Psychiatric reform in Italy: Developments since 1978

International

Pergamon

Journal of Law and PsychiatqVol. 19, No. 3/4, pp. 373-390,1996 Copyright 0 1996 Elsevier Science Ltd Printed in the USA. All rights reserved 0160.2527196 $15.00 + .OO

PI1 SO160-2527(96)00013-l

Psychiatric Reform in Italy: Developments

Since 1978

Lorenzo Burti* and Paul R. Benson**

Introduction

Public Law No. 180 signaled the legislative abandonment of the mental hospital as the cornerstone of Italy’s mental health system. Enacted in 1978, the law stipulated that treatment of the mentally ill be undertaken through the use of a variety of community-based services, supported, when necessary, by general hospital inpatient units. With the law’s passage, the focus of Italian mental health policy shifted from institutional segregation and control to rehabilitation and the reintegration of the mentally ill into all aspects of social life in the community. The premise upon which Public Law 180 is based, the creation of a national mental health system without the mental hospital, has been hailed by many as the most radical shift in Western mental health policy in modern times (Mosher, 1982,1983a, 1983b, Lacey, 1984; Scheper-Hughes & Lovell, 1986). It is thus not surprising that Public Law 180 and Italian psychiatric reform in general have attracted sustained international attention. Although many of the early analyses of Italian psychiatric reform were anecdotal and often polemic, over the past decade a growing body of empirical research has emerged assessing postreform changes in Italian mental health policy (Bollini & Mollica, 1989; Crepet, 1990; de Girolamo, 1989; De Salvia & Barbato, 1993; Tansella, De Salvia, & Williams, 1987). This literature provides data useful in evaluating the reform, now nearly two decades old. This article assesses the impact of psychiatric reform in Italy through a review of research literature drawn from Italian and English-language journals, government reports, and other empirical studies. We begin by sketching the historical and cultural background of Italian mental health policy. After outlining the seminal ideas and work of psychiatric reformer Franc0 Basaglia, and

*Professor,

Cattedra

**Vice Provost 02125, USA.

di Iglene Mentale,

for Sponsored

Projects,

Institute

of Psychiatry,

University 373

University

of Massachusetts,

of Verona, 100 Morrissey

37134 Verona, Blvd, Boston,

Italy. MA

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the development and features of Law 180, we examine the implementation of the policy across Italy, focusing in turn on inpatient services, community mental health centers, residential treatment services, and worker cooperatives. In addition, we review research on patient quality of life and family burden. The article closes with a discussion of factors associated with the many difficulties experienced in implementing Law 180 as well as an examination of recent developments in Italian mental health policy. These include the impact of a new national health plan, the changing role of the National Health Service (NHS), and recent national legislation calling for the closure of all mental hospitals in Italy by 1997. Mental Health Care Prior to 1978

Care of the mentally ill in Italy has traditionally been carried out by the Catholic Church (Canosa, 1979), with the first modern Italian mental hospital, St. Bonifacio, built in 1788. Prior to the mid-1800s relatively few mental institutions were constructed. Between 1875 and 1914, however, the number of Italian mental hospitals increased significantly, and the number of patients rose to over 50,000 (Direzione Generale della Statistica, 1888; quoted in Canosa, 1979). Much of this increase took place in northern Italy, where urbanization, industrialization, and their attendant social problems were most pronounced (Galzigna & Terzian, 1980). Following Italy’s unification in 1861, the need for national legislation concerning the care and treatment of the mentally ill became clear. It wasn’t until 1904, however, that the first national law on asylums was passed by Parliament (Public Law No. 36). Stressing the social control function of asylums, Law 36 provided only for involuntary hospitalization of the mentally ill, based on an assessment of patient dangerousness. An initial 30-day hold was mandated, and the mental hospitalization was automatically entered into the patient’s criminal record. In addition, under the legislation, permanent hospitalization could be ordered, resulting in complete forfeiture of the patient’s civil rights (Canosa, 1979; Maj, 1985). Recognition of the need for an essentially nonjudicial mental health law increased following World War II. However, it was not until 1968 that any significant modification of the 1904 legislation was enacted. These new amendments, issued as Public Law No. 431, introduced several important changes. First, voluntary admission to public mental hospitals was finally allowed under the law. In addition, the registration of psychiatric hospitalizations on patient’s criminal records was abolished. Other provisions of Law 431 prescribed the size of public mental hospitals and individual wards as well as patient-staff ratios. Finally, the 1968 amendments called for the establishment of community mental health clinics, with each clinic connected to a hospital ward serving a specific geographic location. Based on the French model of the Psychiatric de Secteur, one goal of these new community clinics was to provide aftercare to released mental patients and thus minimize rehospitalization (Maj, 198.5; Vidon, Petitjean, & Bonnet Vidon, 1989). While providing an important first step toward restructuring the Italian mental health system, Law 431, in practice, left unchanged much of the old, in-

