Sade et al. report two psychiatrists and 18 nurses over three shifts, and a no-restraint policy for 40 years. Mezzina gives about 30 general-hospital psychiatric beds for the whole region (2017 p. 12).
Housing. About 45 places in group homes and supported housing.
Other services. Day centres, about 12–15 social cooperatives, and a habilitation and residences service (SAR).
Budget. 94% of mental health spending goes to community services and 6% to hospital acute beds (2011 figures: Mezzina 2014 and Czech presentations; Mezzina 2017 p. 24). The network cost about €18 million in 2011, about €79–80 per resident a year. The 1971 hospital cost the equivalent of about €28 million (Czech presentation) or about €55 million (brochure) [uncertain on the hospital comparison]. Personal health budgets take about 18% of the DSM budget (Mezzina 2017 p. 23).

Stage A: Access (same day).

Goal: answer any request without filtering.
Format: the centre is a walk-in service with no waiting list and no selection by severity. The response comes in "real time", usually within 1–2 hours. All staff take turns on reception.
Hours: from 08:00 to 20:00 the CMHC takes direct referrals. Overnight, the hospital emergency department or unit sees people first, and the CMHC team visits the next day to agree a plan.
The brochure gives a first interview within 24 hours of the request.
Move on when: there is a shared understanding of the problem as the person presents it, and a decision about whether the CMHC takes on care (presa in carico) [source: Mezzina 2017 pp. 17–20; DSM brochure].

Stage B: Assessment (up to 24 hours).

Goal: understand the problem and the urgency, partly from the person's and carer's own view. Assessment is problem-based, not diagnosis-based.
A "24-hour rule" allows an extended assessment over a day.
The first assessment is done by a psychiatrist or psychologist together with the team.
Move on when: a provisional plan is agreed: outpatient follow-up, home support, day or night hospitality, or (rarely) compulsory treatment [source: Mezzina 2017 pp. 19–20; DSM brochure].

Stage C: Crisis response in the community (days to weeks).

Goal: resolve the crisis without hospital admission and without breaking the person's social ties.
Format, any of:
- home treatment and home visits;
- day hospitality: a few hours or a whole day of protection, medication and psychotherapeutic support;
- 24-hour hospitality in the CMHC, where people stay as "guests".
Length of 24-hour hospitality: on average 10–12 days per Mezzina 2017; IMHCN gives 14 days [uncertain].
Compulsory treatment: fewer than 10 per 100,000 a year (16 people, 7 per 100,000, in 2010; an average of 8 per 100,000 in the brochure), usually 7–10 days, carried out preferably in the open-door CMHC; about two-thirds take place in the 24-hour CMHC (see 4.9) [source: Mezzina 2017 pp. 14, 23; Czech presentation; DSM brochure p. 2].
Move on when: the crisis has eased and the person can return home with an agreed follow-up. Plans are "decided or rediscussed" during the stay [source: Mezzina 2017 pp. 14, 19–24; IMHCN; CoE page].

Stage D: Continuity and taking responsibility (open-ended).

Goal: the same team stays with the person across settings: home, hospital, prison, forensic services and nursing homes. Mezzina calls this "continuity instead of transitions".
Format: outpatient contact, scheduled home visits, medication management, individual and group work, and family work.
There is no fixed number of sessions and no fixed length of stay [source: Mezzina 2017 pp. 17–19; DSM brochure; Sashidharan 2022].

Stage E: Personalised plan and recovery or social inclusion (months to years).

Goal: housing, work, social relationships and "a life project".
Tools:
- a personalised therapeutic-rehabilitative plan;
- a personal health budget for people with the most complex needs (about 160 a year);
- work grants and jobs in social cooperatives;
- supported housing;
- user and family associations.
Ending: there are no formal discharge criteria. Movement toward less support (independent living, a job) is the aim [source: Mezzina 2017 pp. 21–24; Mezzina 2014 presentation].

Historical stage: deinstitutionalisation. This matters if you are transforming an inpatient service.

Gorizia: ward and general assemblies; wards opened and turned into therapeutic communities; restraints removed; personal belongings returned [source: Lattanzi c. 2020].
Trieste from 1971–72:
- shock therapies and all physical restraint abolished;
- staff organised into five teams by geographical area, with daily management and team meetings;
- regular assemblies with patients;
- group living set up first inside the hospital and then in the city;
- in 1972, a patients' workers' cooperative with union contracts, replacing unpaid "ergotherapy".
Strengthening community services before closing beds was part of the method [source: DSM brochure; Viezzoli 2021 lecture].

Conditions the DSM names for transfer elsewhere [source: DSM brochure; Mezzina 2017 p. 34]:

political initiative and a legal framework;
gradual closure of beds, with community services built up first;
multidisciplinary teams;
training in the field;
developing social cooperatives;
scaling up to the whole system, beyond isolated pilots.

3. Guiding principles

The seven criteria for community practice [source: Mezzina 2017 pp. 17–18]:

Responsibility for the whole demand. The team answers for the mental health of its whole catchment area, "without a severity selection". Practical meaning: no exclusion criteria; you never reply "not for us".
Active presence and mobility. Go to where the need arises, take on the burden in the person's own environment, and avoid bureaucratic filters. Practical meaning: home visits are routine, not exceptional.
Accessibility. Walk-in or drop-in access with a quick response. Practical meaning: whoever is on reception sees the person today.
Therapeutic continuity. One team throughout, in every setting. Practical meaning: you follow the person into hospital, prison or a care home rather than handing them over.
Crisis response in the community. Alternatives to admission come first: home treatment, or respite at the CMHC. Practical meaning: "admission" is not a default protocol.
Comprehensiveness. Health and social responses are integrated, using family and community networks. Practical meaning: housing, money and work are clinical business.
Teamwork. Plans are formulated collectively, with daily training on site, peer review among colleagues (inter-vision) and volunteers as part of the team. Practical meaning: no clinician decides alone about a difficult case.

