COMMUNITY PSYCHIATRY IN ITALYdi GIORDANO INVERNIZZI
Exactly twenty years have passed since Italian psychiatry made its stand, chancing the success of its new treatment for insanity. At that time, all psychiatrists, regardless of extraction, training or background (hospital, academic, biological or psychodynamic), agreed that the system had to be changed, that one could not go on with an organization that dated back to Esquirol and Chiarugi and whose legal regulations were based on the law on mental illnesses unrevised since 1904. There had thus been a kind of popular uprising, by psychiatrists, politicians and patients' relatives, who sided together, totally refusing to continue this type of treatment for the mentally ill. Such was the pressure of these demands for change that
the authorities began to fear an impending national referendum for the immediate abolition of the mental hospitals. This prospect (which would have put the national health system in serious difficulties), spurred the Italian government into unanimously approving the new legislation on psychiatric care.
Psychiatric treatment in Italy underwent a deep-seated and radical change in 1978 with the passing of law 180. This law sanctioned the end of the Psychiatric Hospital as an institution that removed the mentally ill person from society and segregated him, under prison-like conditions, as he was considered a danger to himself and to others and offensive to society. So we have progressed from a situation where society erected a protective barrier against the mentally ill to that in which the subject concerned is considered a sick person in every way, a person who is suffering and who has a right to be treated, and not only guarded and segregated. Psychiatry thus stopped being a peripheral area of medicine and began to be integrated into the general health service.
Psychiatric hospitals had traditionally been located well outside the towns; they were isolated, divorced from reality. Instead, with the passing of the new law, psychiatry was again a part of medicine; a psychiatric disorder had the same dignity as an illness; it no longer stigmatized the sufferer and set him apart.
The abolition of the Psychiatric Hospitals meant that psychiatry had to be integrated within the social context of the community: out-patient clinics were organized in the various districts and Departments created in the General Hospital. Patients were thus brought into closer contact with normal life and with their families, and there was a rejection of the concept of mental illness as something different, something dangerous, to be hidden and denied. Admissions to psychiatric wards were no longer motivated by the fact that the patient was dangerous, but by an urgent need for a form of treatment that could not feasibly be provided outside the context of a hospital stay. Admission was therefore no longer tantamount to an arrest, but solely a measure taken for health reasons.
Legal provisions established that the new health service facilities were to be organized on a regional basis and set in the context of the General Hospital. The new structures were assigned specific functions, including the provision of suitable outpatient and in-patient care and social welfare and health services. The organizational model is based mainly upon the joint and co-ordinated action of psychiatric services operating within one and the same area, in accordance with the principle of therapeutic continuity, whereby users are identified according to their area of residence.
This revolution has obviously not been easy to carry out and, still today, there are ideological and practical problems impeding its realization As you well know, Italy is made like a boot. It is an elongated peninsula stretching from the Alps almost as far as Africa. There are still considerable differences in culture, economic conditions and industrialization between north and south. It is undoubtedly one of the most heterogeneous countries in Europe. The outcome was inevitable: the psychiatric revolution, conceived and engendered in the north, has not been interpreted and implemented in the same way in all regions. Although the theoretical model is universally accepted in principle, it is still hard to achieve homogeneous results in terms of practical application; each region has changed its old organization and services to suit the local situation. So, today, what we effectively have is a General Plan of objectives entitled The Protection of mental health 1997-1999, drawn up by the Ministry of Health that establishes broad guidelines for the changes, plus a series of regional projects, which present quite substantial variations.
I shall now go on to illustrate the model realized in Milan. Milan is in Lombardy, a Northern region, and the new organization achieved in this city most nearly approaches the complete organization according to the inspiring principles of law 180. The model I am about to present to you is further complicated by the fact that it is directed by the university. This is a rare situation in Italy, where district Psychiatric Services are nearly all under hospital management.
The basic structure is the Department of Mental Health (DMN), which is ultimately responsible for prevention, care and rehabilitation in connection with mental illness in the adult population. The Department also provides for emergency treatment at home or in hospital; it possesses acute admissions' wards and hospital first aid units. In order to carry out their programmes, the Departments draw on the services of out-patient centres or health clinics that provide treatment in a hospital setting or in residential or semi-residential communities.
The basic programmes cover the following areas:
- social and health care and
- social support.
The Department has various health centres that are able to guarantee therapeutic continuity and to intervene during the various stages of mental illness.
The Psycho-social centre (PSC) provides a range of services relating to out-patient treatment and home care. It also ensures that patients and their families have access to a special information service to assist them with their problems. The PSC works in conjunction with the other basic social and health welfare services for the district. It guarantees emergency psychiatric intervention; it runs training and occupational reintegration programmes for young people and adults; it acts as a filter for admission to private nursing homes and other private institutions and supervises all aspects of the relative stay. It also performs consultancy activities for hospitals that do not possess a psychiatric diagnosis and care service of their own. It organizes socialization programmes, including holidays and excursions, and arranges financial assistance through subsidies.
