Medicina Historica 2018; Vol. 2, N. 3: 133-144 © Mattioli 1885

Original article: history of medicine

1978-2018. The Basaglia Law forty years after Mario Augusto Maieron ASL Varese (now Agenzia di Tutela della Salute – ATS - dell’Insubria)

Abstract. Forty years after the Law 180 gives the author an opportunity to speak about the changes brought about in psychiatry since 1978 and to assess psychiatry today, in its organisation, expertise, epistemological references, clinical expressions and operative methods in addition to its critical issues.

Key words: Law 180, , psychiatric renewal, reorganisation of Mental Health Services, sector psychiatry, community psychiatry, residential psychiatry

The Law 180, known as the Basaglia Law, is forty fined them, and earlier still, as remembered by Michel years old. Foucault, placed them as diseases of the soul, fruit of It is the law that sanctioned the closing of mental insane passions, in the category of vices (2). asylums, the conclusion of a period, defined by Edoar- Not only Binswanger however. do Balduzzi as “the years of Italian psychiatry”, that go Other phenomenologists such as Edmund Hus- from 1964 to 1978 (1), in which the reform movement serl, with his epoché, Martin Heidegger between phe- was developed and completely modified the prerequi- nomenology and existentialism, Eugène Minkowski sites of care and assistance for persons with psychic with his ideas of time, of Bergsonian derivation and disturbances that were put into practice in the years lived time and Jean Paul Sartre with Being and Nothing- to come. ness, had influenced his thoughts. His merit, however, Alberta Basaglia, psychologist and vice president lies not only in his original re-elaborations of philo- of the Basaglia Foundation, remembering her father in sophic conceptualizations, but also in having brought one of the numerous interviews granted on this occa- concreteness from a practical point of view to his ideas sion, underlined his great merit, besides the organiza- concerning his experiences above all in Gorizia and tional aspects of psychiatry, was that of restoring dig- and his battle against the mental asylum which, nity to those who had been marginalized and excluded. during the Seventies of the last century together with Franco Basaglia who, in the Padua University MAI (the Anti Institutional Movement), had become Clinic where he had initially worked, was known as the dominating theme of the reform movement ex- “the philosopher”, had his cultural roots in phenom- pressed by official psychiatry and its associations. enology and more specifically in the anthropophe- This is perfectly summed up in the conclusion nomenology of Ludwig Binswanger (and in Italy that given in Wikipedia on his thoughts and way of con- of Danilo Cargnello). They considered mental distur- ducting psychiatry bances, apart from the health-illness antinomies, as as- pects of human presence, creating the prerequisites for […] keep listening and divest yourself of every a radical change in the methods of their confrontation certainty, […] make a suspension, an epochè, of compared to the where and how that positivistic medi- all the sclerotic categories, in order to let the pa- cine, born at the end of the 18th century, had con- tient have his say (3). 134 M.A. Maieron

The Law 180 represented the conclusion of his Chamber, which also involved loss of civil rights and battles, it was not, however, his law, even though he registration in a special judicial register. The sentence accepted to give it his name. could be modified only by another sentence and the In parliamentary circles it was a preview of a law problem of the treatment was secondary. It had be- then under discussion in National Health Service in- come relevant for the progress in the therapies made stitutions that also included psychiatry. This had been for some disturbances above all from the Twenties on- promoted by the psychiatrist Bruno Orsini, a Demo wards, but it only had an effect on legislation with the Christian M.P. to avoid holding a referendum pro- Law 431 in 1968 that allowed for voluntary hospitali- posed by the Radicals for the repeal of the 1904 law on zation “for findings and treatment” without the legal mental hospitals that, if rejected, would have proved a effects that were in act for authorized admissions. disaster for the reform projects that would have been The 180 instead cancelled all the legislations set difficult to remediate. It was in fact a compromise be- out in the 1904 Law and always considered the psychic tween those (SIP – Italian Society of Psychiatry – and disturbance as a problem of the person, while laying AMOPI – Association of Italian down certain principles of reference for the treatment. Doctors-) who intended to eliminate the psychiatric The subject on the findings and the compulsory hospitals by setting upwards inside General hospi- health treatments with ample guarantees on times and tals and those (MAI – Anit-Institution Movement – methods for the persons involved (six articles) was ex- ) who retained even these were plained in greater detail. unnecessary (4). Other matters concern hospital psychiatry, with The law, as far as the closure of asylums was the creation of Psychiatric Services for Diagnosis and concerned, coincided with the ideas of Basaglia. He Treatment (SPDC) in general hospitals which were retained, however, that placing psychiatry inside equipped with a very limited number of beds, intended hospitals and the same National Health Service was to manage only extremely critical situations, regarded somewhat mystifying, because it tended to reattribute as coordinated