Further principles from the sources:

Bracketing the illness. Following Husserl, Basaglia set the diagnosis and psychiatric knowledge aside to meet the person "empty-handed" (a mani vuote) [source: Lattanzi]. Practical meaning: start from the person's story and needs, not the label.
Only freedom is therapeutic. This is the Trieste motto (solo la libertà è terapeutica) [source: Lattanzi]. Practical meaning: every restriction has to be justified, and is temporary.
Open door at every level. This applies even during compulsory treatment [source: Mezzina 2017 p. 19; Mezzina 2014 presentation]. Lattanzi warns against "fake" open doors with staff guarding the exit. Practical meaning: the door is open because staff are present with people and trust them, not because someone stands watch.
No restraint, no ECT, in every service [source: Mezzina 2017 pp. 23–24; DSM brochure]. Practical meaning: restraint is not an available option, so the team must find other responses.
Hospitality, not hospitalisation; guests, not patients. Stays are agreed without formalities, rules are agreed and flexible, and time is shaped by the guest's needs [source: Mezzina 2017 pp. 19–20; Mezzina 2014 presentation]. Practical meaning: negotiate the house rules with the guest.
Crisis as part of the life story. Understand the crisis by activating the resources and ties around the person [source: DSM brochure]. Practical meaning: ask what happened in the person's life, not only which symptoms appeared.
The person makes the request. When relatives or neighbours call, the service works so that the person in difficulty becomes the one asking for help, and protects confidentiality [source: DSM brochure]. Practical meaning: engage the person directly; do not act only on the family's demand.
Personalised, not standardised. Interventions are personalised, with no standard protocols and no preset lengths of stay. Care focuses on capacities and resources [source: DSM brochure]. Practical meaning: build the plan around this person's life.
Right to care comes before any judgment of dangerousness, as in Law 180 [source: DSM brochure]. Practical meaning: risk is managed through care, not by excluding the person.
Change the place of care to change the methods. Care for the spaces, furnishings, food and cleanliness, because they shape relationships [source: DSM brochure]. Practical meaning: treat the environment as a clinical tool.
Citizenship and rights as the aim. This includes the 1995 Charter of users' rights, meaningful work and independent living [source: DSM brochure; Sashidharan 2022]. Practical meaning: measure progress in rights regained, not only in symptoms reduced.
Whole person, whole life, whole system. Holistic and ecological work that addresses context, networks and social groups [source: Sashidharan 2022; Mezzina 2017 pp. 18, 32–34]. Practical meaning: map and work with the person's network.
Negotiation instead of force. In a crisis, negotiate and reassure, with no fixed time limits. Staff leave behind the custodial role and put themselves into the relationship (corpo a corpo) [source: Lattanzi]. Practical meaning: stay with the person and keep talking.
Risk is part of care. Fear-driven closure makes services useless [source: Lattanzi]. Practical meaning: share risk decisions within the team rather than locking doors.
Collective, non-hierarchical deliberation. Assemblies sit in a circle "without predetermined hierarchies". Agreements reached together are preferred to rigid rules [source: Lattanzi]. Practical meaning: reach house rules and plans by discussion.
Ethics, Evidence and Experience (the "3 E's") [source: Mezzina 2017 p. 30]. Practical meaning: weigh lived experience alongside data and rights.

4. Intervention inventory

These are service-level and clinical practices, not branded techniques. Unless marked otherwise, "Purpose" and the core of "Steps" come from the cited Trieste sources. The sources describe what is done, not session scripts. Finer step detail is therefore marked [synthesis], and all example language is illustrative.

4.1 Walk-in reception with rotating intake

Purpose / when. Gives every new or returning person an immediate response, usually within 1–2 hours, with no waiting list. Use it for every request: walk-in, phone, GP, district office, or a call from a family member or neighbour [source: Mezzina 2017 pp. 18–19; DSM brochure].
Steps.
1. Each shift, one staff member covers reception. All disciplines take turns, nurses included.
2. Receive the person in person, in a non-clinical space.
3. Hear the problem in the person's own terms. Record who asked for help and why now.
4. Decide together on the next step today: a first interview, a home visit, day hospitality, or a return appointment.
5. Bring the case to the next team meeting. Steps 2–5 are my synthesis of the sources' description.
Example language (illustrative). "You don't need an appointment. Tell me what's happening and we'll work out together what would help today."
Watch for. People turned away because they are "not severe enough" or "belong elsewhere": that breaks the no-selection principle. It is working when people return on their own initiative and crises reach you early rather than through the emergency department [synthesis].

4.2 Helping the person formulate their own request

Purpose / when. Use when relatives, neighbours or other agencies make the request. The service works so that the person in difficulty becomes the one asking for help, and protects their confidentiality [source: DSM brochure].
Steps [synthesis].
1. Thank the caller and gather concrete facts.
2. Explain that you will contact the person directly.
3. Reach out by phone or a home visit, saying who called and why, unless that would be unsafe.
4. Ask the person what they themselves see as the problem.
5. Build the offer around their answer.
6. Agree with the person what will be shared with the family.
Example language (illustrative). To the person: "Your sister was worried and called us. I wanted to hear from you how things are, and whether there's anything you'd want from us."
Watch for. Acting only on the family's demand: it turns help into control. It is working when the person names their own goal, even a small or practical one.

