The Italian asylum law: moving towards the deinstitutionalization model
Giuseppe Dell’Acqua Mental Health Department — Trieste ( Italy)
Time seems to have passed very quickly. Last year, the law’s twenty years of existence have been commemorated at different times and in various places. Political, sociological, cultural and epidemiological analyses have helped to provide an assessment (more accurate today) of the two decades in which the legislation which reformed psychiatric assistance in Italy has been in effect. New experiences, services and programs, stories, personalities and polemics have, in a perspective which is already historical, revealed the responsibilities, the forms of resistance and critical moments in a process of change which has certainly left its mark on the history of the latter part of this century.
Today, nothing is as it was before.
At present, it is possible to re/examine the problems as they manifested themselves during those years, and to distance oneself from the heat of controversy and the urgency of the moment.
Whether we record the successes, the victories and unhoped for recovery of individuals affected with mental disorders (their situation has always been desperate) or, on the contrary, recognize their misery, their infinite solitude and unfathomable tragedies, or their familiar daily dramas, we obtain a sense, and an image, of just how vast this problem is today. And when these are seen as connected inextricably with the individual and the contests then we see the (infinite) amount of work which still remains to be done. We also can appreciate just how right the choice was to escape from the two-dimensional and negating world of psychiatric institutions (otherwise we would never have been able to grasp the enormity of the problem and operate in a practical manner).
If we reflect on what has occurred, we realize just how close, in real terms, the next step is.
And with that realization, time once again seems to pass with agonizing slowness: the same immutable slowness of time "the servant" of total institutions. Time always passes slowly before the violent and tumultuous impulse of those who need and ask for change. And even more today, for those still forced to endure senseless treatments, violent practices and processes of mortification, and to live in places which are unjustifiably miserable where their very existence is negated.
Italy’s psychiatric reform law.
The laws reforming psychiatric assistance in Italy have brought about profound and far-reaching changes. Despite the many, and often superficial and disinformed, controversies and debates which accompanied the growth of the new system of community-based services and the progressive abandonment of the psychiatric hospital over the last twenty years, persons affected with mental disturbances have experienced, and are still experiencing now, an historic change which must be acknowledged. Full constitutional rights have finally been recognized, and resources are currently being employed to guarantee full rights of citizenship as well.
New therapeutic and rehabilitation prospects are possible today based on multiple forms of social integration, as are positive outlooks for recovery.
The clouds of pessimism which during this century have always obscured psychiatry’s hopes for healing and recovery seem finally to be clearing.
Persons with mental disturbances, and especially those affected by schizophrenic disturbances, until now have been objects devastated by psychiatry. But today they have access to therapeutic, rehabilitative and emancipatory programs which treat them as subjects in full possession of their rights, and permit them to continue living in the concrete reality of their daily lives and within their family and social environments.
Mental health centres, emergency psychiatric units in general hospital, community residences, or living groups, are now widespread, representing a rich and diversified alternative to internment, deprivation and institutional abandonment, and providing a real response to the need for real relationships.
Cooperatives, (social enterprises) which began with the processes and changes brought about by the closing of the psychiatric hospitals, are today an important tool for liberation. The possibility of working and of assuming a social role other than that of being "mentally ill", has radically transformed the field and vistas of re/(h)abilitation. Today, "social enterprises" develop processes and promote aims and expectations which were unthinkable and unknown to persons affected with schizophrenic disturbances. Thousands of young, often highly motivated operators (teachers, instructors, non-professional escorts) are active in this area, bringing with them points of view, exchanges and relationships not usually found in the cold, sterile and geometric environments of psychiatry.
Mental health associations, made up of users/patients, family members and ordinary people, have been formed. These associations, with their active presence in the mental health network and within the city, represent the clearest sign of the reform.
And yet psychiatry still has difficulty recognizing these "new subjects" who no longer ask for restraint and control, but want a cure, healing, the possibility of recovery and to keep on living in spite of illness.
