sabato 20 giugno 2020

Italy as example in good practices in "mental health"?

Italy as example in good practices in "mental health"?

by Erveda Sansi
In Italy there are not fusion laws, the law articles (law 833 art. 33-34-35) who also regulate forced treatment and commitment, says nothing about alleged social danger or harm against oneself or others.

Roberto Mezzina, from Trieste’s “Basaglian” Psychiatry, writes: “In the Law 180, the reason for a very limited use of involuntary care is linked to the severity of the conditions and the denial of care on the part of the person. Dangerousness is not anymore mentioned as the reason for it, so there is no power assigned to the judiciary system. The overcoming of the architrave of the previous legislation, which combined mental illness with social danger for oneself or others, and of being a public scandal, led to a radical change in the system of involuntary treatments”; in Roberto Mezzina: “Forty years of the Law 180: the aspirations of a great reform, its successes and continuing need”

A very limited use of involuntary care? Radical change? In reality psychiatric patients lose, in most cases, the freedom to decide for themselves. Not only to take or not psychiatric drugs, but also to decide on their own money and other important decisions that affect their life; not only for a limited period of time, but for always. I often hear cries for help uttered by psychiatric patients who don't know how to get out of this situation. But often they cannot ask for help, because at the moment of hospitalization their cell phone is removed and relatives cannot go to find them.

Normally, after two weeks or so of forced hospitalization, they are so sedated that they can no longer rebel against psychiatric drugs and if they oppose, during the hospitalization or after the discharge, they are threatened with forced treatment. After that, the person in question is forced to take depot psychiatric drugs, usually for a lifetime. There is no law that imposes it, but there is no possibility to get out of this vicious circle.

In my opinion this happens because at the base there is the very serious prejudice that presume that people with the diagnosis of mental disorder, is automatically incapable.

This happens not after the psychiatric patient has a big crisis, but also because of banal, everyday things, a quarrel, an altercation or simply thoughts or behavior, that someone, in good or bad faith, judges as “abnormal”.

The Civil Code (articles 414 to 432) governs the institution of interdiction and incapacity. Even today, in fact, the Civil Code provides that for people who is considered to be in a condition of habitual mental illness, which makes them unable to provide for their own interests, an interdiction measure may be requested, with the appointment of a guardian. They are interdicted when necessary to ensure their protection. (Article 414: “Persons who may be interdicted. The adult and the emancipated minor, who are in conditions of habitual mental illness who make them unable to provide for their own interests, are interdicted when this is necessary to ensure their adequate protection”). (Article 415: “Persons who can be incapacitated. The mentally ill adult, who's state is not so serious as to give rise to an interdiction, may be incapacitated”);

In Italy in 2004 was established the institution of the support administrator (Civil Code Articles 404 to 413). Article 404: “The person who, due to an illness or a physical or mental impairment, is unable, even partially or temporarily, to provide for his own interests, can be assisted by a support administrator, appointed by the tutelary judge of the place where this has the residence or domicile”.

"The support administrator is a figure established for those people who, due to an illness or a physical or mental impairment, are unable, even partially or temporarily, to provide for their own interests". So begins, on the website of the Ministry of Justice, the information sheet relating to this institution, as required by law 6 of 2004.

The elderly, disabled, etc. and also psychiatric users, can request by appeal, even if they are minors, disabled or incapacitated, that "the judge to protect will appoint a person to take care of their person and their property". But this request, which does not require the assistance of a lawyer, can also be presented by the partner, by relatives, by the guardian or curator and by the public prosecutor. However, the fact sheet also states that "those responsible for health and social services directly involved in the care and assistance of the person, if they are aware of facts such as to make the opening of the support administration procedure appropriate, are required to propose to the judge the appeal or in any case to inform the public prosecutor about it" (art. 406).

The practice of the support administrator has led to many abuses, there are ongoing trials that often lead to nothing because the people involved have ties to the judges or because psychiatric users don't have enough power to defend themselves.