4.3 Problem-based first assessment and the "24-hour rule"

Purpose / when. Understands the problem as it is presented and judges urgency partly from the person's or carer's own view. Assessment is problem-based, not diagnosis-based. When the picture is unclear or in crisis, the "24-hour rule" extends the assessment over up to a day, at the CMHC, or for night arrivals at the hospital emergency unit with a CMHC visit next day [source: Mezzina 2017 pp. 19–20; DSM brochure].
Steps.
1. A psychiatrist or psychologist sees the person with at least one other team member [source: DSM brochure].
2. Cover the presenting problem, the life situation (housing, money, relationships, work), resources and capacities, and current risk [synthesis on content].
3. If needed, offer to stay: day or night hospitality for observation and support, rather than a formal admission.
4. Within 24 hours, agree a provisional plan with the person and, where they consent, the network.
Example language (illustrative). "We don't have to decide everything right now. You can stay here today and tonight, we'll get to know each other, and tomorrow we'll decide together what comes next."
Watch for. Assessment turning into diagnostic labelling with no plan. It is working when the person can say what was agreed and who their contacts are.

4.4 Home visits (scheduled and emergency)

Purpose / when. Visits let the team:
- learn the person's living conditions and family situation;
- give medication and support to people who find it hard to attend;
- accompany the person to hospital, offices or work;
- manage crises and mediate neighbour conflicts in critical situations. Visits can be scheduled or an emergency response [source: DSM brochure; IMHCN CMHC page; Mezzina 2017 p. 18].
Steps [synthesis for the sequence].
1. Agree the visit with the person where possible.
2. Go in pairs during a crisis.
3. Start with the person's concerns and practical needs.
4. Observe the home and the relationships.
5. Deliver or review medication if it is part of the plan.
6. Agree the next contact.
7. Report back at the team meeting.
- In a neighbour conflict: meet each party separately, then together if useful. Look for concrete arrangements such as noise or shared spaces, and stay as the point of contact [synthesis].
Example language (illustrative). "We'd rather come to you than ask you to come in. Is Thursday morning a good time? We can also sort out the electricity letter while we're there."
Watch for. Visits that only check medication compliance: they are felt as surveillance. It is working when the person opens the door, raises their own agenda, and conflicts with neighbours ease.

4.5 Day hospitality

Purpose / when. Gives a few hours or a whole day of protection at the CMHC in a moment of crisis or tension. It includes medication, psychotherapeutic support and taking part in ordinary activities. Use it when a person can sleep at home but needs to be held during the day [source: DSM brochure; IMHCN; Mezzina 2017 p. 20].
Steps.
1. Agree the hours and the purpose with the person.
2. Name a staff member they can turn to.
3. Include them in the centre's daily life: shared meals, outings, cooking, talk groups.
4. Review at the shift-change meeting whether to continue, step up to night hospitality, or end. Steps are my synthesis; the activities are from Mezzina 2017 p. 19.
Example language (illustrative). "Come and spend the day with us. We eat at one, and there's a group going out this afternoon if you'd like to join."
Watch for. Social over-stimulation, which Mezzina lists as a critical point (p. 28). It is working when tension visibly drops and the person can go home in the evening.

4.6 24-hour (night) hospitality at the CMHC: "guests, not patients"

Purpose / when. An alternative to admission for crises. It also protects from particular risks, or puts some distance between the person and their family for a while. Stays range from one night to several weeks; the average is 10–12 days per Mezzina 2017, or 14 days per IMHCN [uncertain] [source: DSM brochure; Mezzina 2017 pp. 19–21; IMHCN].
Steps.
1. Agree the stay informally with the person and their relatives "without formalities" (Mezzina 2017 p. 19).
2. Agree flexible house rules instead of institutional ones.
3. Keep visits unrestricted and aim for "maximum co-presence" of the social network (p. 21).
4. The guest joins everyday life in the same house where others come for care, so the crisis is "dissolved" into ordinary routines (p. 20).
5. Two night staff are present (p. 13).
6. At the morning meeting, guests new and old join staff to plan the day (p. 18).
7. Decide or re-discuss the ongoing plan during the stay (p. 20).
8. End the stay by agreement, with follow-up already in place.
Example language (illustrative). "You're a guest here, not admitted anywhere. The door is open, your family can visit whenever they like, and we'll decide together each day how things are going."
Watch for. "Abusing bed use", which Mezzina lists as a critical point (p. 28): beds used as housing or as a default. Signs it is working:
- the guest takes part in the life of the house;
- family contact continues;
- there is a concrete plan for going home. The readmission rate to CMHC beds is about 30% (p. 24).

4.7 Open-door management and re-negotiation

Purpose / when. Keeps doors open at all levels, including during compulsory treatment. When a guest leaves without agreement, the team "operates a re-negotiation" rather than locking the door or calling for coercion [source: Mezzina 2017 pp. 19–20; Mezzina 2014 presentation; Lattanzi].
Steps [synthesis beyond "re-negotiation"].
1. Keep staff physically present and available in shared spaces. Openness rests on relationship, not on a guard at the door (Lattanzi).
2. When a guest wants to leave, sit with them and ask what is pushing them out.
3. Offer alternatives: a walk with a staff member, a phone call to someone, going home with a visit arranged for later that day.
4. If they leave, phone them, visit their home, and involve their network.
5. Bring it to the team meeting and adjust the plan rather than the rules.
Example language (illustrative). "You're free to go. Before you do, can we talk about what's made today so hard here? If you go home, I'll come by this evening."
Watch for. "Fake" open doors, where staff stand guard at the exit (Lattanzi). Risk when a guest leaves during acute suicidal crisis is covered in 5.3. It is working when guests who leave come back or accept a home visit.