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stitutional system of psychiatric care. Most of the provisions of the 1904 law on involuntary commitment, for example, were unaltered. Moreover, the growth of new community clinics mandated by the 1968 amendments was extremely slow (Mosher & Burti, 1989; Ramon, 1985). As late as 1973, for example, only 13 mental health centers had been established in all of Italy (Zanetti, 1974). Franc0 Basaglia and Psi&atria

Democratica

The person most responsible for psychiatric reform in Italy was Dr. Franc0 Basaglia, a brilliant psychiatrist heavily influenced by existentialism, phenomenology, and neo-Marxism. During the 1960s Basaglia had visited Maxwell Jones’s therapeutic community in Britain and decided to implement that treatment model in Italy. When Basaglia became director of a state mental hospital in Gorizia, a small city in northeastern Italy, he found himself responsible for hundreds of drugged, stigmatized, and apathetic patients. Profoundly distressed by what he believed to be the dehumanizing effects of long-term institutionalization, Basaglia attempted initially to reorganize the hospital according to therapeutic community principles. However, he soon decided on a much more radical approach-the total dismantling of the mental hospital (ScheperHughes & Lovell, 1986). While often described as a representative of antipsychiatry, Basaglia always rejected the label. Unlike Thomas Szasz, Basaglia never questioned the existence of mental illness per se. Instead, he was concerned primarily with the dehumanizing consequences of institutional psychiatric treatment. Basaglia contended that prolonged mental hospitalization disempowered the patient, making successful treatment virtually impossible. Empowering the patient by freeing him is the first necessary prerequisite of treatment and rehabilitation. Therefore, in Basaglia’s view, psychiatrists should not repudiate their institutional role; instead, they should use that role for therapeutic purposes, redirecting their efforts toward meeting patient’s psychiatric, social, and political needs (Basaglia & Ongaro Basaglia, 1975; Scheper-Hughes & Lovell, 1986; Love11 & Scheper-Hughes, 1986). Based on these principles, over the course of several years the mental hospital at Gorizia was completely transformed by Basaglia and his staff. Previously locked wards were opened, allowing patients to move freely within the hospital and in town. Electroconvulsive therapy, seclusion, and restraints were banned, and a program of discharge was implemented. The original experiment in Gorizia was then replicated by Basaglia and his staff in a number of other Italian cities, including Arezzo, Ferrara, Parma, and Reggio Emilia. In 1971, Basaglia moved to a mental hospital in Trieste where he established a number of innovative treatment programs (Bennett, 1985; Jones & Poletti, 1985,1986; Mosher, 1982). In particular, two important programs were first tested in Trieste: the “guest status” and the worker cooperative programs. The guest status program was initiated by Basaglia for patients at Trieste who were unwilling or unable to leave the hospital owing to ill health, senility, or a shortage of housing in the community. While officially discharged, these individuals were allowed to remain at the hospital as “guests.” In addition, worker cooperatives were begun at Trieste as a way to convert demeaning patient la-

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bor into employment that could support life outside the hospital. Beginning with patient groups cleaning and gardening within the hospital, over several years the worker cooperatives expanded to include a variety of hospital and community-based employment programs (see below). In addition to initiating a series of innovative methods of treating individuals with mental illness, Basaglia’s ideas and charisma led to the emergence of a major social movement during the early 1970s. In 1974, Basaglia and his followers (which included workers, students, and others) founded Psichiatria Democratica (The Society for Democratic Psychiatry). Basaglia and Psichiatria Democratica were able to gain considerable political support for their anti-institutional program, especially from Left-wing parties. With the increase in power of the Italian Left during the mid-1970s (culminating in the so-called historic compromise between the Communists and Christian Democrats), many social reforms, including divorce, abortion, and expanded workers’ rights, were approved. These political and social factors created a supportive environment for psychiatric reform. Aside from gaining the support of the political Left, Psichiatria Democratica was also able to bring the problems of mental hospitals to the attention of the general public. National conventions of Psichiatria Democratica were well attended, particularly by young people, and were extensively covered by the press. The efforts of Basaglia and Psichiatria Democratica were also supported by well-known radicals, intellectuals, and psychiatric critics of the day, including R.D. Laing and Jean-Paul Sartre. Basaglia’s books became best-sellers. As a result, the need for significant psychiatric reform was increasingly acknowledged. Even official psychiatric bodies, such as the Italian Psychiatric Association, agreed with many of Psichiatria Democratica’s objectives such as phasing out mental hospitals, developing community-based alternative services, and incorporating psychiatry into the national public medical system (Mosher & Burti, 1989). In 1977, a small but influential political party, the Radical Party, launched a referendum campaign to repeal the antiquated 1904 psychiatric law. If successful, the referendum would have made most psychiatric practices in Italy illegal and would have badly embarrassed the government. To avoid the negative consequences of such a referendum, the government hurriedly created a parliamentary commission to draft new mental health legislation. Although not a member of the commission, Basaglia was consulted extensively by the commission in writing the new legislation, Law No. 180.