and integrated with territorial Psychi- psychiatric suffering to illness, in a naturalist and posi- atric Services and Mental Hygiene that were, however tivistic sense, negating the work accomplished to give only generically indicated. Competence for the organi- it a social dimension, both in an anthropological and zation of the entire sector, which up to then had come sociogenetic sense. under the auspices of the Provinces, on the basis of This has been expertly documented in Conversa- the 1865 Law, made just after the Unification of Italy, tions concerning the Law 180, that Basaglia published in was assigned to the Regions. The final articles refer, as 1980 not long before his death (5). mentioned, to the repeal of the 1904 Law, some articles The 180, however, although giving only very lim- of the Penal and Civil Code and the law on active and ited indications on psychiatric reorganization, brought passive voting rights, indications on a transitory phase to an end not only a period of certain treatment meth- for patients in psychiatric hospitals and on the exper- ods for persons with serious psychic disturbances but, tise of the psychiatrists and their various qualifications. compared to the 1904 Law, it completely modified the Apart from considerations on the law itself, approach and herewith lies its revolutionary character. speaking about the 180 forty years after its enactment In fact, the 1904 Law, for involuntary commit- signifies above all talking about how the change in ment, dealt primarily with the social problem of “dan- psychiatry has taken place and what psychiatry is like gerous to oneself and others” and “public scandal”. today, not only its organisation, that is affected by sev- Hospitalization, temporary for the first thirty days, for eral regional legislations, but also its skills, its doctrinal the purpose of checking the mental disturbances, cause references, its clinical expressions and ways of working. of behavioural disorders and their persistence, and the It signifies speaking about those persistent criticisms “definitive commitment” were not the responsibility and precariousness and how, in recent years, society of the patient’s psychiatrist but of a judge who gave has changed, in its culture, symbolic expressions, its authorization with a sentence issued in the Council reference values and how this has effected not only the 1978-2018. The Basaglia Law forty years after 135 behaviour of persons but also the ways of expressing 833/1978, the Lombardy region under the 1997 re- their conditions of malaise. gional law 31/1997 introduced, as previously men- As far as the organisation of Psychiatric Services tioned, profound changes in the operational proce- is concerned my point of reference is the Lombardy dures of the entire health sector. These separated the region and in particular the province of Varese. programming and control, assigned to new institu- It is, in a general sense, still that which was de- tions, the ASL (Local Health Authorities) with a wider fined in the Eighties and Nineties and, as far as resi- territorial responsibility compared to the USSL, often dential structures are concerned in the following dec- coinciding with the provinces, from those providing ade too, with some important modifications due to the specialist services, in which also included were those reorganization of the Regional Health Services which provided by the UOP, which came under the respon- came into effect with the 1997 Law 31 and from the sibility of the general hospitals (AO: Azienda Ospe- norms and guidelines of the long term regional plan- daliera -Hospital Authority) ning that specifically concerned both territorial and At the same time, the USSL were abolished, residential psychiatry. with the creation of the Departments of Mental Health Monocentrism, represented by Varese’s psychiat- (DSM) including one or more UOP and relationships ric hospital where territorial services had been adopted between the ASL-DSM and DSM-UOP were de- almost immediately after its opening in 1939, as the fined. last of the psychiatric hospitals to be built in Italy, and The DSM is the organism that includes all the considerably increased under the direction of Edoardo structures in any given territory and their job is to take Balduzzi and later under Carlo Romerio, was, from charge, in terms of coordination and planning, of the 1981, taken over by the UOP (Psychiatric Opera- care, assistance and safeguarding of mental health. tive Units). These were responsible for several USSLs At the end of the nineties, in order to cope with (Local Social-Health Units), authorities that came into the requirements derived from the definitive closure existence with the application of the Law 833/1978, of the psychiatric hospitals (1999), that had retained instituted by the National Health Service. a temporary role for patients who could not be dis- Initially, the activation of the Hospital Services charged, without however the possibility of admit- for Diagnosis and Treatment (SPDC) in the general ting new patients and those with chronic diseases, the hospitals expressly provided for by art. 6 in the Law Residential Communities came into being. These were 180, which still retained ties of dependence to the Psy- structures managed directly by the Health Services or chiatric Hospital Management in its transitory phase by private accredited facilities that the Region then where new admissions, however, had been blocked, decided to further differentiate, according to the pur- concerned the hospitals in Varese and Busto Arsizio. pose (mainly rehabilitation or assistance), the intensity In 1981, roughly