4.8 No-restraint practice

Purpose / when. No mechanical restraint, seclusion or ECT in any service, the general-hospital unit included: "open doors, no restraint, no ECT in every place including hospital Unit" (Mezzina, Czech presentation) [source: Mezzina 2014 and Czech presentations; Mezzina 2017 p. 23; DSM brochure p. 11; Sade et al. 2020]. Lattanzi describes the historical starting point: untying people, returning their belongings and restoring their trust; and in crisis, negotiation and reassurance with no fixed time limits.
What the Trieste sources say staff do instead. Mezzina 2017 names a working stance rather than a procedure: "doing with, being with" as a principle of support (p. 18); "reasonable negotiation" with the person's concerns and needs (p. 18); "negotiate and be accountable for everything" (p. 20); a continuous effort to gain cooperation through a relationship of trust (p. 20); two night staff with overnight guests (p. 13); visits without restriction and the person's network present (pp. 19–21); medication through information and negotiation (p. 26). The brochure adds a "non-bureaucratic approach to crisis situations, outside the medical model", aimed at restoring balance quickly (p. 5). The home crisis team (4.24) works the same way at home.
Steps. No published Trieste step-by-step de-escalation procedure was found, and the Trieste sources (Mezzina 2017; DSM brochure; Mezzina's presentations; Sade et al. 2020) do not say how staff handle physical aggression [uncertain]. Each step says whether it rests on a Trieste source, another named source, or is my synthesis:
1. Prevent. Keep staff present in shared spaces day and night, with two night staff for overnight guests [source: Mezzina 2017 p. 13], and keep known staff with the person [source: Mezzina 2017 pp. 17–18]. Agree an individual crisis plan with the person in advance, written together, setting out what helps and what to avoid when they are distressed [source: WHO/Europe 2025, which presents such plans as helpful but not sufficient on their own]. Attend to unmet practical needs [synthesis].
2. Early signs. Approach calmly, reduce the audience, offer space and a familiar person [synthesis].
3. Stay and negotiate. Stay with the person, hear the grievance and negotiate concretely, with no fixed time limit [source: Mezzina 2017 p. 18; Lattanzi]. Validate and offer concrete choices [synthesis].
4. Bring in trusted people, relatives or friends, if the person wants them; network presence is normal practice during hospitality [source: Mezzina 2017 pp. 19–21].
5. Offer medication only as an informed, negotiated option [source: Mezzina 2017 p. 26].
6. If the person leaves, re-negotiate (4.7) instead of locking the door or using force [source: Mezzina 2017 p. 19].
7. Afterwards, debrief with the person and the team and change what provoked the episode [synthesis]. Record any injury to staff and review the episode as a multi-professional team; Italian no-restraint hospital units commonly track staff injuries from aggression and audit any restraint episode [source: Pocobello et al. 2024].
Example language (illustrative). "No one here is going to tie you down or lock you in. Tell me what's wrong and we'll sort it out together. Take the time you need."
Watch for. Restraint returning in disguise: locked rooms, heavy sedation as routine, transfers out of the service to places that do restrain. It is working when episodes resolve through talk and staff feel backed by the team [synthesis].

4.9 Compulsory treatment (Italian TSO, Mandatory Health Treatment) within the open-door CMHC

Purpose / when. For the rare cases where Italian law allows compulsory treatment (Trattamento Sanitario Obbligatorio, TSO; Mezzina's "Mandatory Health Treatment"). Trieste reports under 10 per 100,000 a year (16 people, 7 per 100,000, in 2010). Mezzina gives the Italian rate as 17 per 100,000 (2017 p. 11); the CoE page gives about 30 [uncertain]. In Trieste it is carried out "preferably" in the person's own CMHC rather than in hospital, with the door open even during compulsory treatment; about two-thirds take place in the 24-hour CMHC; it usually lasts 7–10 days [source: Mezzina 2017 pp. 14, 19, 23; Mezzina Czech presentation; Mezzina 2014 presentation].
The legal procedure in Italy (Law 833/1978 arts. 33–35, which carried over Law 180) [source: Morra 2025, paraphrased]:
1. TSO is an exception to voluntary care, used only when urgently needed treatment is refused and community measures are not feasible; its purpose is care, not public safety.
2. Two medical opinions are required (Mezzina's slides: "2 psych. to mayor") [source: Morra 2025; Czech presentation]. Which service the second doctor must belong to is not stated in these sources [uncertain].
3. The mayor, as local health authority, issues the order.
4. The order reaches the guardianship judge (giudice tutelare) within 48 hours of admission; the judge confirms or refuses it by reasoned decree within the next 48 hours. If it is not confirmed, the mayor orders the treatment to stop.
5. Since Constitutional Court judgment 76/2025, the person must be told of the order and of the judge's decree, and the judge must hear the person before deciding, at the place where they are; the same applies to extensions. The commentary says the ruling concerns TSO during hospital admission, not extra-hospital TSO. How it applies to a TSO held in a Trieste CMHC is not covered by the cited sources [uncertain].
6. Beyond the seventh day, the responsible psychiatrist must make a new reasoned proposal and the procedure is repeated; the law sets no maximum total length.
7. The person, or anyone with a concrete interest, can appeal.
How Trieste runs and ends it. The sources give where (the person's own CMHC, open door, same team) and how long (7–10 days), not how staff conduct or end it [uncertain]. Steps consistent with the stated principles:
1. Keep the same team and key worker throughout [source for continuity: Mezzina 2017 pp. 17–18].
2. Tell the person openly what is compulsory and what is not, and keep negotiating ("negotiate and be accountable for everything", Mezzina 2017 p. 20) [synthesis on application].
3. Keep the door open and visits unrestricted [source: Mezzina 2017 pp. 19, 21].
4. Review daily for the earliest move to a voluntary agreement; once the person accepts care, seek an early end to the order rather than letting it run its full term [synthesis; the legal route for early ending is not given in the cited sources, uncertain].
5. Afterwards, review the episode with the person and agree a crisis plan for next time (5.1) [synthesis].
6. Outside Italy, follow your own jurisdiction's procedure [synthesis].
Example language (illustrative). "The order means you have to stay in our care for a few days. It doesn't mean we stop listening. Every day we'll look at whether it can end."
Watch for. Compulsion becoming the default response to non-adherence. Outside Italy, legal frameworks may not allow compulsory treatment in an open, non-hospital setting [synthesis].

