Feature

Italy’s mad law

Britain is in the throes of emptying its asylums in favour of ‘community care’. Bob Quick visited Italy recently and reflects on its 10 year experience of ‘Psichiatria Democratica’

In the late 1960s and early 1970s a group of radical Italian psychiatrists and mental-health workers began a campaign for more a more enlightened approach to mental health care. The group became known as ‘Psichiatria Democratica’.

Although many of their ideas came from the writings R D Laing and David Cooper, the major influence was that of Franco Basaglia, then professor of Psychiatry in Trieste.

Before 1978, Italy had no national health service, and health services, were to say the least, patchy. Mental healthcare was particularly poor, with services concentrated in large institutions, as they have been in Britain. A large proportion of mental health care was administered by the private sector, which in practice meant the church.

Psichiatria Democratica led a high-profile campaign aimed at publicising the desperate plight of mentally ill people who suffered the appalling conditions of the asylums. The political pressure paid off, and in 1978 the coalition government enacted Law 180. The new law in effect stopped admissions to psychiatric hospitals, and established the framework for a new community-based care.

I was recently invited to Italy by FISOL, the Italian Sister Union of Britain’s Confederation of Health Service Employees, to visit Milan and the surrounding Lombardy region, in order to see for myself how mental healthcare had progressed in the decade since the Law 180 was passed. What might be the lessons for Britain, itself in the throes of restructuring community care?

I spoke first to Natale Gritti, a senior nurse at Trevilio, 40km from Milan. He was a union activist and told me that the union had been very enthusiastic in supporting Law 180.

He himself had moved from work in a large mental hospital, which has since closed, in nearby Bergamo and was in charge of a 15-bed acute psychiatric unit in the town’s general hospital.

Natale’s support for Law 180 was tempered by his view that ‘only now, after 10 years, are we constructing the right structures to match the radical ideals of Psichiatria Democratica’.

His other main criticism, echoed by everyone that I met in the region, was that the ending of specialist psychiatric nurse training had been a major mistake. The new course produced the ‘Infermierre Professionale’, trained in both general and psychiatric nursing. The lack of expertise of the newer nurses led to conflicts with the older psychiatric nurses and, perhaps more seriously, to doctors increasingly dominating and planning of care. Despite this, great emphasis was placed on multi-disciplinary teamwork at every level.

My next visit was to the Institute Paolo Pini, once one of the great mental institutions of Milan, but now caring for only 170 patients — some of whom had lived there for as long as 30 years. I was allowed to walk round the wards and see the conditions at first hand.

The hospital was divided into six ‘communities’, the term ‘ward’ being avoided by all. Two of the communities were labelled as ‘experimental’, operating very much like halfway houses for the residents, who lived as independently as possible. The experimental communities had very few day staff, and none at night. Each resident had their own room, and some had jobs outside the hospital.

The four other communities appeared to be like any traditional psychiatric ward. There were four or six bedded rooms, with the smell of stale urine, tobacco-smoke and disinfectant familiar to British mental hospitals.

In the corridors there was the usual echo of shuffling elderly patients. The only difference the pictures of Inter Milan Football Club on the bedroom walls and the olive trees lining the hospital grounds.

The hospital managers found great difficulty in staffing the hospital. The older trained staff were retiring, and the younger generic nurses were attracted more to the new community services than to the old asylums.

I spoke to Dr. Osimo, senior registrar at the Paolo Pini, who remained enthusiastic about ideals of Basaglia’s Law, but expressed reservations about the reality.

He believed that the politicians did not care about the older patients who remained in hospital, and allowed the hospital to run short of the necessary resources to provide high-quality care. The staff had not been adequately trained, he said, or prepared for the new structure of care. This was agreed by the chief nurse Signor Pozzi.

The hospital was officially allowed to admit patients to a small number of designated beds, but many of the staff felt that the restrictions imposed by the law allowed insufficient time to offer full treatment.

In the provincial town of Serengo, near the infamous chemical plant of Seveso, I visited a cento psichosocial — a modern purpose-built unit containing a 15-bed rehabilitation unit and a day hospital.

Dr. Giorgio Scorza was in charge of the centre, now two years old, which offered a complete example of the structures which Law 180 intended. The only problems Dr Scorza encountered were lack of funding and the shortage of qualified staff. The ending of psychiatric nursing training was blamed for this.

However, the centre was an example of a multi disciplinary team in action, led — as you might expect — by doctors. As well as working in the day hospital, all the staff in the centre offered domiciliary care. The centre has been designated responsible for the care of 400 former hospital patients, but 146 were not seen. A total of 254 did come on a voluntary basis, and of these, 169 continued to have treatment at the centre. Of the staff in the centre, only seven were previously employed in an old hospital.

Perhaps the paradox of Law 180 has been the apparent growth in the private sector. I was taken to visit a private, church-run mental hospital in the town of Brescia.

The Ospedale Psichiatrico Fatebenfratelli held 360 patients. Most were elderly or suffering from chronic mental illness, and required long-term care. This was the kind of care that was most limited in the state sector. It was estimated that about a third of the patients would remain in hospital permanently.

Apart from the more traditional wards holding about 30 patients each, at the far end of the hospital, across field and vineyards, was the ‘therapeutic community’. This housed an enterprising industrial therapy unit, with a toy-assembly line which provided piece-rate work for some of the patients, and a rabbit-raising farm.

Near the production line was a beautifully equipped day hospital.

The hospital itself operated as an isolated unit, selling its services to the local community. Though officially not a part of the new structure, one couldn’t help thinking that without this sort of hospital the new system would be in great difficulty. This seemed to be the hidden face of Psichiatria Democratica’s revolution.