Law

180

Passed by Parliament in May 1978, Law 180 (known popularly as Basaglia’s Law) included a number of significant provisions: 1. Law 180 called for the phasing out of public mental hospitals by immediately ending new admissions to these facilities (readmissions would be ended by 1980). In addition, the construction of new public mental hospitals was prohibited, as was the upgrading of already existing facilities.

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2. The law stipulated that treatment of the mentally ill take place primarily in community mental health centers (CMHCs), which would be responsible for providing a full range of psychiatric services to persons within a specific geographical area and would be staffed largely by individuals drawn from depopulated mental hospitals. 3. When needed, psychiatric hospitalization would take place in general hospital psychiatric wards (GHPWs). These inpatient units would not exceed 15 beds and would work closely with CMHCs in order to maximize the continuity of patient care between hospital and community. 4. Involuntary hospitalization would take place only when (a) urgent intervention is required, (b) the patient refuses necessary treatment, and (c) alternative community-based treatment is unavailable or not feasible. The duration of the initial period of involuntary treatment was 7 days, with mandatory judicial review within 2 days. As noted elsewhere (Mosher, 1983a; Mosher & Burti, 1989) the Italian approach to deinstitutionalization was both radical and gradual at the same time, with the primary emphasis being on altering the structure of the treatment system rather than simply moving patients out of institutions. By “closing the front door” of the mental hospital, Basaglia and other Italian psychiatric reformers hoped to develop a system of public mental health care without the mental asylum. While clearly a stunning success for Psichiatria Democratica and the political Left, the passage of Law 180 was also initially widely approval by the Italian public. In 1980, however, shortly after assuming the post of superintendent of psychiatric services for Rome, Franc0 Basaglia died of cancer. His unexpected death left the Italian psychiatric reform movement without its founder, leader, and most charismatic champion. Implementation

of Law 180

Following its passage, the task of actually implementing Law 180 was given to the regional governments. l There are 20 regions in Italy, each differing widely in terms of geographical, cultural, political, and socioeconomic characteristics. Because of this, as well as a number of other factors, the pace of implementing psychiatric reform has been extremely uneven across Italy. In some areas, the dismantling of state hospitals and creation of a comprehensive system of community-based mental health care proceeded rapidly. This was particularly true in the north, where some community-care services had been developed prior to 1978. In other areas, particularly in southern Italy, changes in the mental health system have been slow or nonexistent. While regional variation is significant, marked variation in the type and level of mental health services is also often pronounced within the same region (Bollini & Mollica, 1989; Crepet, 1990; De Salvia & Barbato, 1993; Mosher & Burti, 1989). ‘This section

on the implementation

of Law 1X0 draws heavily on Mosher

and Burti (1989).

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The generally slow and uneven implementation of psychiatric reform in Italy was further affected by Italy’s difficult economic and political circumstances. Beginning in the late 1970s a severe recession coupled with high inflation, battered the country. As a result, Italy’s public debt increased tremendously, cooling both public and political enthusiasm for the social reforms of the 1970s. Social service spending by the government was slashed, negatively affecting the implementation of psychiatric reform from its very inception. As one cost-cutting mechanism, from 1980 to 1985, no mental health worker leaving his or her position was replaced. As a result, most public psychiatric facilities during this period were severely understaffed. As has been the case in other nations undergoing deinstitutionalization, reallocating funds from mental hospitals to community services has also been a problem. As of 1988, it was estimated that the 30,000 inpatients still in Italy’s public mental hospitals absorbed up to 80% of the nation’s total expenditures for psychiatric services (Ongaro Basaglia & Associates, 1988; CENSIS, 1985). The characteristic instability of Italian politics also adversely affected the development of new programs mandated by Law 180. Between 1978 and 1983, Italy experienced seven government crises. During 1979/80, the “historic compromise” between the Christian Democrats and the Communists broke down in the aftermath of the kidnapping and assassination of former Prime Minister Aldo Moro. Moro’s murder had a profound demoralizing effect on the nation. Strict anti-terrorist measures were enacted, and political activity became more muted and cautious. In this context, the energy, dedication, and zeal necessary to implement social reforms were difficult to sustain. Following the electoral success of the Socialist Party in 1983, Prime Minister Bettino Craxi enacted further cuts in social programs. Among these was a 1985 Cabinet degree stipulating that any “social expenditures,” including living allowances and nonmedical lodging, could not be supplied by the National Health Service. As a result, the mentally ill were forced to compete with the rest of Italy’s poor for meager social welfare funding. Other problems also plagued implementation of the reform. To save money and to minimize opposition to the law by mental hospital staff, Law 180 prescribed that existing personnel be used to staff new community services. This caused delays and, in some cases, impeded the widespread adoption of noninstitutional treatment methods and philosophies in community settings. Retraining the staff of closed mental hospitals, in addition, has been and remains a major endeavor, particularly because Law 180 provided no funds for this purpose. Finally, slow and uneven implementation of Law 180 led to increased public and political discontent with the legislation. During the 198Os, a number of proposals were presented from different political parties to modify Law 180 in a variety of ways. These included easing legal restrictions on involuntary treatment and expanding the use of GHPWs to include intermediate and long-term psychiatric care. Other and more reactionary proposals suggested that closed public mental hospitals be reopened to accommodate both new and old chronic cases. Not all legislative proposals, however, sought to roll back psychiatric reform; some, for example, sought to expand and provide better funding for