about the same period that the (high or low) of the interventions necessary relating Psychiatric Operative Units (UOP) were put into to the type of patients admitted, with differentiations practice, a third service was also activated, the Verbano concerning the organogram of the personnel, their Psychiatric Operative Unit, with Hospital Services for working hours and also the payments to the hospital Diagnosis and Treatment (SPDC) in Cittiglio and in relation to the length of hospitalization. subsequently, in 1996 UOPs in Gallarate and Saronno. The Nineties also saw the arrival of Day Centres. Every UOP had a Hospital Service and at least These, too, were run by the Health Services or by pri- one CPS in each USSL under its jurisdiction. On the vate accredited facilities followed by the latest opened basis of regional laws, during the second half of the in 2009, the Light Residency, another form of residen- eighties, in Varese in 1986, the first residential struc- tial care with both low protection and cost that pro- tures came into being: the CRT (Residential Centres vided solutions for individual patients or small groups, for psychiatric therapies and rehabilitation). with only limited support from health professionals, to In the following decade, with the application achieve greater autonomy. It should provide a bridge of the 1992-93 ministerial decrees modifying the between the Communities and the recuperation of 136 M.A. Maieron complete autonomy but for some patients it can also concerning the modification of cultural aspects and be a long-term solution. prejudices. These had been the causes of social exclusion Recently, further modifications to the Lombardy and marginalization of which the mental hospital had legislation for improvements in function and cost/ben- been an emblematic expression that had affected and efit ratio, have led to mergers of the ASL and AO and even now still affects persons with psychic disturbances. broadened the scope of the DSM. I have given a broad description of this in various From the mergers of the ASL of Varese and chapters of my previous publications (7). Como came the ATS Insubria (Insubrian Agency for Over the years psychiatry has however seen a the Safeguarding of Health, while the Varese AO has marked change in the clinical outcomes that have re- become ASST - Sette Laghi; Seven Lakes Social- mained within its competence and the onset, for a va- Health) and includes the hospitals in Varese, Tradate, riety of reasons, of new pathologies. Luino, and Cuasso al Monte while the Mental Health The nosodromia of psychosis besides changes Departments in the province have been reduced from brought about by various pharmacological, psycho- three to two, and have acquired the responsibility for logical and social approaches has been considerably Ser.T. (Drug Addiction Service). influenced, in cases that once would have been long- The Law 180, with its drastic reduction in beds, term hospitalization and institutionalisation, with the reserved for the management of critical situations has exception of critical situations, by management in out- also considerably modified the way many pathologies patients’ or day-care centres. are managed that in the past had the psychiatric hos- Many are the considerations that can be put for- pital as a reference for both short term and long term ward concerning treatments in residential structures care. Drug addiction alone, in that period, mainly due but these will be the subject of future analysis. to alcoholism, amounted to 25% of total admissions Over the years it has also been possible to ascertain and came under the auspices of the newly formed SerT the emergence of new clinical forms of psychic distress (Drug Addiction Service). Psycho-organic patholo- with a considerable increase, particularly among the gies, outcomes of ageing, dementias, in their various young, in personality disorders, the result of changes etiopathogenesis and some confusion and amentia syn- that have taken place in society in recent years. dromes, which made up 23-24% of total admissions, Above all changes have occurred in reference val- were dealt with by other Health or Welfare Services (6). ues, the concept and types of the family, the approach to Apart from competency on pathologies, the move sexuality, the relationship between children and parents to centralize assistance to the Psycho-Social Centres, often disturbed, adulterated or absent, the entrance age leaving the hospital to deal with only extremely critical and ways of carrying out job activities, the age of reach- situations, also considerably modified the approach to ing psychological and economic autonomy and also, in the various conditions of psychic suffering. In addi- certain situations, changes determined by the migration tion to psychopharmacological therapies, individual or of persons from other ethnic cultures. All of this has group psychological and psychosocial treatments have led to the appearance or accentuation of various forms assumed increasing relevance and it has finally been of dependency not just on substances with easy suggest- possible to introduce a form of rehabilitation with the ibility, but conditions of low self esteem and loneliness purpose of social reintegration. or vice-versa dangerous aggression, the search for af- The CPS, besides clinical activities, has also tak- firmation or compensation often through abnormal en on a central role in integrated assistance. This was methods and a rejection of rules, all conditions that fa- thanks to the multi-professionalism of the operational cilitate the emergence of genetic or epigenetic