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From asylums to REMS

From asylums to REMS

At the beginning of the nineteenth century, in France, with Philippe Pinel psychiatry was constituted as a practice, theory and specific institution, through the creation of kindergartens which with the law of 1938 would take the name of psychiatric hospitals. Pinel grasps the relationship between social disintegration, misery and mental illness with acute sensitivity and defines the asylum as a place to defend the sick from a turbulent society rather than society from the sick, ensuring that they meet the minimum as well as primary needs like having a bed, food, warming up, recreation and treatment. The abolition of restraint and the use of drugs guide psychiatry to understand treatment as an environmental and moral re-education, as a remedy for the damage produced by society itself.

Until the twentieth century, nurses were recruited without any selection and immediately placed in the workplaces made up of asylum pavilions, without any training. In 1902 the first national competition for psychiatrists was launched in France and a specialized and homogeneous medical body was then established. Thus emerges throughout Europe the need for a system organized by territorial sectors which could be managed by a therapeutic team capable of taking care of the treatment of psychiatric patients and prevention in this sense. In Italy, a law of 1938 obliged each region to create a structure that would welcome and treat the mentally ill.

The history of psychiatry is linked to that of its institution par excellence: the asylum. In Italy, the law 36 of February 14, 1904 “on mental asylums and the alienated” stipulated that: “people affected by mental alienation for any cause must be kept and treated in mental asylums when they are dangerous to themselves or others or are publicly scandalous and they are not and cannot be conveniently guarded and cared for except in asylums “.

asylums were structures located outside the city, where the individual, or as it was used to say, “the alienated”, lost not only his civil rights, but also the dignity of man and became places of imprisonment, deposits without time, where the concept of care was being lost. From the 30s, with the introduction of shock therapies and later, from the 50s, with the discovery and therapeutic use of the first psychotropic drugs, we witness a first great change and we begin to talk and relate to the patient and mental illness in a new way and with a new code.

Law 431 of 18 March 1968 then provides for the restructuring of psychiatric hospitals, the insertion of psychiatry also in civil hospitals, the institution of voluntary hospitalization, the abolition of the obligation to record hospitalization measures in the criminal record. Many years will still have to pass before the changes triggered by Franco Basaglia are accomplished in their entirety, in fact only at the end of the 70s will there be a radical change in the approach to mental illness.

In 1978 law 180 was approved, which provides for the overcoming of psychiatric hospitals, the integration of psychiatric assistance into the national health system, the creation of territorial structures for psychiatric assistance in specific structures and the limitation of compulsory health treatment in conditions of hospitalization and only in case of serious danger for oneself or for others and in case of inability or refusal of drug therapies.

Following Law 180, psychiatric hospitals are gradually dismantled, where interned patients remain hospitalized before the law comes into force. All new patients are expected to be admitted to psychiatric wards in civil hospitals.

The doors of the asylum are opened and with them new perspectives for clinical practice, still to be reorganized.

The psychiatric service is constituted by the Department of Mental Health (DSM) on which the Psychiatric Operative Units depend, which in turn are divided into various units including the SPDC (Psychiatric Diagnosis and Treatment Service) and the CPS (Psychosocial Center) coordinator of territorial psychiatric, psychotherapeutic and rehabilitative outpatient activities.

The CRT (Residential Psychiatric Therapy Center), which is responsible for medium and / or long-term treatments, also includes the CP (Protected Community) housing structures aimed at individuals who need longer-term rehabilitation and / or assistance interventions.

Finally, there are the semi-residential structures to which the Day Hospitals and Day Centers belong, where mainly rehabilitation activities are carried out, throughout the day, aimed at patients who do not need residential structures but for whom the outpatient treatment.

All these services are linked together and coordinated in a project developed by the Psychosocial Center of reference and aimed at taking care of the patient. Services are born and based on team work, a privileged tool through which patient care passes and takes place. Over time it has become necessary to redefine the theoretical reference models for the psychiatric team, developed for institutional management, to adapt them to a wider management also on the territory.

WHO defines health as “a state of complete physical, mental and social well-being and not the simple absence of a state of illness or infirmity”. Starting from this definition, the bio-psycho-social model is configured as one of the most suitable and requires the reprogramming of interventions that “build and follow the network of social relations”. As regards this passage, great merit goes to Health Psychology, which has demonstrated the role of lifestyle and stress in morbidity and mortality, developing a series of theoretical models that help to understand the effects of these factors on our health.

One of the aspects that psychology has highlighted is that health, diseases and disabilities do not exist in the social vacuum, but arise and fit into relational, social and cultural contexts. On these principles Engel, in 1977, elaborated the Bio-Psycho-Social Model, according to which the diagnostic process needs to take into consideration biological, psychological and social aspects in assessing the state of health and prescribing adequate therapy.

Despite the fact that the “psychic sufferer is today the object of attention in an attempt to recover a more human dimension”, the measure of hospitalization in the OPG, hospitals dedicated to the assistance of the psychiatric patients who have committed the crime, has so far resisted any attempt at reform by the Italian government. Despite the attention and the will not to retrace the path that made the history of mental asylums and insane asylums unjust and inhuman, much still needs to be done to reach a historical, sociological and legal understanding that affects the total institution of OPG. The OPGs have long remained a complex, multifaceted and stagnant reality, the subject of complaints about the conditions of the inpatients, in some cases incompatible with the protection of fundamental rights.