The reform act and the critical approach to total institutions have made it possible for our country to utilize, both in theoretical and operational terms, the latest know-how and discoveries concerning mental disturbance (and schizophrenia).
Mental disturbances can no longer be represented, either historically, relationally or environmentally, as an existential rupture, as a static and unchangeable condition.
They are always defineable, visible and recognizeable with respect to the individual, and are as in apparent contradiction with an individual life as they are always traceable back to it.
This is what the "Italian Law" means to us.
The complex processes of transformation have been slowed down and made more difficult by resistance to change within the university and within psychiatry itself. Administrative backwardness and an intense regionalization have often resulted in discordant operational set-ups and in reduced and uneven investments.
With a few praiseworthy exceptions, the Italian university has ignored and continues to ignore the entire problem. Research goals and training programs continue to be subordinated to imported cultures oriented towards the clinical/medical model which is, in any case, far removed from the community-based approach and the provisions of national and regional laws.
We have witnessed and continue to witness, have tolerated and continue to tolerate administrative delays, opposition and confusion, and idiotic technical choices which have caused and will continue to cause harm.
Though the number of psychiatrists in the public sector has increased in the last fifteen years from 700 (in the psychiatric hospitals) to about 7000 engaged in the community services, community psychiatry has still changed very little.
And yet the process goes forward. Twenty years after the law which initiated the process of change by prohibiting new admissions to Psychiatric Hospitals, the Health Ministry has decreed their definitive closure and has imposed economic penalities on those regions which either delay implementation or are in non-compliance.
The ministerial decree accelerates the process of closing down hospitals and gives more evident support to the growth of the community Mental Health Departments. By the end of 1998, approximately the last 15,000 guests (in the 70’s there were 120,000 inmates) still present in the 57 Italian psychiatric hospitals (they numbered 90 in the 70’s) were resettled in residences and family groups, and returned, after an entire lifetime, to their towns and communities. In fact, at the end of 1998, the lady Minister of Health was proudly able to announce the definitive closing of psychiatric hospital in Italy.
To the superficial observer, the Italian situation, with its regional and community "deregulation", might appear confused. And yet it guarantees that a person affected with a mental disturbance is treated as a "citizen" in all respects: that he always be considered as a person, a subject, an individual, and not as someone who is "mentally ill"; and that (psychiatry) mental health must be considered wihtin public health policy.
These last statements find their confirmation in well-known historical experiences which have taken place both inside and outside of psychiatric hospitals, in countries both rich and poor, in the hearts of great cities, on their outskirts and in rural areas. And everywhere these changes have been the result of long critical processes, of changes in psychiatry and in its professional organizations, and of the involvement of patients and the presence of social movements.
A cycle is ending in Italy. It is our hope that in the new Europe of "citizens" (and in the rest of the world, as well) the century of the insane asylum has closed for good, a century which has certainly not been to the everlasting honour of either psychiatry or psychiatrists.
The organization of services in Trieste.
An Italian model, as such, does not exist.
However, the "Italian way" of reform has succeeded in closing psychiatric hospitals "as an elementary act of justice already contained for some time in the bill of human rights".
The progressive closing of psychiatric hospitals is orientating and conditioning the development of community services.
Our report concerning the Italian situation refers to the work carried out in Trieste.
The present network of services in Trieste was, with few variations, already operational in 1978, before the new law for psychiatric assistance in Italy was passed.
This network is a result of the total reconversion of the resources of the psychiatric hospital during the course of ten years of working within it, which led to its effective and formal closing in 1980 (see appendix).
From 1981 onwards, the new network of Mental Health Services (D.M.H.) took on a definate form and continued to reinforce itself. The Department of Mental Health replaced the administrative structure of the Psychiatric Hospital. The direction of the Psychiatric Hospital, and subsequently of the D.M.H., was assumed by Franco Rotelli, who launched a major effort for the start-up and development of the social cooperation connected to programs for the emancipation of persons effected with mental disturbances.