fragility. team, becoming part of a wide network of social as- These phenomena have been particularly exacer- sistance within the community, while broadening the bated in the last two decades but they had already be- scope of their activities, in collaboration with others gun to manifest themselves previously. In fact, during (Public entities, associations, individuals) who are in- the Fifties, the World Health Organisation had, quite terested in programmes of prevention and initiatives rightly, when redefining the concept of illness, that had 1978-2018. The Basaglia Law forty years after 137 historically been interpreted preternatural and later and the many other metapsychologies later developed naturalistic, underlined the importance of social cul- inside and outside of this (Alfred Adler, Gustav Jung, tural factors in its aetiology, specifying, as remembered Melania Klein, Heinz Hartmann and later Jacques by Gilberto Corbellini, that the processes can depend Lacan, to name just a few of the most important au- on genetic and epigenetic alterations but that these thors and founders of schools of thought) (10). It was only after the mid 20th century that they were accepted operate within ever-changing contexts; there- into official psychiatry, even though it is only correct fore the same causes give rise to different clinical to remember previous experiences such as those of the forms on the basis of the life experiences of each American psychiatrist Henry Sullivan (in the Thirties person affected. This would suggest that the con- and Forties) with his The Interpersonal Theory of Psy- cept of illness must take into consideration both chiatry and his attempts to extend forms of treatment evolutionary and functional factors and the bur- inspired by psychoanalysis to schizophrenia and those den of individual experience within a determined of the French Paul C. Racamier and George Daumé- social-cultural context. (8) zon (in the Fifties) with their Institutional Psycho- therapy. In the second half of the last century, when com- In the second half of the twentieth century, how- pared to a previously long period, psychiatry had radi- ever, other types of psychological psychiatry with ref- cally changed its epistemological references and its erence to metapsychology came into being. These were modus operandi even if it is true to say that this had be- founded on other aspects of mental activity, the princi- gun before the 180, the law itself made many of these ples of which were Cognitivism (Aaron Beck) and the changes unavoidable. Relational-Systemic theory (Gregory Bateson) and were The crisis in biological psychiatry and the prob- often the doctrinal reference for activities emerging in lem of ethics for the care and assistance of persons the newly adopted facilities after the 180. with psychiatric disturbances was born, as previously Also to be remembered is Social Psychiatry that mentioned, with the conceptualization of Ludwig came into being at the same time and which was not Binswange and phenomenological philosophy (Hus- so much an alternative to other procedures but rather serl and Heidegger in particular) that permitted over- an integration and completion of them. coming the exclusion that even Freud and Jaspers had It may be said that its theory is independent of maintained with regard to psychotics. The former due the causes of mental illness that can be social, psycho- to retaining them unsuitable for the transfert, the latter logical or biological because of his ideas of conceptualizations of incom- prehensibility and not partecipation, genetic misun- for persons with these disturbances, it is the en- derstanding concerning deliriums, not participation vironment of the community where they live that for the supposed inability of psychotics to internalize must become therapeutic so that they can find the experiences of others. conditions of equilibrium and the possibility to Biological psychiatry that was itself, in many recuperate and reintegrate into society. (11) respects, a hypothesis devoid of significant scientific validations, was replaced by psychological psychia- However, just when biological psychiatry, which try, or rather many kinds of psychological psychiatry all in all had not gone beyond the asylum and shock with reference to meta-psychological hypotheses even therapy, seemed to be completely unsuccessful, an event though not scientific and, for this reason in fact, long contrary to the evolutionary trend in new concepts and rejected by official psychiatry that was anchored to the therapeutic practices suddenly brought it back to life. hypotheses which had as its reference the concept of This event was the birth of psychopharmacology. disease expressed by Giambattista Morgagni. This created problems from an epistemological The references were initially Freud, the psychoa- point of view, not so much for social psychiatry, but nalysis and its metapsychology, born at the end of ‘800 for psychological psychiatry and of compatibility and 138 M.A. Maieron coherence between psychotherapy and pharmacologi- posing itself, quite rightly defended, when com- cal therapy. pared to other clinical disciplines, in the relation- They were ideological problems and derived, for ship to the sick, that favours inter-subjectivity psychological psychiatry, from the conviction and al- rather than objectivity of the empiric sciences leged self-sufficiency of their theoretical approaches. [and somatic medicine], and on the other hand This was the topic of debates and meetings that landed because, after the divorce from neurology, which on the pages of the psychiatric section of the Medical- only