4.10 General-hospital unit as a short filter

Purpose / when. The general-hospital unit (SPDC) handles emergencies, especially at night. It normally keeps people under 24 hours, then hands back to the CMHC team, who visit the next day to agree a plan. Its doors are always open and it never uses restraint [source: Mezzina 2017 pp. 14–15, 20; DSM brochure].
Steps.
1. The CMHC psychiatrists cover the unit in turn.
2. The CMHC team visits the person the next day.
3. Agree whether the person transfers to CMHC hospitality, goes home with home visits, or (rarely) stays longer. Hospital stays always stay linked to ongoing community care.
Example language (illustrative). "The team from your local centre will come and see you tomorrow morning, and we'll plan from there."
Watch for. The unit becoming a holding ward, and people lost between hospital and community.

4.11 Negotiated medication

Purpose / when. Mezzina describes "medication management strategies with information and negotiation" (2017 p. 27). The 2014 presentation reports mostly oral medication. It also reports about 75% adherence to antipsychotics, which Mezzina links to the therapeutic relationship and to network support [source: Mezzina 2017; Mezzina 2014 presentation; CoE page].
Steps [synthesis].
1. Explain the options, likely effects and side effects in plain language.
2. Ask what the person has experienced on medication before.
3. Agree a trial with a review date.
4. Where the person agrees, involve someone close to them.
5. Bring medication on home visits for people who struggle to collect it.
6. Revisit the agreement when side effects or doubts come up.
Example language (illustrative). "This is what I'd suggest and why. What worries you about it? Let's agree to try for two weeks and then look at it together."
Watch for. Medication offered as the only intervention. Missed doses treated as defiance rather than as information.

4.12 Daily team meetings, shift-change meetings and collective case formulation

Purpose / when. Make the team, not the individual, the unit of care. The day includes:
- a morning meeting with new and returning guests;
- staff meetings at shift change to plan afternoon priorities;
- daily team meetings with a "whole life" focus;
- collective formulation of plans, daily on-site training and inter-vision. Historically, Trieste held daily management meetings and daily team meetings [source: Mezzina 2017 pp. 17–19; DSM brochure].
Steps [synthesis on structure].
1. Morning. Run a short round with the guests: how was the night, what does each person need today.
2. Staff huddle. Allocate in-house roles (guests, outpatients, medication, groups) and outreach roles (home visits, network work, escorting people) (Mezzina 2017 p. 19).
3. Shift change. Hand over the cases and set the afternoon priorities.
4. Team discussion of difficult cases. Cover the whole life: housing, money, family, work, health. End with a named key worker and next steps. Mezzina says key workers are defined within the team (p. 29).
Example language (illustrative). "Before we decide about Marco, let's hear from everyone who's seen him this week, including the night staff and the cooperative."
Watch for. "Delegation and confusion", and staff burnout, both listed by Mezzina as critical points (p. 28). Night shifts weakening daytime continuity (p. 29). It is working when every person in care has a named key worker and the team is clear on the plan.

4.13 Personalised therapeutic-rehabilitative plan and personal health budget

Purpose / when. The main tool for people with the most complex needs. It is a "joint and shared plan of recovery" built around three areas: housing, work and social relationships, plus "a life project".
- Money moves from the institution to the person.
- Budgets are allocated by intensity, from high to low.
- Plans are delivered through partners: cooperatives, volunteer groups, cultural associations and foster families.
- Case managers coordinate, and quality is monitored against the plan's goals.
- Scale: about 160 clients a year (Mezzina 2017 p. 24), or 142 projects in his Table 3 [uncertain]. In 2010 this was 14% of department costs (2014 presentation), about 18% in 2017 [source: Mezzina 2014 presentation; Mezzina 2017 pp. 21–24, 31].
Steps.
1. Build the plan with the user, the district team and welfare services (2014 presentation).
2. In each area (home, work, relationships), set concrete goals in the person's own words.
3. Set the intensity level of support.
4. Name the partner agencies and the case manager.
5. Review progress against the goals. Mezzina does not describe a formal review cycle [uncertain]. Steps 2 and 5 are my synthesis on operational detail.
Example language (illustrative). "If things were going better a year from now, where would you be living, what would you be doing in the day, and who would you be spending time with? Let's build the budget around that."
Watch for. The budget turning into a funding stream for placements rather than for the person's own goals. It is working when spending tracks the person's stated goals and support intensity steps down over time.

4.14 Work grants, social cooperatives and job placement

Purpose / when. Restores the right to socially meaningful work.
- Paid training grants (borse di formazione al lavoro), which the DSM calls "a very important therapeutic tool".
- Placements in accredited social cooperatives. About 12–15 cooperatives employ roughly 400–600 people, 30–70% of them "disadvantaged". Figures vary by source and year [uncertain].
- Under Italian law from 1991, at least 30% of a social cooperative's workers must be disadvantaged.
- A job-placement office has run since 1996.
- Each year about 30 people move into jobs.
- Since 1972, patient-workers have been on union contracts instead of unpaid "ergotherapy" [source: DSM brochure; Mezzina 2017 pp. 22–24; Mezzina 2014 presentation; Viezzoli 2021].
Steps [synthesis on sequence].
1. Explore the person's work history and interests.
2. Offer a grant-funded traineeship in a cooperative sector that suits them: cleaning, catering, gardening, carpentry, theatre, media, a hotel, a call centre and others.
3. Agree hours and support.
4. Review with the cooperative.
5. Move toward an employment contract where possible.
Example language (illustrative). "There's a gardening cooperative that takes trainees. It's paid, the hours are flexible to start, and if it works out it can become a real job."
Watch for. Sheltered work that never leads to a contract. Placements framed as therapy rather than as work.