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Senator Franca Basaglia (the of Franc0 filed a mandating that of the budget be for mental services during The European was 15% Basaglia & 1987). This failed to as did other proposed changes to 180 from through 1993. chief reason these various legislative modifications economicno was available fund changes the law. Psychiatric Services in the Postreform

Era

Unfortunately, only general national data are available on Italian psychiatric services both prior to and following the passage of Law 180. What information we have, however, suggests a significant restructuring of public mental health care since 1978. Inpatient Services Public Mental Hospitals. According to national hospital statistics collected and published annually by Centro di Statistica (ISTAT), Roma (Central Institute of Statistics), the number of patients in Italian public mental hospitals peaked at 91,700 in 1965. During the 1970s a progressive decrease in the number of residents began, with a concomitant rise in the number of admissions. After the passage of Law 180 in 1978 however, the number of mental hospital admissions fell rapidly and nearly stopped. By 1984, when the Ministry of Health appointed the CENSIS (Centro Studi Investimenti Sociali) to carry out a comprehensive, national survey of Italian mental health services (CENSIS, 1985; Maranesi & Piazza, 1986), the number of public mental hospital inpatients had decreased to 30,000. By 1989, that figure had dropped to 20,000 (Ufficio Ricerche e Documentazione, 1992). Wide variation has always existed in the availability of public mental institutions across Italy, with most hospitals located in northern and central Italy. In southern Italy, by contrast, a relatively small number of mental hospitals must serve very large geographic areas. Deinstitutionalization in southern Italy occurred a decade later than in other areas of the country. In addition, deinstitutionalization in southern Italy has generally proceeded more slowly than elsewhere. Relatively little is known about the social and clinical characteristics of public mental hospital patients in Italy prior to 1978. The few studies that were conducted on this population, however, suggest that patients in Italian mental hospital prior to 1978 were disabled, diagnosed with a major mental illness, alcoholism, or substance abuse, and were largely from the lower classes (Bollini & Mollica, 1989). Law 180 outlawed both new admissions and readmissions to public mental hospitals. However, the law did allow current patients to remain as “guests” if no alternative treatment setting could be found. Although no comprehensive studies have been completed on patients remaining in Italian public mental hospitals, studies of two groups of hospitals by Bollini and her colleagues (1986, 1988) suggest that these individuals are older, less educated, and more chronically disabled than other mentally ill persons treated in the community.

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They also often have lengthy histories of psychiatric hospitalization, with a small but significant subgroup exhibiting violent behavior (Saraceno et al., 1984). The extent to which individuals left behind in Italian mental hospitals differ from discharged patients is not known (Bollini & Mollica, 1989). It is likely, however, that these differences vary regionally, depending, in part, on the level of available community services (Crepet, 1990). Finally, very little information is available concerning the quality of care currently afforded to patients in public mental hospitals, although anecdotal evidence suggests that it is very bad. Neglect, generally inadequate care, and a lack of rehabilitative services are believed to be the norm in all but a few of Italy’s public mental institutions today (Crepe& 1990; Mosher & Burti, 1989). Private Mental Hospitals. In Italy, private mental hospitals are largely supported by public funds and are, for the most part, similar to public mental institutions. Historically, private psychiatric hospital beds were more common in areas where public mental hospitals beds were generally unavailable. In the South, for example, the number of private hospital beds is approximately three times higher than in the North (Tansella et al., 1987). The number of private mental hospital patients has decreased slowly, from approximately 20,000 in 1968 to 15,600 in 1983. This suggests that public mental inpatients were not “transinstitutionalized” to private hospitals. No data is yet available on the social or clinical characteristics of private mental hospital inpatients in Italy. General Hospital Psychiatric Wards. Law 180 stipulates general hospital psychiatric wards (GHPWs) as the only public facilities allowed to admit psychiatric inpatients. In addition, Law 180 stipulates that involuntary hospitalizations be carried out only within GHPWs. General hospital psychiatric wards, which were relatively rare in Italy before 1978, multiplied quickly following the passage of Law 180. In 1981, a total of 216 such units were in operation. By 1984, some 236 GHPWs were operating nationwide, with about 3,100 beds (De Salvia & Barbato, 1993). This overall increase, however, masks significant regional variation, with 50% of all GHPW beds located in the North (Cardea & Frisanco, 1987). By 1989, the number of GHPW beds nationwide had risen to 4,672 (Ufficio Ricerche e Documentazione, 1992). Studies suggest that, in some areas, GHPWs have nearly replaced mental hospitals as the locus of psychiatric inpatient treatment (Massignan, 1984; Martini, Cecchini, Corlito, D’Arco, & Nascimbeni, 1985). However, problems with these facilities have also been identified. Located inside of general hospitals, GHPWs often suffer from limited space, poorly trained staff, and a paucity of recreational and rehabilitative services. In addition, GHPW staff primarily utilize a biomedical approach to treatment with a strong reliance upon psychopharmacology. Finally, coordination between GHPWs and local community mental health centers is often poor (CENSIS, 1985). Judicial Mental Hospitals. There are six judicial mental hospitals in Italy, with bed capacities ranging from 170 to 500. At the close of 1987, a total of