The general First Aid Department includes an Emergency Psychiatric Unit. This functions round the clock, dealing with crisis situations and deciding on the best form of treatment. Again within the General Hospital context, there is a Psychiatric Diagnosis and Care Service (PSDC), which provides for the needs of patients requiring medical treatment involving a stay in hospital, both in the case of voluntary admissions and in that of compulsory treatment. It also guarantees emergency treatment in conjunction with the hospital's emergency department. The PDSC is part of the framework of the general hospital in a particular district. It is an integral part of the DMH, and is structurally linked with the other health centres. The PSDC is officially allocated one hospital bed for every 10,000 inhabitants.
The intermediate semi-residential structures are designed to provide medical and psychiatric treatment and opportunities for daytime re-socialization for subjects requiring this. The structures include the Day Hospital and the Day Centre.
The Day Hospital is a semi-residential structure in which short- and medium-term therapeutic and rehabilitative programmes are carried out. It is intended for patients with sub-acute psychiatric disorders who are in need of drug therapy, psychotherapy and/or rehabilitative therapy. The aim is to avoid as far as possible the need for a full-time hospital stay during periods of patient relapse or inability to cope, and to limit the duration of such stays should they be indispensable. The structural configuration of the Day Hospital thus envisages a possible necessity for drug treatment and guarantees the availability of suitable premises for patients requiring infusion and sedative therapy.
The Day Centre provides a free environment where therapeutic and rehabilitative programmes and re-socialization activities aimed at the recovery and development of the patient's social skills are carried out in a semi-residential, community setting. The Day Centre may take the form of:
- an intermediate structure designed for medium-term rehabilitation of persons with social and occupational problems;
- an intermediate structure for difficult patients, helping patients to maintain their autonomy within the community and to improve their clinical condition. Hence the Day Centre lays emphasis on specific and personalized rehabilitative intervention tailored to the specific requirements of the patient, avoiding the necessity of a prolonged stay in the centre. Rehabilitative programmes are designed for psychotic patients, for those suffering from serious personality disorders and for subjects who are distressed or in a pre-crisis situation linked with objectively difficult external conditions. However, a psychotic or seriously disturbed patient is only assigned to a rehabilitative programme when there are identifiable areas of functioning that indicate the possibility of improvement.
The Intermediate Residential structures have been designed to meet medium- and long-term health care needs engendered by the so-called new psychiatric chronicity. They mainly cater for subjects whose illness is of recent onset, but who are soon found to have problems with social functioning and autonomy. Such patients often require intensive care in a sheltered residential setting in order to help them recover the skills they have lost. The residential structures are organized in different ways according to the degree of shelter required and, above all, according to duration of stay and prescribed treatment or therapy.
The Residential Centre for Psychiatric Therapy and Rehabilitation (RCPTR) is organized as a therapeutic community. Its function is to carry out fixed-term therapeutic-rehabilitative programmes which entail a temporary stay in a residential setting. The RCPTR is a health centre, not a hospital centre.
Communities are structures designed to meet the health and social welfare needs of psychiatric patients requiring therapeutic and rehabilitative assistance to underpin and develop their residual capacity for autonomy. Treatment is provided in a sheltered residential setting, with no pre-determined time limits.
All sheltered communities run by each DMS are classed together as Sheltered Community Centres. These Centres are organized to provide various levels of protection: from round-the-clock assistance for patients suffering from marked personality destructuring, to relatively limited care for those who possess a certain degree of autonomy. The various levels of shelter may coexist within a single structure or be provided by separate structures.
These days, the Italian model of psychiatric care is organized so as to provide several differentiated kinds of treatment, chosen according to the prognosis for and characteristics of the psychiatric disorders concerned. Essentially, the aim is to reduce the need for hospitalization to a minimum and to limit its duration where unavoidable. This is achieved by operating within the patient's social context and family, by trying to prevent chronicization and by maintaining the patient in his own relational network. The aforesaid orientation has led to the closure of the traditional psychiatric hospitals and to the organization of prevention, treatment and rehabilitation on a local basis. Psychiatry has thus become one of the General Hospital Departments, with the same status as all other medical specializations, and without any negative connotations as a less worthy science.
The following concept is fundamental: psychiatric intervention must not be limited to a single option (whether pharmacological, psychotherapeutic or rehabilitation); nor can it rely on multiple but disconnected options. Several phases of the various disorders can be identified, each of which requires specific and appropriate intervention: prevention, the emergency phase, acute episodes, the stabilization phase and prevention of relapse. Several therapeutic techniques are available for each different phase. It should, however, be stressed that our aim is to integrate somatic, psychological, behavioral, family and social interventions.
Studies performed in different countries, among people from different cultural groups, all support the theory that no mental illness need necessarily become chronic, a principle that extends to even the most serious disorders, such as schizophrenia. The continually-increasing rate of chronicization is only partly due to the endogenous structure of the personality; in most cases it is linked to factors which are extrinsic to the disease, in particular, those concerning the family and the individual's social environment. Interventions during the acute and emergency phase must therefore be set in the context of a global therapeutic program but, most importantly, we need to identify those interventions which obviate the danger of chronicization right from the earliest stages of the illness.
Above I have described Italy's experiences over the last twenty years in its attempts to change psychiatric care and make it more civilized. Unfortunately, results are not as yet uniform throughout the country. There are regions which provide a shining example of what can be done, and other, more backward areas, but today, we are proud of what we have achieved so far and we are committed to pursuing this path, thus enhancing the quality of our patients' lives.