4.15 Supported housing and residences

Purpose / when. For people without a family network or needing support to live independently.
- Small group apartments with "a friendly, non-medicalised environment".
- Residences for social integration.
- Therapeutic-rehabilitative residences, with different levels of support.
- Homes sit preferably in town, with personal space and the residents' own time.
- The aim is stepping down to less supported living [source: DSM brochure; Mezzina 2014 presentation; Mezzina 2017 p. 14].
Steps [synthesis].
1. Match the level of support to the plan.
2. Treat the place as the residents' home: their keys, their routines, and agreed rather than imposed rules.
3. Review the step-down at plan reviews.
Example language (illustrative). "This is your flat, shared with two others. Staff come by daily at first; the aim is that over time you need us less."
Watch for. Group homes turning into mini-institutions.

4.16 Family programme

Purpose / when. Running since 1987, it offers:
- emotional and practical support for relatives;
- information meetings and psychoeducation;
- multifamily groups and self-help groups;
- meetings with parents of young people in a first episode;
- family therapy for dynamics and conflicts. About 70 families a year take the course [source: DSM brochure; Mezzina 2017 pp. 15–16, 31].
Steps [synthesis].
1. Meet relatives early, with the person's consent.
2. Find out what burden they carry and what they need.
3. Offer the course or group.
4. Bring family conflicts into family sessions.
5. During CMHC hospitality, keep the family present (open visiting).
6. Use night hospitality to give "distance" when the conflict is acute.
Example language (illustrative). "You've been carrying a lot. There's a group of families who meet every month, and we'd also like to see you together with your son to talk about what happens at home."
Watch for. Families sidelined, or families taking over the plan.

4.17 Individual and group therapeutic work and everyday group activities

Purpose / when. The treatment mix includes individual and group psychological work and social network interventions [source: Mezzina 2014 presentation; IMHCN].
- Daily informal activities in the CMHC: outings, cooking and shared meals, talk groups, informal contact (Mezzina 2017 p. 19).
- The Politecnico day centre runs arts, crafts and cultural workshops (theatre, visual arts, music, weaving) that are also open to other citizens (DSM brochure).
- Group activities aim to build social networks beyond the family (IMHCN).
Steps [synthesis].
1. Choose individual work with the person's priorities in mind. The sources name no single psychotherapy model [uncertain].
2. Invite people to the shared activities as ordinary participants.
3. Where possible, link them to activities that also involve citizens without a psychiatric history.
Example language (illustrative). "The music workshop is open to anyone in the neighbourhood. Want to come along on Wednesday?"
Watch for. Activities that only include service users, which reproduce segregation.

4.18 Practical and rights-based support

Purpose / when. Treats practical needs as clinical:
- economic subsidies and grants;
- referral to and liaison with housing, courts and social security;
- with the person's agreement, help managing their finances and assets [source: IMHCN; Mezzina 2017 p. 24; DSM brochure].
Steps [synthesis].
1. Ask early about money, housing, legal problems and benefits.
2. Accompany the person to the offices.
3. Advocate directly.
4. Record a financial-management agreement in writing and review it regularly.
Example language (illustrative). "Let's go to the housing office together on Monday. I'll explain your situation alongside you."
Watch for. Financial management slipping into control without consent.

4.19 User and family associations, self-help and peer support

Purpose / when.
- The DSM works with about 11–15 accredited associations, which run residences, leisure activities, an information line and anti-stigma work.
- Self-help clubs and groups exist.
- Partner associations run recovery houses with peer support workers.
- A Participation Committee involves users in planning.
- A Charter of users' rights was adopted in 1995.
- The stated aim is to restore power and a voice to users [source: DSM brochure; Mezzina 2017 pp. 22–23, 31; Mezzina 2014 presentation].
Steps [synthesis].
1. Tell people about the associations and peer roles from the first weeks.
2. Introduce them in person.
3. Include peer workers and association members in planning forums.
4. Respect the associations' independence.
Example language (illustrative). "There's a group run by people who've used the service themselves. Would you like me to introduce you to someone there?"
Watch for. Token involvement.

4.20 Assemblies (Gorizia democratic-psychiatry practice)

Purpose / when. At Gorizia, ward and general assemblies let patients speak, voice needs and protest, often for the first time. The assembly was a tool of emancipation and drove the opening of wards.
- Arezzo's later assemblies were more structured: an agenda, a microphone, a daily coordinator who was usually a patient, and participation by families and citizens.
- Everyone sat in a circle "without predetermined hierarchies".
- Trieste held periodic assemblies with patients during the transformation [source: Lattanzi; DSM brochure].
Steps (adaptation for a ward, residence or CMHC today; the format details are from Lattanzi's account of Arezzo, the rest is synthesis):
1. Hold a regular meeting open to all guests or residents and all staff on shift, plus invited families.
2. Sit in a circle; a resident coordinates.
3. The agenda is set by participants.
4. Staff answer complaints concretely.
5. Decisions about house rules are taken there.
6. Report back on what changed.
Example language (illustrative). "This is the place to say what isn't working here. Staff will answer, and anything we agree changes from tomorrow."
Watch for. Assemblies used as a "psychosocial experiment" or for show (Lattanzi). It is working when complaints lead to visible changes.