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1,225 individuals were detained in these special inpatient facilities (Fornari, 1989). Administered by the Ministry of Justice, these facilities are excluded from the provisions of Law 180. According to Italian criminal law, three categories of individuals may be sent to a judicial mental hospital: (1) prisoners who become mentally ill while in custody and, as a result, cannot stand trial; (2) individuals charged with a crime who are hospitalized to undergo forensic tests; and (3) offenders found guilty and a “danger to society” but incapable of “understanding and free will” because of mental illness (Ghirardelli & Lussetti, 1993). Individuals found “guilty but mentally ill” can be hospitalized for 2,5, or 10 years, proportionate to the crime. A significant amount of interest exists in whether deinstitutionalization in Italy has led to an increasing “criminalization of the mentally ill’ as has been described in the United States and elsewhere (Teplin, 1983). Data collected by the Italian Ministry of Justice, however, show a slow but steady decrease in the number of patents housed in judicial mental hospitals from 1978 through 1985 (De Salvia & Barbato, 1993). This suggests that the increased use of correctional facilities to manage the mentally ill has not occurred as some critics suggested it might following the passage of Law 180 (Jones & Poletti, 1985). Community-Based

Services

Community Mental Health Centers. Despite the central role assigned to community mental health centers (CMHCs) in Italy’s new mental health system, there are no data regularly collected on these facilities by ISTAT or other government agencies. Instead, only the 1985 CENSIS survey and a small number of local or regional CMHC studies are available. According to CENSIS (1985) by the end of 1984, some 674 CMHCs were in operation, 63% of which had opened following the passage of Law 180 in 1978. Nationwide, CMHC services are available to over 80% of Italy’s population in their own catchment areas. However, as is the case with general hospital psychiatric wards, CMHCs are unequally distributed across Italy, with the North having the greatest number of CMHCs. In general, the development of CMHCs in the South has been slow. As late as 1985, for example, 139% of catchment areas in southern Italy had no CMHC. Nationally, about a third of Italy’s CMHCs were constructed before 1978, with more prereform CMHCs developed in the North than in the South (CENSIS, 1985). Studies also indicate marked differences between northern and southern Italy in regard to the variety and availability of clinic services. In the South, for example, where CMHCs are more likely to have been recently opened, services are, on average, more minimal and available for fewer hours per week. Regional differences in staffing also vary markedly, from 2.4 physicians and 4.3 nurses per 100,000 population in the South to 4.8 physicians and 10.0 nurses per 100,000 population in the North (CENSIS, 1985). Many CMHCs are poorly staffed and are housed in inadequate facilities, particularly in the South. Significantly, 43% of treatment personnel working in CMHCs in 1985 were transferred to them from public mental hospitals. Despite this fact, nationally, only half of CMHCs provide their staffs with formal training in community psychiatry (CENSIS, 1985).