Currently, after 20 years of working within the community, the network of services is well defined and identifiable.
There are four operational community units active in the city, whose territories correspond to the general health districts and the community operational units for the City’s basic social services.
Each area has a Mental Health Center which is open 24 hours a day, 7 days a week. In addition, there are two centers open 12 hours daily and a Women’s Mental Health Center whose activities and programs are designed to deal with the special problems women face with respect to mental disturbance and the institutions. Another operational unit manages and coordinates all the programs and resources regarding residences and rehabilitation and a final operational unit provides emergency psychiatric care (Psychiatric Diagnosis and Treatment Station, SPDC) at the General Hospital in close cooperation with the community services.
At San Giovanni (the park of the ex-psychiatric hospital) there are 50 guests in 10 living groups. Another 60 persons live in residences within the city, with varying degrees of support. (Of the 40 buildings which made up the Psychiatric Hospital only a few are being used by the D.M.H. as residences for the S. Giovanni M.H.C., the SERT (Service for drug dependence), as workshops, literacy classes, offices and workshops for the coops; the other structures have been acquired and reutilized by private and public agencies for public schools, universities, workshops.
The Department of Earth Science occupies six pavilions which have been completely restored; others who have found a place in the park are the International School for the Perfecting Navigation, a Day Center for Adolescents in difficulty run by the City, a School for Management (MIB), a technical institute taught in Slovene (from 1979), the Direction of the Health Department Prevention Division. The pavilions which remain unoccupied will be used as additional structures for the university. Moderate automobile traffic passes through the park of the ex-hospital which is gradually integrated into the S. Giovanni residential district. )
Specific locations for recreational, training, educational and creative activities have been established. There is an intense series of programs for job training and job placement in the abovesaid cooperatives, as well as in various companies and businesses throughout the city.
The make-up of the community services and mental health centers, of the cooperatives and the Women’s Mental Health Center, and the active participation of users and family members, all create an extremely articulated scenario which better than any other indicator restores the meaning and repays the effort, risks and contradictions of the project (the utopia) in which operators and services are engaged for the creation of new mental health institutions.
The community work which has grown up in Trieste in the last 25 years, the proximity to conflicts, the early recognition (and shouldering the burden) of the suffering of individuals, has prevented (prevents) this suffering from "assembling" the psychiatric diagnosis before it is seen and recognized, thereby requiring interventions upon "the illness" which are hospital-based.
This, in our view, is the most important result to be obtained from the organization of the services. The "virtuous circle" which begins at the moment of contact (of recognition) between user and service is the "product" which these services must try to promote. The negative spiral connected with mental illness (and with schizophrenia) must be interrupted. Today, community services succeed in maintaining an interdiction "zone" with respect to illness, prejudice, stigma, social deterioration, disability and the impairment of rights. We expect still further results from this work.
Defining a model of deinstitutionalization.
The deconstruction of the psychiatric hospital and of psychiatric institutions and the creation of a network of community services constitute the substance of the experience in Trieste and help indicate the stages of transition necessary in order to construct the networks and circuits for "shouldering the burden" of persons with severe mental disturbances and especially persons affected with a schizophrenic disturbance.
The process of change begun in 1971 can be summarized, with considerable simplification, around three major themes:
- The closing of the psychiatric hospital as a practical criticism of psychiatric culture and the clinic, and which recognized in the end of the great utopia of the mental hospital the failure of psychiatry.
- The construction of a network of services which would be alternative in real terms, as the practical search for innovative cultures and procedures which would in any case have to be different.
- Placing the "patient and not the illness" at the center of the effort to create therapeutic, rehabilitative and emancipatory processes as the construction in the praxis of the user’s active participation (as one of the actors for change) in the services.