4.21 Care for the environment and restoring dignity

Purpose / when. The DSM treats the quality of spaces, furnishings, food and cleanliness as decisive for relationships. Historically this meant returning personal belongings and removing restraints and shock treatment [source: DSM brochure; Lattanzi].
Steps [synthesis].
1. Audit the setting: locks, bare rooms, signage, food, private space, access to belongings and phones.
2. Change these with the people who use them.
Example language (illustrative). "What would make this room feel less like a hospital to you?"
Watch for. Clinical-looking spaces that signal custody.

4.22 Continuity into prison, forensic, hospital and care-home settings

Purpose / when.
- A prison service has run since 1979, with volunteers. It keeps therapeutic continuity and supports alternatives to custody: semi-liberty, probation and outside work.
- Referral to forensic psychiatric hospitals is avoided; no Trieste resident is held in one.
- Staff also consult in hospital wards, nursing homes and district services, including early intervention and support for older people, to avoid admission to care homes [source: DSM brochure; IMHCN; Mezzina 2017 p. 17].
Steps [synthesis].
1. The key worker keeps visiting the person in custody or hospital.
2. Liaise with the court or probation service about community alternatives.
3. Plan release jointly.
Example language (illustrative). "I'll keep coming to see you while you're inside, and we'll work with your lawyer on what could happen instead."
Watch for. Losing people at the prison gate.

4.23 Microareas (community health and social areas)

Purpose / when. Since 1998, Trieste has run 16 small neighbourhoods of 400–2,500 residents jointly with the municipality, the public-housing agency (ATER) and the health agency. They offer social, educational and recreational activities to prevent marginalisation and conflict.
- Staff include cooperative workers, volunteers, a "social concierge" service and a full-time health-agency Microarea lead [source: Viezzoli 2021].
- This is a wider health and social programme, not a mental-health intervention as such.
Steps. A mental-health clinician links clients to the Microarea lead and to local activities [synthesis].
Watch for. Its relevance outside Trieste depends on similar municipal partnerships existing [synthesis].

4.24 Intensive home crisis team (Trieste, since 2017)

Purpose / when. A home-based crisis team set up by the Trieste health authority in October 2017, modelled on crisis resolution and home treatment, to care for people in crisis at home and reduce hospital contact and compulsory admissions. Referrals come from the hospital unit (SPDC), the CMHCs and emergency services. Inclusion: acute symptoms with recent deterioration; a relationship crisis or severe isolation; distressing family, work, neighbourhood or emergency situations. Exclusion: severe self-harm risk; acute intoxication or substance use needing medical care first; dementia or delirium; refusal by the person or family; no ongoing crisis; or need for compulsory treatment with no alternative [source: Sade et al. 2020].
Team and hours. 12 staff: two psychiatrists, a GP, a social worker, an occupational therapist, six nurses and a medical student. Weekdays 08:00–20:00, weekends and holidays 09:00–17:00; two cars and two phones whose numbers users and services hold; 4–10 people a day [source: Sade et al. 2020].
Steps [source: Sade et al. 2020, paraphrased]:
1. Screen the referral against the criteria (usually a psychiatrist), within two days.
2. First assessment, usually by nurses and jointly with the person's CMHC where possible: personal and family history, past difficulties and current problems, with attention to trauma and suicide risk. Standard symptom and functioning ratings (BPRS, GAF) are taken at the start, at discharge and at 3 and 6 months.
3. Co-construct a short written plan with the person, family and CMHC staff: strengths, vulnerabilities, needs and short-term goals. Review it at regular meetings.
4. Visit in pairs drawn from a small rotating group, at home or elsewhere as agreed, up to twice a day, reducing as the person improves. Involve the family at once and anyone else the person chooses. Offer daily-life support, individual and family psychological support, physical-health and medication monitoring, and links to community activities.
5. Hold a morning team meeting (overnight admissions and monitored cases) and an afternoon one (visit reports, next day's plan).
6. After about four weeks, hand over to the CMHC, which continues the agreed approach, and inform the GP and other services about medication and physical-health needs.
Example language (illustrative). "Two of us will come by every day this week, at a time that suits you. Your mother can join if you'd like. Together we'll write down what would help most over the next few weeks."
Watch for. Coordination with the CMHCs, which the authors name as a challenge given the team's small capacity and the CMHCs' caseloads. First-year report (Oct 2017–Oct 2018): 124 assessed, 59 cared for; symptoms improved in 93% and functioning in 81% at discharge; compulsory admissions fell 29.4% and 78.8% in the two halves of 2018 against 2017. This is an uncontrolled one-year service report [source: Sade et al. 2020].

5. Handling problems

Mezzina names his own "critical points" (2017 pp. 28–29): social over-stimulation, abusing bed use, delegation and confusion, staff burnout, "not forsaking difficult users", and night shifts that weaken continuity. He does not discuss violence or what to do when someone refuses all contact. Responses below are tagged by source.

5.1 The stuck or "difficult" person, and repeated crises.

The source's stance: do not discharge or transfer the person away. Mezzina lists "not forsaking difficult users" as a critical task, and the readmission rate is about 30% [source: Mezzina 2017 pp. 24, 28].
Response [synthesis]:
- Take the case to a full team discussion and look at the whole life rather than at symptoms.
- Change one concrete thing in housing, money, work or relationships.
- Consider a personal budget (4.13).
- Bring in a different staff member or a peer worker.
- Agree a crisis plan in advance with the person: which centre, who to call, and whether day or night hospitality is wanted.

5.2 Refusal of contact, or "resistance".

The source's stance: build trust and make a continuous effort to engage [source: Mezzina 2017 p. 20]. The person, not the family, should be the one asking for help [source: DSM brochure].
Response [synthesis]:
- Keep offering low-demand contact: short visits, practical help, contact through a trusted relative or neighbour.
- Accept refusal of specific treatments while staying present.
- Write down what the person does accept.
- Escalate to compulsion only on the narrow legal grounds of your jurisdiction, after the team has reviewed the case.