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staff were largely psychopharmaceutical, mostly social. Drug treatment ported as frequently prescribed at located in the South. Finally, CMHCs (Aroasio 1985; Bollini & Mollica, 1989; Rolle, & Amodeo, 1986; 1986). One conducted Gruppo Interdiscipliare Valutazione Interventi 1986) provided information on the clinical social characterisrandom sample 1,716 patients attending 35 located in northern Italy during using CMHCs were generally poor. either schizophrenia major affective disorder, prior mental hospitalization was virtually absent in CMHC clients whose illness began after In sum, the development CMHCs 1978 presents mixed picIn some areas, particularly in the North, CMHCs provide fully grated system of community mental health services, including clinic and home rehabilitative services, and assisted Burti, BenBottaccioli, 1982; Garzotto, Siciliani, Zimmerman 1986; Lesage 1993; Martini et al., Mosher Burti, Ramon, 1985; 1985). In areas, public mental hospitals has all but been eliminated. other areas, however, few exist, those that do provide a much less comprearray of services. these areas, mental hospitals other inpatient facilities continue used. Residential Services. Available data on Italian residential psychiatric facilities is extremely sketchy, with the only comprehensive national picture provided by the CENSIS survey. At the close of 1984, some 248 residential-care facilities were operating in Italy, most of them public and built after 1978. On average, residential facilities housed 12 patients each, providing a total of approximately 3,000 beds nationwide. Over half of these alternative services were in the North. Programs were almost equally divided between high (24 hours a day), medium (9 to 18 hours a day), and low (4 to 8 hours a day) levels of supervision (facilities providing fewer than 4 hours of staff supervision daily were not recorded). Staffing was provided primarily by nurses, many of them employed formerly by public mental hospitals. Treatment activities included training in social and daily living skills and other rehabilitative tasks. Occupational therapy was found to be commonly employed, although few programs reported actively assisting their clients in locating paid employment. Users tended to consist largely of patients discharged from mental hospitals; few places were available for younger patients. Finally, many clients were found to be long-term users of these residential programs, with less than a third discharged over the course of a year (CENSIS, 1985). In recent years, rising concern has been expressed regarding the number of long-term patients in residential facilities and the increasing possibility that

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these facilities will take on greater institutional characteristics. Studies have suggested this possibility is more likely in private rather than public residential facilities (Gaia, Pietrasante, & Zuccolin, 1993; Mastroeni, 1994). Worker Cooperatives. As noted earlier, during the early 1970s work cooperatives were begun by psychiatric reformers as a way to end the exploitative use of patient labor by hospital staff. Following the passage of Law 180 in 1978, these programs spread rapidly. By 1985, a total of 1,400 members were employed by 50 work cooperatives located across Italy: 19 in the North; 23 in central Italy; 8 in the South (CENSIS, 1985). By 1989, the number of worker cooperatives operating in Italy had almost doubled as had the number of mentally ill members employed by them (Ufficio Ricerche e Documentazione, 1992). In recent years there has been a proliferation of worker cooperatives, serving both disabled and nondisabled individuals (Warner, 1994). Cooperatives are involved in manufacturing and service enterprises of various types, often successfully competing with regular businesses. Not surprisingly, worker cooperatives are most common in the North, where reforms have generally had the most impact. Cooperatives begun by Basaglia and his co-workers in Trieste and Pordenone, in particular, have achieved considerable size and diversity in businesses, including a restaurant, hotel, beauty shop, furniture workshop, mail delivery service, and cleaning service. In 1994, worker cooperatives in Trieste included a total of 250 positions and generated the equivalent of U.S. $5 million in income. The Pordenone cooperatives included some 560 positions and generated $11 million in business. About half of the workers in the Trieste and Pordenone cooperatives are employed full-time; other work parttime or are in training. Those in training receive scholarships provided by European Community vocational programs (Warner, 1994). Within most cooperatives, members are both “employees” and “shareholders” in the “company” (Ghirardelli & Lussetti, 1993). While formally private firms, in some cases the staff of psychiatric services support cooperative members in their work or promote new initiatives. In some cases, as well, worker cooperatives (termed “social cooperatives”) are subsidized by public funds until the enterprise is able to be self-sustaining. In 1991, an important new law (Public Law No. 381) was passed that prescribed the characteristics of “social cooperatives.” To be accredited as a social cooperative, at least one-third of the cooperative’s employees must be mentally or physically handicapped. A number of economic advantages accrue to legally approved social cooperatives, including publicly subsidized start-up costs, special tax advantages, and the ability to enter into contracts with governmental bodies without competing with ordinary businesses. Outcomes Associated With Psychiatric Reform Longitudinal Studies and Quality of Life

There are no national data on client outcomes and quality of life following the passage of Public Law 180. However, research has been conducted in sev-