In the light of our experience, it is evident that today there is a lack of reflection and research on the questions of change and deinstitutionalization in psychiatry. For too long now, in Italy and worldwide, the closing of psychiatric hospitals has not been accompanied by changes in the theories and practices of psychiatry. This has produced questionable or, worse, negative results in some places.
From 1971 onwards, Trieste became a great laboratory. The preceding text indicates just how profound the process of change was. The first four years seemed to burn with the tension of change and looking back now it seems as if everything occured in those years. There was no room for compromises or delays. Basaglia’s builders were faced with a double task: with the one hand dealing formidable blows to the hospital walls, with the other creating the structures of a possible community.
The gates of the great park of the Psychiatric Hospital were opened. A patient wrote this graffitti on a wall: "San Giovanni is an open hospital: both coming and going". The opening up of the hospital was discussed in the weekly meetings. The doors of the wards were opened. Everyone was in movement, coming out, talking with one another.
If before freedom was unthinkable, now it seemed equally unthinkable that it could ever end, that it would ever stop its course.
But, as they say, freedom is never enough. In fact, closing the psychiatric hospital is not enough and one law is perhaps not sufficient to regulate madness.
It is the question of freedom which is at issue. It is not the freedom of the psychiatric hospital and not only the freedom to be insane, to howl one’s delusion at the moon, and to pay for it with marginalization, abandonment and the loss of one’s rights. It is certainly not the freedom of being alone, bizarre, against everyone and in the end at everyone’s mercy, both forgotten by the world and a slave to it; and to administrative inertia, and the stupidity of so many therapeutic practices, and the violence of the institutions. Freedom is invoked by us in order to construct life experiences, individual existences, processes of emancipation.
We cannot help but recall experiences which were both historic and manifest in their meaning: the joy of freedom in the first therapeutic communities created in the psychiatric hospitals which were being opened up, the voices and excitement of the meetings, the freedom of inmates who experimented with amazement the possibility of expressing ideas and feelings, of having paying jobs and being members of a coop, of obtaining their own house and with it the possibility of an individual, intimate life. And how forget the procession of "poor devils", the population of the psychiatric hospitals which finally set off, awkward and fatigued, uncertain, viewed with distrust and hostility and yet filled with hope as it began its journey towards an equality which at that time could barely be imagined.
It is this transition (the passage to freedom) which, through the conflicts and contradictions, opens the way for the creation of new "mental health institutions" ("invented institution" as we like to say) and the redefinition of the question of responsibility in psychiatry. No longer the responsibility exercised and constructed by the doctor in the psychiatric hospital as the guarantee for systems which are coercive, punitive and objectifying, but the responsibility of taking care of others. Freedom and responsibility as risk, education, as the limits of the search for an alternative to the codes for social control, for the safeguarding of personal stories, relationships, exchanges, conflicts.
And here it becomes necessary to refer to the limits, the points of resistance of psychiatric institutions; to the conflicts around power, the rigidity of roles, the vertical nature of heirarchies. It was precisely the criticism of the vertical nature of heirarchies and unproductiveness of institutional power which helped liberate resources, discover subjects, reduce distances and initiate balanced relationships. The centuries-old distance between the various roles (nurse, patient, psychiatrist) was reduced, and systems of communication, as rich and unique as they are conflictual, were activated.
In this sense, the theory and practice of group work became possible and work with the individual (or "shouldering the burden" as it came to be called) took on meaning.
Thus, freedom and the criticism of power as the premises for guaranteeing the intrigueing, fascinating presence of subjects, of men and women. And, in thinking on it now, it is this presence which is the most important transition in all the transformations which have taken place over the years. We refer to the affective dimension, to subjective feelings; yes, feelings, all that is humanly concrete and real within the fascinating presence of individuals.
The criticism of institutional power, the transgression of the distance between professionals in traditional psychiatry, and between these and the patient, call into question the times and places in which to act, the repetition and reproduction of relations, and define the scope of the service’s shouldering of responsibility. The question of time and place must be completely reconsidered in this context: no longer the times and places of the clinic but the times and places of the relationships which are formed and transformed in the context of the modifications of the relationship between the patient’s demand and the Mental Health Service taken as a group.