came about fifty years ago, the prefix neuro- Surgical Encyclopaedias ( Jean Guyotat and M. Ma- is frequently seen as a threat to one’s own identity rie-Cardin). (12) and autonomy and as a dangerous return to im- The diverse positions taken went from an alleged positions that are too biological and reductionist. incompatibility, to the acceptance of their synergy, (17) with a yes or no separation of competence between the psychotherapist and the psychiatrist. In effect, however, the enormous progress at- Psychopharmacology represented a considerable tained in neuroscience in the physiology of the brain, step forward in the treatment of psychosis. However, is opening up a new phase in the history of psychiatric it also had the merit, due to the understanding of brain doctrine. physiology, of furthering considerable development in After an extended biological period characterized the knowledge of neurotransmissions and of providing by the equating of mental disturbances to somatic ill- a relevant contribution to the development of neurosci- nesses such as diseases of the brain and a second period ence, which had become, after long-term neglect, one during the Sixties of the last century, with the many of the most advanced sectors of bio-medical research. types of psychological psychiatry born, in contrast to The interest in this aspect of scientific research, which previous psychiatry, refering to the numerous forms of is by its nature multidisciplinary, involved, as far as metapsychology previously mentioned, a third period mental activity is concerned, above all neuropsychology is now emerging characterized by a newly-found non- and philosophy, with Philosophy of Mind that attained divisive psychosomatic unity, which evaluates biologi- its own autonomy both in research and teaching. cal, psychological and social aspects, thereby giving As for neuropsychology, which has become, them a scientific validation that the doctrine of the thanks to new investigation techniques such as fMRI, previous periods did not have or had only partially. PET and many others, in all respects, an experimental And this also provides confirmation concerning science, it has been able to achieve innovative results, the mind-brain relationship, of the monistic hypoth- not only on neurobiological correlations of cognitive esis from which differs only slightly the latest dual- processes (Elkonoon Goldberg) (13) but also on affec- ism of Karl Popper and John Eccles (18) who with tivity and decisional processes ( Joseph Le Doux) (14), the acceptance of evolutionism and neo-emergentism (Antonio Damasio) (15), even managing to render the recognizes the causal link between mental activity and study of consciousness an autonomous experimental neurobiological substrate, placing both in a naturalism science (Stanislas Dehaene) (16), something consid- with the same laws. ered unthinkable until not long ago, for its non-reduc- The effects of the Law 180 that most underline ible subjectivity. what it was and what it provoked in psychiatry, more Psychiatry, although involved in biological aspects than in specific indications on its organisation, lie in under its jurisdiction, did not play a significant role in the fact that they sanctioned the end of an era and de- the development of neuroscience, maintaining a dis- termined the beginning of something new and com- tant and sometimes suspicious position, closed in a de pletely different. facto dualism. And that, as I have previously said, The period of psychiatric renewal, which goes from 1963-64 to 1978, had seen two opposite schools for various reasons, that on the one hand, has its of thought. One that was prevalent for about ten years own prerequisites in the different ways of pro- which had as its reference the French experience of 1978-2018. The Basaglia Law forty years after 139

Sector psychiatrists, considered the problem of elimi- bances from the hospital to the territory and the nating the psychiatric hospital as a goal to be reached competence of the team; gradually and had even inspired a bill, the Balconi bill • Multi-professional team because the needs of the of 1965 (19) that had aroused great expectations but patients, multiple and complex and not only had in fact never materialised. The other, more po- clinical, cannot be tackled with only a traditional litical and revolutionary became dominant in 1972 on- doctor-patient relationship; wards, backed by Basaglia and the MAI (Anti-Institu- • Taking charge because these needs must not be tional Movement) that proposed as a single objective just highlighted and analysed but managed di- the closure of psychiatric hospitals, considered anach- rectly and professionally; ronistic, ethically unacceptable and anti-therapeutic, • Therapeutic continuity, with a single hospital and in spite of the changes brought about by the 1968 territorial team to indicate the uniqueness of the Law 431 (Mariotti Law) that had permitted voluntary therapeutic and care relationship, necessary for admissions for medical examinations and treatment, solving one of the most important problems of abolished judicial registers, introduced by the Rocco psychotic conditions, the difficulty of creating code in 1930 and defined some standards for the or- and maintaining meaningful relationships. ganograms and organisation of psychiatric hospitals. During those years there were various experiences As ideological references, in their most radical ex- of Sector Psychiatry or at least the start of territorial pressions, it had the denial theories (Thomas Szasz) or activity and among these the most important was that in any case interpretations