It is a fact that justice needs places that deal with violent psychiatric patients. The reflection was whether OPGs were still the most suitable places, the only solution to be able to manage that delicate and sometimes too heterogeneous category of subjects, defendants, convicts, who lives there. This reflection cannot be separated from the analysis of four fundamental components such as structures, internees, staff and financial resources.

The structures that hosted the NGOs referred to destinations of use that had little to do with their hospital nature. It was in fact structures intended for convents, barracks, prisons or, in the specific case of Castiglione delle Stiviere for example, of simple modification of the destination of civil psychiatric hospital, already abolished, in OPG.

As for the internees, they could be:

  1. Subjects acquitted for mental illness, and subjected to hospitalization in a judicial psychiatric hospital as socially dangerous, and therefore not attributable but socially dangerous.
  2. Subjects with supervening mental illness for whom internment was ordered in a judicial psychiatric hospital or in a nursing home and custody (for example, interns in double diagnosis are included).
  3. Temporary defendants subjected to a security measure in a judicial psychiatric hospital in consideration of the alleged social danger and awaiting a final judgment.
  4. Persons with a partial defect of mind, declared socially dangerous and assigned to the nursing home and custody.
  5. Psychic handicapped people, a complex category because they include subjects considered imputable who already have a psychiatric pathology at the time of the fact that does not allow their stay in an ordinary institution but is not serious enough to compromise their ability to understand and want.
  6. Convicted prisoners, for whom mental illness occurred during the execution of the sentence or, finally, prisoners for whom mental illness must be ascertained.

The emerging critical issues concerned the absence of a diagnosis and treatment service capable of taking on these situations if not with the transfer of the prisoner to the OPG and the lack of homogeneity of the interned population, in particular for the personological, criminal and clinical aspects.

There were 6 OPGs in Italy and welcomed more than 1400 people. The goal of the legislator, who authorized its creation, was to guarantee adequate care for people with mental illness and face their “social danger”.

The penal code provides for the minimum duration of the security measure, in 2, 5 or 10 years, in relation to the seriousness of the crime committed, but it is not pronounced with respect to the maximum possible duration of the internment which, in the absence of alternatives, often translated in “white life sentences” or the permanence in OPG for life. Some reports and inspections ascertained the inhuman conditions of detention of the patients.

Already in 1974, following the death of a woman, due to the fire of the mattress to which she was tied, the then Minister of Justice Oronzo Reale, declared that the Government would be committed to the closure of the OPG. But although several sentences of the Constitutional Court have reiterated the possibility of adopting the probation as an alternative to internment in the OPG, it took thirty-four years before the Prime Minister’s Decree of April 1, 2008 sanctioned their overcoming and that the law number 9/2012 identified the date by which the OPGs should have been closed on 1 February 2013, which was extended to 1 April 2014.

In 2010 a parliamentary commission of inquiry was launched on the effectiveness and efficiency of the National Health Service and Ignazio Marino was responsible for it. The investigation thus desired, allowed the technicians of the parliamentary commission to go personally, with surprise inspections, to all the OPG present on the Italian territory and to check the sanitary, structural and administrative conditions. The degradation of which they were spectators was defined by the President of the Republic Giorgio Napolitano “an unacceptable horror in a barely civilized country”. The commission following the dramatic reality found decided to make public a video, which shows the images, the voices and the statements of the sentenced to white life imprisonment,

In the Judicial Psychiatric Hospital of Barcellona Pozzo di Gotto (province of Messina) the commission, by inspecting the restraint department, was able to see how the prisoners were treated. They found naked men, tied to an iron bed, without a mattress, without sheets. The hands and feet tied, with gauze used as ropes, at the four corners of the iron structure and in the center of the bed, a hole for the fall of feces and urine in a well below. Conditions and restraints these could last for days.

Law number 9/2012 definitively establishes that as of March 31, 2013 the assistance measures of the former patients of the OPG would be carried out exclusively within health facilities, it being understood that the people who had ceased to be socially dangerous had to be without delay discharged and taken over by the mental health departments of the area. A series of loans was provided for the construction of new structures, for the completion of the process and for carrying out monitoring and verification activities throughout the entire process.

The regions have therefore been called to face the need to identify, create and support places that can welcome and treat patients detained at the OPG. The ASLs of the Italian Regions allocated funds and arranged for the creation of new structures and new teams necessary for taking charge of these patients.

Some regions have been more efficient than others but today the picture is complete albeit with many differences between REMS (Residence for the Execution of Health Safety Measures), which end up jeopardizing the principle of equality in treatment. Currently 28 REMS are operating on the Italian territory, for a total of 624 places available and with the transfer of the last 2 interned from the OPG of Barcellona Pozzo di Gotto in May 2017 ended the centuries-old history of criminal asylums in Italy, later called Judicial asylums, OPG.

REMS were created to guarantee the execution of the safety measure and at the same time the activation of therapeutic-rehabilitation courses.