Clearly, such places are no longer limited to specifically psychiatric locations, but any location can become a place for therapeutic action and can add specific elements or dimensions to the therapeutic relationship.
The redefinition and enrichment of place, of locations for therapeutic action, require the psychiatric operator to develop completely new abilities in order to deal with these diverse locations which do not belong to him and which are beyond his control.
In reality, a place for "shouldering the burden" does not exist as such. It can only exist as a place to be created and imagined out of the stuff of daily relationships, until it becomes a sort of antechamber while the cognitive relationship between the service and the operational group on the one hand, and the patient and his family members and neighbors on the other, takes shape.
The same thing can be said about the time of therapeutic action. If being in the community also means trying to act in real time, for example, by reacting to a crisis immediately, "live and direct" as it were, the dimension of "time" becomes a variable which tends to produce further changes.
In this regard, a capacity for "elastic" definitions and limitations of time develops within the therapeutic relationship. In community-based practice it is possible to imagine (utilize) a "time without end", a time for the therapeutic relationship which does not end and produces no chronicity.
The psychiatric hospital and psychoanalysis determined (and determine still) infinite times. But what is meant here is that when the dimension of time is removed from the inertia of institutions, the group and the service will develop the ability to "last" over time by transforming the relationship, the organizational set-up and the use of resources with respect to the patient.
The problem of human and material resources, like the problems of time and place, occupies a central position in the process of transformation. A service’s lack of resources should be linked to the rigidity of relationships defined by power and, consequently, to the lack of projects and the impossibility for the individuals involved to invest or risk anything. The persistance of clinical and psychological models whose only objective is sickness and the sick body results in the exercise of power and the perpetuation of the emptiness of the material and relational poverty which surrounds individuals.
Instead, taking responsibility for the person, and not the illness, confers value on the different and (for psychiatry) "unusual" resources which can be found as readily in minor trades as in the operators’ subjectivity when it is put into play; in well tended and personalized spaces as well as in the activation of the extended family; in personal abilities as well as in the involvement of the social network.
These transitions have elicited and conferred value on diversity (by revealing the process of alienation connected with mental illness). They have made the recognition of individuals and their personal histories possible, as opposed to the histories of their illnesses and the institutions which contain them. They have brought about the recognition of patients’ needs and not the institution’s need for reproduction, and the emphasis on the abilities, feelings and affections of individual subjects and not the disabilities and limits connected to the illness. Through these transitions, community practice has been able to build a relationship with patients and the general public based on reciprocity, and to negotiate the therapeutic relationship on equal terms and to reduce heirachies and institutional distance
With these premises it is clear that community work must (and can) be undertaken only after a critical examination of psychiatry itself.
The procedures, the clinical practices and institutions that today perform the "recognition" of mental disturbance must be subjected to a dismantling of the knowledge and know-how (deinstitutionalization) upon which they are based. To continue to sustain the objectifying regard of psychiatry in this day and age is no longer justifiable.
The choice of promoting the growth and strengthening of subjects (and of their rights) and of constructing strategies of "recognition" able to safeguard and guarantee both the multiple courses of action and the identity of individuals - processes and strategies for normalcy capable of influencing and altering social relationships, workplaces, the family - all this seems to be both clearly evident and widely shared by now.
At present, the contamination of normalcy represents the most important way for breaking out of the spiral of mental disturbance / labelling / marginalization, given that prejudice, stigma, disability and social abandonment all pass through the opinions, values and expectations which individuals and the collective build up around the question of mental disturbance.
In this country, the legal reform of psychiatric assistance and the consequent closing of the psychiatric hospitals represent the first measure (worldwide) which has proven itself capable of creating effective processes for realizing this contamination.
This prospect substantiates the thought and work of Franco Basaglia.