of mental disturbances that in Varese, which extended over the entire province. placed them more in an anthropological and sociologi- The promoter was Edoardo Balduzzi, during his direc- cal category than a medical one. tion of the psychiatric hospital from 1964 to 1968. Both these schools of thought, however, were well Because of his knowledge and rapport with aware of the ethical problem of the brutality of insti- French psychiatry and the “Sector” ideology he be- tutionalization, expressed by deportation, social exclu- came, in those years, the guiding light. sion, isolation and a life style that left little or no space Despite the friendship between Balduzzi and Ba- for personal choices, naturalness and privacy. saglia, confrontations on the experiences that they had Sector Psychiatry, born in France in the Forties both encountered materialized in meetings in Varese with the conceptualisations of Lucien Bonnafé who, and Gorizia, when in 1972 the climate changed and considering the internment of metal health patients as references to Sector were suddenly abandoned and ex- “primitive”, had proposed a welfare policy that would periences and renewal programmes, as they were not place an emphasis on the natural and social environ- aimed at an immediate closure of the hospitals, were ment they had come from, which would favour their considered to be in collusion with the asylum. recovery. It was not, as some had thought, a merely History, in recounting these experiences in the organisational proposal but a bona fide ideology with decades to come has, generally speaking, has been the aim of eliminating the asylum. none too kind. Bonnafè’s ideas had been put into practice in a Only in recent years has there been a reconsidera- pilot scheme carried out from 1954 in the XIII district tion of that time as being, in fact, an experience that by Philippe Paumelle, Serge Lebovici and René Diat- had anticipated that which is or would like to be psy- kine and in 1960 Sector Psychiatry was made official chiatry today: a psychiatry that in its relationship with in France with acts and directives of the Ministry of society has built or is endeavouring to build, albeit Health. with regional and area diversities, its new paradigms. Its innovative significance is perfectly expressed It may therefore be said that with the 180 Sector in some keywords: Psychiatry and Balduzzi both gained a victory. It was • Territory (or rather area or sector) to underline the shift of centrality in the care and assistance in a different name, less technical but emotional- of persons suffering from psychiatric distur- ly more captivating, community psychiatry. Some 140 M.A. Maieron

wordings at that time found a more precise and coming out of an isolation that had concerned not only accurate conceptualisation, other things have the patients, and the ability to influence those complex also changed. For example, better clarified was prejudices and cultural aspects of society that had de- the role of psychiatry within the social frame- termined and determine even today stigma, exclusion work with the evaluation of other subjects: the and isolation. families, associations, single persons or groups In fact, the asylum besides being a physical place in civil society, that operationally, in fact, often is also a mental category whose virtual walls are much acquire greater relevance that the Health Ser- more difficult to break down and this group has made vices themselves. Better specified also was the a significant contribution to dealing with this problem. concept of culture, in its values and symbolic The most important leverage in this was the alli- expressions, positive and negative, for the effects ance of the Health Services with family members and and the relapses on distress and psychic distur- their associations, not only for reciprocal comprehen- bances. The concept of taking charge has been sion but for doing things together, comparing assess- extended, although technically it still predomi- ments, aims and programmes with interventions, out- nantly bears professional references, socially it side the specific competences of the Health Services should however be much broader. The roots of and institutional technical meetings, that have, how- all this nevertheless lie in the keywords of those ever, proved to be invaluable for the results that they bygone years: territory, multi-professional team, have achieved. therapeutic continuity, taking charge, and in those This alliance proved useful to the associations of phenomenological derivation of relationships themselves, that thanks to the initiative of a Varese and intersubjectivity. (20) journalist, Lisetta Buzzi Reschini, founded the Co- PASaM (Provincial Coordination of Associations for In perfect continuity with his previous experience Mental Health). This too was both unique and exem- during the Sixties and Seventies a further contribution plary and it gave the family associations and volunteers made by Balduzzi to the renewal of psychiatry and in the possibility of creating a partnership with the Insti- this case also to the implementation of the 180, was tutions, otherwise impossible for separate associations. the proposal, in 1986, for the setting up of a work- It was, however, an important conquest for the ing group in the Provincial Administration under the Health Services as well and a highly effective way of acronym of GLP (Psychiatric Working Group, later influencing society and its culture. modified to an extended expression, Provincial Work- Many were the initiatives put into effect that ing Group for Mental Health). should be remembered: interventions