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• Italy

From the asylum to territorial services for mental health
The reform of psychiatry and the implementation of mental health services in practice

It would be impossible to define a model (applicable everywhere) of reform for mental health services, considering the complexity of these processes and the great differences between countries, cultures, and services. However, following the phases of the experience of Trieste, it is possible to indicate the universal aspects of a reform process for mental health services.

The Law 180 of psychiatric reform
On May 13, 1978, under the pressure of the process of deinstitutionalization in place in Trieste and in other parts of Italy, Law 180 was approved in Italy, which decreed the gradual replacement of psychiatric hospitals with a radically new model of territorial care services. At the time of the promulgation of the law, the structures of the psychiatric hospital in Trieste were almost completely dismantled and the turnover of patients was minimal.
The Law 180, states that, even in psychiatry, the basis of health care is a person's right to care and health rather than the assessment of dangerousness. Treatment becomes voluntary and usually carried out in facilities operating to a minimum in local areas.
In the case of needed hospitalization, treatment is carried out by the Psychiatric Diagnosis and Treatment Services of General Hospitals. Law 180 establishes that no one can be hospitalized in psychiatric hospitals. It is the first law in the world that bans mental asylums and represents a fundamental victory for those who worked for reform.

The reform initiative and its legislative requirements

In 1971 when Franco Basaglia took over the provincial psychiatric hospital in Trieste and started the experience of transformation, psychiatric care in Italy was governed by a law of 1904 which focused on the need to protect society from the mentally ill. Hospitalization occurred with the certification of a physician and the order of a commissioner, and alienated the civil rights of the person. Psychiatric care was administered by the provinces, each of which had their own mental hospital.
Law 180 initiates a new phase of work to introduce new provisions in national and local regulatory frameworks to progressively define the responsibilities of the Departments of Mental Health, their services and standards of operation. In March 1999 the Ministry of Health announced the successful final closure of all public psychiatric hospitals. This completed a cycle, which lasted more than two decades, and included the startup and testing of the reform, characterized by lively debate among workers, family members, administrators, politicians and public sectors.

The change in the organization of the psychiatric hospital

Until 31st December 1971, 1182 people were hospitalized in Trieste, with an annual turnover of 2500 patients, of which 90% underwent forced hospitalization. The introduction of voluntary admissions meant that patients were not deprived of their rights, patients were given freedom of movement in and out of hospital, and treatment and care was improved thanks to a change in the relationship between patient and doctor through dialogue. Starting in the first months of 1972, a great deal of attention was focused on the organizational changes needed in the interior spaces and on improvements in relations between staff and patients.
The operators were organized into 5 teams, each of which was in charge of an area of the city. There were daily team meetings and discussions. In periodic assemblies, coordinated by Basaglia, patients were presented with the reform process. The doors of the hospital wards were opened and shock therapies and physical constriction methods ended. Also sexual segregation was abolished and mixed departments introduced.
Hospital community activities include parties, bars, and newsletters. However, patients also have the chance to go around the city alone or in small groups. In this way, people are also gradually reintegrated even by using money to access public places, thanks to subsidies provided by the provincial administration.

The return of rights to inmates

Team work focuses on reconstructing patient’s needs and personal lives, trying to rebuild relations with their families and places of origin. As the larger departments are downsized, housing groups are organized, first at the hospital and then in the city. The style of work is oriented to the involvement of nurses, who must abandon the traditional role of "guardian" to take an active role in the changing process.
Many different patients’ organizations were instituted, and among these, the most important was established in 1972, the United Workers Cooperative, which includes 60 hospitalized people, with different tasks: cleaning the departments, working in the kitchens and in the park.
The assignment of a regular union contract to each hospital-worker is a big change from the old practice of exploitation of the internees, improperly referred to as "occupational therapy". Instead this new practice anticipated what in later years would lead to the creation of social cooperatives.
The recognition of the right to work, and the replacement of hospital wards with smaller and autonomous community units, demonstrates that it is not a disability or disorder that obstructs the construction of rehabilitative processes but the juridical and administrative status of the patients. Day and night care is also recognized as a right for people who, while not requiring hospitalization, are still obliged to reside in the hospital as "guests" due to a lack of alternative housing.