5.3 Suicide risk in an open-door setting.

The source: Trieste reports a suicide-prevention project and a fall in suicide rates. Figures differ: 25 to 12 per 100,000 over 20 years versus a 50% fall over 15 years [uncertain] [source: Mezzina 2017 pp. 25, 31]. No procedure is described.
Response [synthesis, following standard current practice]:
- Assess current suicidal thoughts, intent, plans, history, protective factors and supports, and write a collaborative safety plan.
- Increase presence rather than locking: a named staff member with the person, more frequent contact, family co-presence if wanted.
- Counsel on lethal means: with the person and family, agree safe storage or removal of medicines and other means at home.
- Agree what happens if the person wants to leave the centre, including a call or visit within hours.
- Do not withhold hospitality or care because of risk.
- Document team decisions.

5.4 Overwhelm and over-stimulation in the CMHC.

The source: social over-stimulation is a critical point [source: Mezzina 2017 p. 28].
Response [synthesis]:
- Offer quiet rooms, the right to opt out of activities, and shorter day hospitality.
- Offer outings with one staff member instead of groups.
- Ask guests at the morning meeting what pace suits them.

5.5 Agitation, aggression and pressure to restrain.

The Trieste sources (Mezzina 2017; DSM brochure; Mezzina's presentations; Sade et al. 2020) do not describe how staff respond to physical aggression. They give the stance only: "being with", negotiation with no fixed time limit, the person's network present, and no restraint anywhere, the hospital unit included (see 4.8). The responses below are synthesis unless a source is given [uncertain].
Response [synthesis]:
- Follow 4.8.
- Make sure enough staff are present at known flash-points: evenings, arrivals, family conflicts.
- Debrief after every incident.
- Support staff who were hurt.
- Analyse what provoked the episode (rules, waiting, a feeling of not being heard) and change it.
- If a criminal act has occurred, the law applies as for any citizen; this is not a reason to abandon care.
- Where your jurisdiction or employer requires restrictive interventions to be available, push for a reduction strategy and keep detailed records [synthesis]. In a 2024 survey of Italian hospital units in the Club SPDC No Restraint network (which grew out of the Trieste model), most units had a written procedure for managing the risk of aggression with regular staff training, individual care plans, and a register and multi-professional audit of any restraint episode; the authors link written aggression-risk procedures and routine outcome assessment with fewer people restrained [source: Pocobello et al. 2024].

5.6 Non-adherence (medication, appointments).

The source: negotiation and information (4.11). Mezzina links adherence to relationships and networks [source: Mezzina 2017; CoE page].
Response [synthesis]:
- Treat stopping as information. Ask about side effects, meaning and practical barriers.
- Renegotiate the dose or form within the prescriber's role.
- Bring medication to the home.
- Involve a trusted person.

5.7 Ruptures with the team.

Response [synthesis]:
- Name the rupture openly and apologise for your part.
- Offer a change of key worker within the same team; continuity of the team matters more than of one person.
- Bring the person's complaint to the team meeting or assembly and report back what changed.
- Tell them about the user associations and the rights charter.

5.8 Families demanding admission or control.

The source: night hospitality can give "distance" between person and family, and there is a family programme [source: DSM brochure].
Response [synthesis]:
- Hear the family's exhaustion.
- Offer day or night hospitality as respite for everyone.
- Schedule a family meeting.
- Explain the open-door, voluntary-first approach and what you will do if risk rises.

5.9 Staff fear, burnout, "delegation and confusion".

The source: these are listed critical points. Daily team meetings, inter-vision and training on site are the structural answer [source: Mezzina 2017 pp. 17, 28].
Response [synthesis]:
- Share decisions about risk within the team.
- Give each person a named key worker.
- Protect time for meetings.
- Rotate demanding roles.
- Provide supervision.

5.10 Applying it outside Trieste.

The source: commentators warn that success may depend on context. Portacolone et al. (2015) point to a small youth population, low drug use and adequate, inclusive housing. Allison et al. (2020) argue against citing Trieste as an exemplar. Carta et al. (2020) report uneven results across Italian regions [source: as summarised on the CoE page; uncertain: secondary].
Recent reports describe the Trieste service as under threat [uncertain: secondary, unverified].
Response [synthesis]:
- Without 24-hour centres, take over the elements an individual clinician or team controls: no waiting list, home visits, rotating duty, team ownership of every referral, negotiated medication, hospitality-style crisis alternatives (crisis houses, peer respite), practical and rights support, and family work.
- Check local law before assuming compulsory treatment can happen in open settings.
- Adapt for young people and people who use substances, with partnerships in those sectors.

5.11 Bed misuse and dependency.

The source: "abusing bed use" is a listed critical point [source: Mezzina 2017 p. 28].
Response [synthesis]:
- Tie every stay to a stated purpose and a plan for returning home.
- Review daily.
- When the stay is really about housing, solve the housing.

Sources

Main sources:

Added during verification (October 2026):

Cited as summarised on the CoE page: Mezzina R. (2014) Community mental health care in Trieste and beyond. Journal of Nervous and Mental Disease 202: 440–445; Portacolone E. et al. (2015); Allison S. et al. (2020); Carta M.G. et al. (2020). Background: Basaglia F. (ed.) (1968) L'istituzione negata. Torino: Einaudi.

Further reading (no claims rest on it): Mezzina R. (2014) Recovery oriented acute and crisis services in Trieste (IMHCN); WHO (2019) Strategies to end seclusion and restraint: WHO QualityRights specialized training, course guide (https://www.who.int/publications/i/item/9789241516754).

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