in the schools The GLP, that two years ago completed thirty and in public demonstrations, raising awareness in years of activity, is both unique and exemplary in Italy Government Bodies and public and private structures, because it has signified a different way of practising activities for the patients themselves and the promo- psychiatry. It is a working group open to Health Ser- tion and their participation first hand in formulating vice operators, family associations and volunteers and programmes and activities that concerned them. (21) persons who for various reasons are interested in psy- Present day psychiatry, all things considered, pre- chiatric renewal in which, without any hierarchical and sents precarious and critical aspects above all evident, operative constraints and without subtracting anything albeit with pros and cons, in the new residencies. from the institutional competences and relations with the individual UOP interact with the territory, com- This is how Armocida summed up the situation a pare evaluations, suggestions, proposals and initiatives. few years ago: One of the problems that psychiatry had to face in its reorganisation after the 180 was that of finding the If unexpectedly, in the singular political and cul- right connections in the territory for introducing itself tural atmosphere of 1978, the law came into force into the network of various social and health agencies, that suppressed psychiatric hospitals by substitut- 1978-2018. The Basaglia Law forty years after 141

ing them with treatment of the patient in his own then Therapeutic Communities highly differentiated familiar and social environment, after thirty-five by type with a further form of low protective residen- years the “credibility” in long-term care has re- cy: light residency. This complex legislation in Lom- turned. […] If we take a look at where psychia- bardy would seem to be an optimal method for giving trists and patients are today we can realise that adequate and diverse solutions to the various needs of the manifestations of the revolution, together the users while also paying attention to the cost/ben- with the fantasies of those who were enlightened efit ratio. In reality, however, this has not been so. The with the idea of being able to renounce places of criticisms that can be made are multiple and regard “segregation”, no longer have the same voice as both the legal aspects and the management. To in- in the past. Perhaps psychiatrists have changed dicate just a few: Therapies conditioned by different their ways and are no longer in the blaring posi- types of communities on the basis of the intensity of tions that had led them forcibly to the Law 180. the intervention and the conditions of the patient fore- While asylums have now been dissolved, many see a complete resetting and restarting instead of an comments are possible, but it must be recognised indispensable continuity in the therapy in patients that that the same outsourced assistance that worried already have difficulty establishing meaningful rela- psychiatrists in the past, knows moments of un- tionships; the time constraints penalizing the length of deniable fortuity allowing a certain amount of rehabilitation make it easier to fall into welfare catego- flexibility in terms of healthcare solutions. (22) ries; the lack of territorial restriction in the choice of the community, even though allowing in its activities The way in which the problem of chronic care has interventions aimed at maintenance and a recovery been tackled, for which these structures are destined, is of “ability”, makes it more difficult or even impossi- in effect full of ambiguity in the way it has been evalu- ble to programme social inclusion, partial and gradual ated and for the uncertainties and errors in how the experiences of autonomy are in conflict with the regu- solutions have been determined. The concept of chro- lations concerning the running of the Communities. nicity, as far as psychosis is concerned, is the example Ample arguments can be made for each and every case. of ambiguity because besides the clinical criteria all too This is the conclusion I had reached, speaking often ideological prejudices are also expressed. Resi- about this problem in one of my earlier publications: dency in psychiatric mental institutions was intended for the persistence of symptoms above all if these were In therapeutic communities the inadequate in- expressed with behavioural disorders and the incorrect vestigation into the problems connected to per- assumption that an ordered lifestyle away from family sistent chronicity of severe psychic patients, all or pathogenic environments contributed to their im- to often collocate these persons in a dimension provement. The new residencies, on the other hand, that is almost exclusively assistive, proposing are derived from a declared emphasis on the disability many of the objectives that are characteristic of aspect and rehabilitation as its declared motive, failing the asylum: marginalisation, exclusion, in many to mention instead a negative prognostic judgement cases deportation, difficulties, obstacles and re- as far as recovery or precarious and difficult existential nunciation of projects leading to even partial situations are concerned. recovery. The improved quality of life and the The problem of severely ill patients with persis- attention that most of these institutions reserve tent symptomatology applies not only to Italy. Even for restoring abilities, or at least for maintaining advanced legislation such as that in France in 2005 them, does not modify judgement, particularly if speaks about psychic handicap as equivalent to per- the assessment is prospective. The low turnover, sistent chronicity and of Treatment Units as organisa- the result of experiences that come about sim- tional solutions for difficult patients. ply from the changeover from one community The region of Lombardy, as previously mentioned, to another or for not renewing the programme had foreseen, as residential structures, first the CRT, already initiated, without having obtained results 142 M.A. Maieron