I found only now the document from September 2017 by the The National Bioethics Committee (CNB), an Italian governmental institution: “The care of people with mental diseases: some bioethical problems”. They made also several references to the World Network of Users and Survivors of Psychiatry, Implementation Manual for the United Nations Convention on the Rights of Persons with Disabilities, February 2008,

At page 16 I read: “The fact that in some States - but as we will see not in Italy - people can be deprived of their freedom on the basis of their current or perceived impairment, pursuing other reasons, including that of the fear that they are dangerous for themselves and for others, is considered a practice incompatible with art. 14, "discriminatory", and that "corresponds to an arbitrary deprivation of liberty"”.

Italy is the exception among the other States…? Then they go on: “The concerns and recommendations expressed by the Committee on the Rights of Persons with Disabilities in the guidelines return in some points of the Concluding Observations on the initial report of Italy, 2016. Here in particular it is recommended "the reform of the regulations and policies that prohibit detention, including forced hospitalization and/or compulsory health care based on disability as described above, thus harmonizing laws and policies with the Committee's statement on article 14".

On the merits, however, it can be observed that the Italian TSO [forced treatment and forced commitment] legislation does not establish compulsory hospitalization "on the basis of disability", but provides it as an exceptional institution, as such subject to a series of guarantees (mayor's order, transmission of the order to the tutelary judge within 48 hours, possibility of recourse of the person or family members against the measure, additional requirements for the extension of the mandatory treatment beyond the seventh day). […] With reference to article 19, the Committee says "seriously concerned about the tendency to re-institutionalize people with disabilities and the lack of reallocation of economic resources from residential institutions, to the promotion and guarantee of access to independent living in their community" (par.47). Finally, the same Committee asks to repeal the rules that provide for the replacement of decisions by legal guardians and also by support administrators, while it hopes for forms of support for the decision-making of the person with disabilities (par. 28). On the other hand, it should be noted that, as will be better explained below, the figure of the support administrator was introduced precisely to protect as much as possible the legal capacity of people who go through critical conditions related to the disease and to limit use to a minimum of interdiction and incapacitation. (page 17.) […] The second major obstacle is the asymmetry of power: the power of decisions is concentrated in the hands of those who manage the biomedical model and this cannot fail to damage the modern principles of holistic care and can only strengthen paternalism. It is clear that the belief that people with psychosocial disabilities are still dangerous remains strong, "despite the clear evidence that they are commonly victims rather than perpetrators of violence" and that they are unable to make decisions for themselves, despite showing that they can live in a way independent if they have legal protection and support” (page 18).

But as I said before, the institution of the support administrator from 2004 gave rise to numerous abuses, and interdiction and incapacity laws often hang like a Sword of Damocles over the head of people with a psychiatric diagnosis. Often the psychiatrists applies de facto the laws, with the constant threat of forced treatments. The fact that psychiatric users often do not have money available, are unemployed and dependent on relatives who do not wish to safeguard their freedom at all, also explains why so many psychiatric users do not have the opportunity to seek justice.

“For decades now there has been evidence, based on scientific research and experience, to support psychosocial services oriented towards recovery and alternatives to coercive treatments. However, without promotion of these services and economic investments to support them, they will remain peripheral and cannot bring about the promised changes”, the document continues at page 18. I’m not the only who know the real situation: we as taxpayers have to pay a lot of money for the many little private madhouses, in the official language “Psychiatric Rehabilitative Therapeutic Communities” or “Psychiatric Residential Structures” or “Family home for psychiatric patients”, for the Psychiatric wards in the Public Hospitals and for the psychiatric drugs. With that money they could in practice help those in economic difficulty, by helping to pay for food and housing. One could follow the Swedish example of the Personal Ombudsman, or community without the supervision of health and psycho-social staff and so on. It would not cost as much as private structures mentioned above, contracted with the State, which have an interest in making the dependence on psychiatric institutions chronic.

I should also speak about the Judicial Psychiatric Hospitals (OPG) which have throwing out the front door in 2014, to take back through the window in the form of the Residence for the Execution of Security Measures (REMS) for mentally ill people, with an improvement, even that only partial, of the external and internal architecture, leaving the status quo for patients quasi unlike that of the previous institutions.

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