BLOG FOSTREN- ITALY
Raffaella Pocobello, Livia Lepetit, Tommaso Bonavigo, Gian Maria Galeazzi, Giulio Castelpietra, Antonello Leogrande, Francesca Camilli, Giovanni Rossi
What is your Country’s stand on coercion reduction?
Coercion in psychiatry has been a discussed topic in Italy for many years, especially in the long and complex process of deinstitutionalisation that led to the abolition of psychiatric hospitals, which were recognised as places of segregation, violence and violation of human rights. In 1978 national law 180 imposed the closure of asylums and marked the start of a new mental health system based on community-based care, public health and respect for human dignity.
The Italian Constitution states that “personal liberty is inviolable” (art. 13) and that “no one may be obliged to undergo any health treatment except under the provisions of the law”. In any case, personal dignity and human rights must never be violated (art. 32).
According to Law 180, involuntary treatment (TSO, that is Trattamento Sanitario Obbligatorio) must be considered “only if (1) there are such mental alterations to require urgent therapeutic interventions, (2) those are not accepted by the infirm, and (3) the conditions and circumstances do not exist to enable timely and appropriate out-of-hospital health measures to be taken”[1]. No explicit reference in the law is made to coercion in psychiatry in any of its forms, and the lack of regulation may have contributed to the persistence of its adoption[2]. The TSO is required by two independent physicians (one of them must be of the public healthcare system), then authorised by the city’s mayor, and finally approved by a judge. The initial treatment lasts for seven days and can be transformed into voluntary treatment immediately after the patient consents to the treatment. For further reapprovals (each of maximum seven days) the same procedure must be required by only one psychiatrist, who must declare that all efforts made to obtain the patient’s consent to treatment were inefficient. At any moment, the patient herself/himself (or anyone else) can appeal to the judge against the TSO.
The whole TSO procedure was designed to guarantee the patients’ rights, but critical aspects remain unsolved. Though the person authorised to decide on TSO is the mayor, her/his role is merely a formality and the decision is actually made by a psychiatrist or a physician, who can use it to protect the interest of the healthcare practitioners and mental health services to avoid risks of claims for clinical negligence in case of harmful and dangerous behaviours of the patients against oneself or others. In fact, even if the target of TSO is the need for treatment and not the patient’s dangerousness, mental health services and practitioners are constantly pressured by public institutions (i.e., courts, police) to prevent, control and reduce problematic behaviours in society. Indeed some argue that the judge’s guarantee role is insufficient to balance the difference of power, which is mainly in favour of the psychiatrist compared to the patient.
Often legitimated as an “emergency solution” to prevent an actual imminent risk of serious harm to someone (Art 54 of the Penal Code), coercion is still frequently used in many psychiatric services (for adults and minors) and elderly care services, both public and private.[3]
In Italy, chemical and mechanical restraints are the most common forms of coercion (usually bed restraints, while seclusion is far less frequent).[4] Some governmental inquiries have found frequent use of such coercion measures, sometimes for futile or no clear reason[5], occurring in the Psychiatric Units within General Hospitals (the so called SPDCs, that is Servizi Psichiatrici di Diagnosi e Cura, meaning Psychiatric Services for Diagnosis and Treatment),
Due to the regionalisation of the Italian Healthcare System, mental health services and practices can be very different in Italy depending on the region you live in, indeed depending on multiple factors, among which the level of staffing, the political favour for either community-based or hospital-based system as well as to the culture of the service and team.
In 2006, a network of restraints-free SPDCs was born (“Club SPDC no restraint”) to bring awareness to the possibility of not using coercion. Acknowledged as an example of good practices by the Committee for Bioethics (Comitato Nazionale per la Bioetica or CNB), they propose a new culture for psychiatric services aligned with human rights and the Convention on the Rights of Persons with Disabilities (CRPD). The network includes about 20 services all around Italy.
In 2016, an effective campaign against coercion in psychiatry was launched and promoted by Forum Salute Mentale (Mental Health Forum), a group of professionals and activists: “… e tu slegalo subito (“… untie him immediately”).[6]
Initiatives have been taken to raise professional and public awareness about abolishing coercion from healthcare services.
In 2022, around 60 million Euros of funds were allocated to reinforce Mental Health Services, including developing no restraint culture and practices.
By now, political instability has made it hard to pursue any radical intervention in the near future.
What kind of research is happening in your Country on this topic?
The use of coercion is undervalued and remains massively untraced, staying “hidden in the places of care”.[7]
Little research has been made to assess the use of coercion in Italy. Some multi-centred studies have focused on mechanical coercion in specific areas (Sangiorgio & Scarlatto, 2009; Zanetti et al., 2012) but no extensive research has been done to map the whole Country. However, some “No restraint” SPDC have produced interesting reports about their experience.[8]
Other publications focus on historical, clinical, political and juridical aspects of coercion in the Italian context.[9]
The Italian Committee for Bioethics has recommended researching and monitoring the phenomenon at a regional and national level, from tracing the daily coercive practices in wards to introducing training and promoting no-restraints standards.
Why are you in the network? What would you like to achieve with it?
In Italy, mental health services have long experience of coercion-free practices.