from programmes and treatments carried out, in places in […] protected structures superior also paves the way for other effects, already seen to the decrease in places in asylums, while the in the asylum or as a consequence of their clo- prison population, that often has to take in per- sure without taking adequate account of the real sons with psychic problems, has increased in all needs of the patients: the progressive number of of these six countries. (24) patients deposited in this area or on the contrary situations of abandonment. However, it is not And this also has had objective confirmation in the fair to paint everyone with the same brush and province of Varese. (25) Problems however also exist in it is necessary to evaluate situations that due to territorial psychiatry, even where it has been possible to their initiatives are of a less negative prospective, evolve into community psychiatry, which represents the […] the consideration that may be made is that real aspect of innovation compared to the past. this is one aspect of the psychic health organisa- Some are problems that exist not only in psychia- tion that is already present to some extent and try but all branches of medicine, particularly in recent could later have even further regressive develop- years. The excessive bureaucracy that concerns all ments, surreptitiously proposing exactly what the facets of activity and therapeutic interventions, devel- 180 wanted to finally eliminate. (23) oped for control purposes, after dividing the organisa- tion into Authorities that programme, authorize and This is a short excerpt from an article by Franc- quantify economically the health services and other esco Cro, psychiatrist and coordinator of the DSM in Authorities that put them into practice in their insti- Viterbo, in the publication Mente e Cervello (Mind and tutions, has ended up privileging merely documentary Brain) (magazine associated to Le Scienze) in June formalities, taking up a considerable part of the op- 2014, that deals with the same subject from a more erators’ time (particularly those with responsibility), general point of view. subtracting it from clinical activities. The reduction in health costs in certain sectors has often penalized staff- Closure of the asylums, but perhaps it is not ing and reduced activity resources that in psychiatry enough. The Italian psychiatric legislation con- have concerned above all rehabilitation. cerning the closure of the asylums represented And the effects of these two problems are summed an original experiment, viewed from abroad fa- together. vourably or critically, but in any case with inter- The other aspect, above all for psychiatry, concerns est […] however numerous residential structures the number of beds in the SPDC. Those foreseen are still remain throughout the country, in which roughly 1/10.000 inhabitants, in the province of Var- patients are accommodated in the long term ese 75 for a population of approximately 850.000 in- and therefore the problem of chronicity and in- habitants (data from 2015), slightly fewer than what stitutionalization remains unsolved […] Simply there should be. abolishing the asylums by law is not sufficient, This sometimes makes admissions precarious with therefore, to tear the patients away from contain- temporary recovery outside the area and, due to neces- ment structures and reintroduce them into soci- sity, discharges are often hurried which only facilitates ety. Research coordinated by Stefan Priebe, lec- subsequent re-admissions. turer in social psychiatry at the London School The conclusions to be reached in judgement of the of Medicine, has drawn attention to the risk of 180 and what has happened after its activation should an increase in admittance to residential structures therefore necessarily be noted. On the one hand its that is underway in six European countries that ideological and symbolic significance means that its had, on the contrary, set up reform programmes relevance remains unchanged: it is a divide that marks to “deinstitutionalize” – Great Britain, Germany, a “before and after” and the ‘after’ has opened up com- Italy, Holland, Spain and Sweden. Italy and Hol- pletely new horizons, shifting the centrality of psychi- land. Holland, especially, had shown an increase atric intervention to the needs of the persons and re- 1978-2018. 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21. Iannella G, Cantarelli C. I gruppi di auto-aiuto. In Maieron organizzati i servizi sanitari psichiatrici in Italia e nel resto MA. Il matto dei tarocchi, Alice e il Piccolo Principe. La d’Europa. Mente e Cervello; 2014: 114:75 follia come diversità nella cultura e nella società. Milano- Udine: Mimesis; 2013. 22. Maieron MA, Armocida G. Storia, cronaca e personaggi della psichiatria varesina. Milano-Udine: Mimesis; 2015: Correspondence: 211-53. Mario Augusto Maieron 23. Cro F. Salute mentale: l’Italia e le altre. L’incontro sul ter- ASL Varese ritorio con il paziente è cruciale per ridurre il rischio di (now Agenzia di Tutela della Salute – ATS - dell’Insubria) ricadute e favorire l’inserimento sociale. Ecco come sono E-mail: [email protected]