When the transformation process started there was opposition from nurses and alarm among citizens:
"... The prevailing view was that mad people were dangerous and had to be locked up in a mental hospital. So at first it was a case of convincing them that things were not like that. Day by day we tried to show that by changing the relationship with the patient we also changed the sense of this relationship. Nurses began to believe that their work could be different, and thus become agents of transformation. On the other hand, to convince the population we first had to take the mentally sick back onto the streets, to social life. By doing this we stimulated the city's aggression against us. We needed to create a tense situation, to show the change that was happening. In time the city realized what was happening. The important change in the training of nurses was that the new kind of reality led them to no longer be dependent on doctors, to be persons who could make decisions on their own."
                                                     Franco Basaglia, Brazilian Lectures, 1979

The construction of relations between the hospital and the territory

Even though operators continue to work in the hospital, from 1973 their tasks are carried out mainly outside the institution, trying to re-establish inmates’ relations with their families, taking them to the city to look for jobs and accommodation. The hospital itself is open to cities organizing art exhibitions, parties and concerts, so that the psychiatric experience interacts with social actors: young people, women’s organizations, student movements, political organizations and unions, information agencies, public opinion, intellectuals and artists.
In the first empty ward painting, sculpture, theatre, and writing workshops are organized. More and more often, vacations and tours are organized so that patients can participate in normal city activities.
Between 1973 and 1974 patients, before put in wards based on the criterion of seriousness (agitated, violent, filthy, sick, and chronic), were reassigned on the basis of their territorial origin. From this initial situation, the explicit goal became that of discharging patients so they could support themselves at home in their own living environment.

Work outside the hospital met with opposition and numerous conflicts, since it was the first significant change in therapeutic practices and institutional, administrative, and hierarchical organization; it was also a training school for nurses and doctors.

The establishment of the first territorial Centres for Mental Health

At the beginning of 1975, the number of inmates had dropped to 800, and those discharged were placed with their families or in housing groups.
The first Mental Health Centres were activated in the Health Districts in 1975-1976, to support the patients discharged from the mental asylum and care for those in crisis.
As day centres, they worked to reduce the number of hospitalized patients and the duration of hospitalization. They were established before the national reform law, while the psychiatric asylums were still operational, so two different organizational and cultural assistance models were operating at that time. This situation was putting the new system at risk with a possible paralysis of the transformation process.
In this situation, the team therefore took the bold decision to upgrade services so that the mental health centres could operate 24 hours a day. Towards the end of 1977, Basaglia decided to announce the closure of the psychiatric hospital as an irreversible fact.
The number of patients had decreased to 132, while guests in the protected structures inside the hospital numbered 433. That same year, a psychiatric ward service was established, working 24 hours a day, at the General Hospital Emergency Department, to make psychiatric assessments, find the best solutions to crisis situations, and counter the automatic recourse to compulsory admissions.

The closure of the Psychiatric Hospital

The enactment of Law 180 in 1978 represents a victory for all the players involved in the transformation of mental hospitals, and became an essential tool to complete the psychiatric reform process in Trieste, boosting both local services and new initiatives, considering also the allocation of administrative resources.
The General Hospital Psychiatric Service was transformed by law into the Psychiatric Diagnosis and Treatment Service, providing an emergency psychiatric consultancy service to various hospital departments, also having the responsibility of orienting the patients to the territorial Mental Health Centres.
In November 1979, Franco Basaglia was called to supervise the psychiatric services of the Lazio Region, and the new director, Franco Rotelli, was in charge of overseeing the definite closure of the Trieste hospital.
These were years of organizational transition, in which the governance of the psychiatric reform was included in the national health system, transferring powers from the province to the territorial health services. On 21st April 1980, the Provincial Administration passed an internal resolution declaring an end all to the functions and definitive closure of the Psychiatric Hospital of Trieste.

The institution of the Mental Health Department and its services

In 1981 the Department of Mental Health (DSM) was instituted by law. The DSM guarantees the technical, administrative and managerial unity of the territorial service network, its programs and activities. The operational standards of the Mental Health Centres were also defined, each being responsible for 50,000 people, with 8 beds and a refectory for day and day/night care.
In local areas, residential and housing groups were enhanced, to provide accommodation not only to discharged patients but also to people that had never been hospitalized but lived in precarious situations or in conflict with their families.
Rehabilitation, training and socialization programs were developed: recreational and leisure activities, expressive workshops, literacy courses and schooling. The mid 1980s saw an increase in the number of cooperatives involved in work placement, and their range of competences and activities were gradually extended.
In the following years the cooperatives increasingly focused on empowering people with handicaps and disabilities of various kinds, or those who were victims of addiction or social marginalization. The strengthening of their activity, in a perspective of social enterprise, coincided in the 90s with a significant work of DSM helping users of mental health services to fully exercise their citizenship rights. The rehabilitation and empowerment programs, focusing on accommodation, work, social relations, education and training, aimed increasingly at building networks and self-help groups, targeting populations at risk.