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era1 cities and regions examining how patients treated in the community have fared under psychiatric reform. A study by Kemali and Maj (1988) followed 116 schizophrenic patients treated in six different Italian cities (Trieste, Verona, Arezzo, Naples, Cetraro, and Cagliari). Patients treated in Arezzo and Trieste, where comprehensive community-based psychiatric services were available, showed greater improvement at follow-up than did patients treated in other locales. Overall, use of social and/or vocational skills training was shown to be most predictive of better client outcome, whereas number of days as a psychiatric inpatient was most predictable of poor client outcome. In a second study conducted in South Verona by Mignolli, Faccincani, and Platt (1991) 11 public hospital inpatients and 49 community-based patients, each with a diagnosis of schizophrenia, were followed for 7 years. At follow-up, the public mental hospital patients’ symptomatology and social performance were either unchanged or had deteriorated. In contrast, half of those treated in the community had improved in regards to symptomatology, while 26% had improved in social performance. Additionally, no patient in the community sample was hospitalized on a long-term basis during the 7-year study period. In another study on the same sample of community-based patients in South Verona, Lesage et al. (1991) assessed clients ’ “need for care” using a standardized questionnaire. Few patients examined in the study were found to have clinical or living skills problems that were unmet. This finding contrasts with the higly negative picture of Italian community-based services painted by some critics (see de Girolama, 1989). In addition, compared to those treated in other outpatient settings, clients served by the South Verona Community Psychiatric Service, a comprehensive community treatment program affiliated with the University of Verona (Mosher & Burti, 1989) had the greatest number of “met needs.”

Studies of Family Burden

As is the case in the United States and elsewhere (Benson, 1994) many of the deinstitutionalized mentally ill in Italy returned to their families upon hospital release. The percentage of discharged psychiatric patients returning to their families in the aftermath of Law 180 varies from 55% (Gallio, Morosini, & Veltro, 1991; Centenaro, D’Andre, Rizzoli, 1981) to 70% (Rampazzo & Turci, 1988; Erlicher, Roga, & Zabarino, 1984; Casi, Traballesi, & Guidi, 1984; Morciano, 1983). In Italy, the family represents a powerful natural support system and may serve to buffer patients’ need for formal, community-based, psychiatric services (Lesage et al., 1989). In this respect, studies of the impact of psychiatric reform on the Italian family are particularly important. Gallio et al. (1991) interviewed the primary family caregivers of 267 patients randomly recruited from the Trieste psychiatric case registry, half of whom were diagnosed with a major mental illness. Twelve percent of the relatives had retired or changed jobs in order to look after their ill family member. Reported difficulties associated with caregiving included negative changes in family life (57%) fatigue (49%) and reduced family income (29%). Overall,

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respondents’ level of burden was found to be correlated with patient social withdrawal, poor self-care, and unemployment. Nevertheless, despite these difficulties, over 80% of family caregivers in the Trieste study indicated that they were “very satisfied” with the care delivered by local community mental health services. A second investigation, conducted in L’Aquila, examined the relationship between patient behavioral problems and family burden (Roncone, Core, Stratta, & Casacchia, 1992). A total of 43 patients and their family members were studied (30 of the patients were diagnosed with schizophrenia; 13 had bipolar disorder). Increased family burden was most clearly associated in this study with antisocial behavior on the part of the patient, Finally, in Naples, Veltro, Magliano, Lobrace, & Morosini (1993) studied patient social disability and family burden using a sample of 52 long-term mentally ill subjects. A high level of burden was found among interviewed relatives, including poor social relationships with others (70%) depression (78%) and deteriorating physical health (61%). Six percent of family members reported taking time off from work to care for their mentally ill relative in this investigation. Thus, while studies suggest that psychiatric reform has often changed the lives of the severely mentally ill for the better, significant gaps in the provisions of services still remain, adversely affecting the quality of life of both patients and family caregivers. In a number of regions of Italy, special programs have been developed to train family members to take better care of their ill relative and reduce their own distress. In addition, in recent years, various family self-help organizations have proliferated in Italy, many of them politically active (Giannichedda, 1989). Recent Developments

During the past several years, new developments in the Italian health and mental policy have emerged that will clearly have a major impact on the future of community mental health care in Italy. These developments are in some way contradictory, and their ultimate affect on psychiatric reform remains to be seen. The National Mental Health Plan In 1989, a Special Commission was appointed by the Italian Senate to study the implementation of psychiatric reform. While a survey commissioned by the group found high levels of comprehensive, community-based care in some areas, as we have seen, serious problems persisted more than a decade after the passage of Law 180. Attempts to evade the law and delays in implementing the reforms were commonplace in many areas. In some places, for example, patients were admitted to public mental hospitals, in violation of the Law 180. Following release of the Commission’s report, the Senate voted to recommend that the government enact a national mental health plan with an adequate budget set aside for its implementation. Following several failed attempts, a national plan was passed by the Italian Parliament in 1994.