For example, all mental health services have been restraint-free in Trieste for more than 40 years. The ‘Trieste model’ is an open-door and recovery-oriented approach to public psychiatry that WHO and the Council of Europe cited as one of the most progressive in the world.[10]
Through the Fostren network, we wish to increase data and scientific research about our coercion-free services since the topic needs to be better studied nationally and internationally.
Thanks to the research purposes of Fostren, we also urge the Government and the Parliament to monitor the scenario and make the collection of data on coercion in our Country at institutional level mandatory.
Also, we wish to shape and organise our knowledge about coercion in collaboration with all the other teams and countries involved.
An international network is essential to share knowledge, common challenges and practices for a future that can make healthcare systems more humane and respectful towards their patients and workers.
It would be made possible to draft and adopt guidelines, recommendations, policies, procedures, protocols, and shared practices, not only at the medical but also at the juridical and administrative levels.
Coercion is a global healthcare as well as juridical and ethical, issue, and through the network, we could benefit from connections and develop innovative and inspiring solutions.
A strong and reliable network can also influence policymakers and institutions.
Is there anything else that you want to share with us?
Italy seems to be divided on this issue. Critical psychiatry tradition and humanistic approaches to mental health are still strong. Conversely, a biomedical vision of healthcare and an alarming return of institutionalisation are becoming more and more influential.
In the past ten years, the news reported multiple cases of people who died while being restrained to their beds in psychiatric wards. These events were brought into the public eye, raising outrage and shock among people.[11]
Informal groups of citizens, associations of families, peers and survivors are a resource for acknowledging local realities, raising awareness, and promoting good practices.
Promoting a culture of tolerance and awareness about mental health is not just a matter of social inclusiveness, but also of accountability for the entire public care system.
«If we do not recognise that we are part of the world of threat and prevarication by which the patient feels overwhelmed, we will not be able to understand that the patient’s crisis is our crisis.»[12] F. Basaglia
[1] Regarding the third clause, it’s relevant to observe that, when this law was introduced, alternatives to involuntary treatment were seen as a direction to develop and implement, while at the moment they’re largely on divestment.
[2] Juridical legitimacy of coercitive measures in extreme cases is an ongoing debate, also because of the lack of specific laws about coercion in healthcare. Dodaro, G. (2011). Il problema della legittimità giuridica dell’uso della forza fisica o della contenzione meccanica nei confronti del paziente psichiatrico aggressivo oa rischio suicidario. Rivista italiana di medicina legale, 6(2011), 1483-1518.; Sale, C. (2014). Analisi penalistica della contenzione del paziente psichiatrico.
[3] CNB, Proposal for the institution of a parliamentary Inquiry (2017) – www.senato.it/service/PDF/PDFServer/DF/329064.pdf
[4] CNB, La contenzione: problemi bioetici (2015) – https://bioetica.governo.it/media/1808/p120_2015_la-contenzione-problemi-bioetici_it.pdf
[5] Ibidem.
[6] E tu slegalo subito call: www.slegalosubito.com/appello
[7] Ibidem.
[8] Zanfini et al. (2022) È facile smettere di legare se sai come fare: Il no restraint è un metodo di lavoro. Nuova Rassegna di Studi Psichiatrici. Volume 23; Castelpietra G. Non-recours à la contention dans les services de santé mentale: le dispositif de Friuli Venezia Giulia. L’Information psychiatrique 2017.
[9] Some examples: Brutti, C., & Brutti, R. P. (2006). Contenzione e contenimento. Note storiche e prospettive antropologiche. Rivista sperimentale di freniatria; Cipriano, P. (2013). La fabbrica della cura mentale. Milano, Elèutera; Novello M. (2013) Il risolvibile nodo della contenzione fisica nelle pratiche dei servizi di salute mentale. Rivista Italiana di Medicina Legale (e del Diritto in campo sanitario); Del Giudice, G. (2015). …E tu slegalo subito: sulla contenzione in psichiatria. Alpha & Beta; Rossi, S. (2015). Il nodo della contenzione: diritto, psichiatria e dignità della persona. 180-ARCHIVIO CRITICO DELLA SALUTE MENTALE; Cardano, M., Algostino, A., Caredda, M., Gariglio, L., & Pardini, C. (2020). La contenzione del paziente psichiatrico: un’indagine sociologica e giuridica. Il mulino.
[10] World Health Organization. (2001). Mental health in Europe: stop exclusion, dare to care (No. WHO/EURO: 2001-3970-43729-61519). World Health Organization. Regional Office for Europe; Portacolone, E., Segal, S. P., Mezzina, R., Scheper-Hughes, N., & Okin, R. L. (2015). A tale of two cities: The exploration of the Trieste public psychiatry model in San Francisco. Culture, Medicine, and Psychiatry, 39(4), 680-697; Compendium report: Good practices in the Council of Europe to promote Voluntary Measures in Mental Health Services, Council of Europe, 2021.
[11] We want to remember all the persons who died while mechanically restrained in Italy. Among them, Antonia Bernardini, Francesco Mastrogiovanni, Giuseppe Casu, Elena Casetto, and Wissem Abdel Latif..
[12] L’istituzione negata, a cura di Franco Basaglia, Baldini&Castoldi 2010, first edition Einaudi 1968,
p. 145.