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An important feature of the 1994 National Mental Health Plan was its call for the building of a comprehensive network of psychiatric facilities (general hospital units, CMHCs, residential and semiresidential facilities) within each catchment area administered by the National Health Service (NHS). The plan also called for the integration of all local mental health and human services provided to the mentally ill under one administrative umbrella, the Department of Mental Health (DMH). As part of the National Health Service, the DMH receives government funds on a capitation basis to cover all the mental health needs of a catchment area. A DMH is typically responsible for a population of 150,000 inhabitants. According to the 1994 National Mental Health Plan, each DMH should provide the following services: (a) a CMHC open 12 hours a day, offering outpatient and home care, counseling and support to families, case management, welfare interventions, rehabilitative and vocational training, job finding, hospital gatekeeping, and resettlement of released public hospital inpatients; (b) a general hospital psychiatric ward, with one bed per 10,000 population; (c) semiresidential facilities, with one bed per 10,000 population, offering day hospital and day care facilities; (d) small (20 beds or less) residential facilities, with at least one bed per 10,000 population, offering long-term care for former public mental hospital inpatients and other chronically mentally ill; and (e) group homes. Overall, each DMH should maintain adequate numbers of trained mental health staff (at least one mental health worker for every 1,500 persons).

Recent Changes in the NHS In 1979, Law 180 was incorporated into broader legislation (Law 833) that launched the Italian National Health Service. This development deeply influenced the implementation of Law 180 by placing it within the larger context of comprehensive health care reform. The Italian NHS assures health care to all citizens through local health units, Unit Sanitarie Localid (USLs), responsible for catchment areas of 50,000 to 200,000 inhabitants each. Between 1991 and 1993, several important laws were passed that radically altered the organization and financing of the NHS. The number of USLs within the NHS have been reduced, and each USL has been reorganized to operate as an independent administrative enterprise with significant fiscal autonomy. Unlike the situation in the past, the new USLs are prohibited from going into long-term debt. Some health care facilities, viewed as highly specialized or of national importance, may be selected by the region to become enterprises themselves, independent of the USL where they are located. Funds are allocated to the regions by the national government of a capitation basis.

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These changes in the structure and financing of the NHS have created difficulties for public mental health services in Italy. The stress on cost containment under the newly reorganized NHS, for instance, has put mental health services at a disadvantage in comparison to other more lucrative and politically attractive health concerns. As has been found elsewhere, providing quality care to the mentally ill in the community can be expensive. In addition, where a designated “hospital of national interest” exists, autonomous from the USL, mental health care may be provided by separate inpatient and community programs, often with an attendant loss of continuity of care. Financial Law of Fiscal Year 1995

Ironically, the end of the public mental hospital system in Italy may result more from the imperatives of health care cost containment than from Leftwing social reforms. Financial Law of Fiscal Year 1995 mandates the closure of all public mental hospitals by the end of 1996, with each region devising its own way of accomplishing the task as part of its 1994-1996 health plans. Whether 1997 will truly bring the end of the public mental hospital in Italy, however, remains to be seen. Conclusion

Our review suggests that Italian psychiatric reform cannot be simplistically characterized in ways that are either overly positive or overly negative. Rather, Italian mental health policy presents a mixed picture. On the positive side, it is clear that the passage of Law 180 in 1978 ushered in many major advances in the care of Italy’s severely mentally ill. Prior to 1978, the vast majority of patients requiring psychiatric treatment were admitted to large, impersonal state asylums. By the late 1980s only 20,000 long-stay patients were housed in these institutions, a drop of nearly 80% from a previous figure of 91,700 reached in 1965. Contrary to the fears of critics, studies suggest that neither private institutions nor the criminal justice system has replaced the state mental hospital as a primary source of services for discharged patients. Instead, the mentally ill are now cared for in small general hospital psychiatric wards and a variety of community-based facilities, including community mental health centers and residential treatment programs. In addition, significant numbers of the mentally ill are now employed in worker cooperatives where they are able to learn and practice a trade. Where community mental health services in Italy are well developed, evidence suggests that the mentally ill receive excellent, well-coordinated care (Burti et al., 1986; Martini et al., 1985; Tansella & De Salvia, 1986; Torre & Marinoni, 1985; de Girolamo, 1.989). In these areas, reform has been an overwhelming success. On the negative side, it is also clear that psychiatric reform has not been evenly implemented throughout Italy (CENSIS, 1985; Ufficio Ricerche e Documentazione, 1992). In some areas, particularly in the poorer South, community services are underdeveloped or nonexistent. In these areas, public and private mental hospital continue to dominate. In addition, in many cases, former mental hospital staff have been transferred to community treatment

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programs without adequate training. Community programs are often understaffed and underfunded, and large-scale economic and political problems in Italy during the 1980s served to undercut the reforms during a crucial period in their development. Finally, a recent heightened concern with cost containment in the Italian NHS has placed public psychiatric services in increased peril. What will become of the Italian experiment in mental health care in the future is unclear. Nevertheless, what is clear is that Italy has shown the world that it is possible to develop a national mental health policy “without the asylum” (Bollini & Mollica, 1989). It has also shown that the development of mental health policy need not be strictly the province of professionals. Instead, change can, and must, involve professionals, political decision-makers, patients, and the public at large. References Aroasio, L., Bonizzoni, P., Girardengo, dei servizi psichiatrici.

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