Because it’s hard to even think about mental health reform

by Andrea Angelozzi

June 14th

Dear Director,
I confess that I find myself torn between conflicting reflections in the face of proposals for new standards in the field of mental health. This is not so much due to the association with Law 180/78 as to the uncertainty about the effective ramifications of the regulatory aspects in this area.

On the one hand, I think the interest of the legislator is important, as it testifies to the existence of a problem and the political will to deal with mental health.

In this sense, I look forward with interest to the proposal Magi on amendments to accountability laws and alternative measures for the detention of persons with psychosocial disabilities that Pellegrini has given us, or to the Siraciani/Senci proposal on mental health, which is not yet available on the Chamber’s website in its texts and is therefore difficult to analyze in detail. I am also thinking of what Favaretto reported on the subject of TSO in Quotidiano Sanità

On the other hand, I find it difficult not to think that what seems to have emerged from the history of psychiatry over the past forty-five years (and beyond) is the story of a series of disconnects between the Laws and the many realms of psychiatry with which they have to deal.

In fact, we are trying to legislate on scientific, ethical and also social aspects related to folk psychology and prejudices.

The first aspect is actually the relationship between grammar and science. It does not seem to me that there are specific laws that regulate, along the lines of Law 180/78, diagnostic and therapeutic interventions in cardiology or dermatology. Making laws on mental health means regulating aspects that science should also refer to, such as when the advantage of continuity is determined on earth, that it is believed that all insane criminals can be cured and saved from crime, that there should be no chronic and in any case one can live normally Suitable outside asylum institutions.

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Even defining diagnoses that can alter people’s criminal responsibility as a rule is a foray into the scientific aspects, where moreover, categories are not defined, are not natural things, nor are they stable over time. The danger is the emergence of hybrids that are not a science and not the norm, but only a temporary coding of some ideological universe.

This is also evident in the difficulty of the laws starting from the data. I don’t know the content of Serracchiani / Sensi’s proposal to amend Law 180/78, but I remember well how, among the various bills of the previous legislature (Marin, Boldrini, Beni), none started from data analysis and none from planning even if it simply alluded to What we have learned scientifically. It was therefore not surprising to find, as in Bini’s suggestion, the legal obligation for operators to always smile, and provides for penalties in case of non-compliant behaviour.

But the second disconnect is the one that involves the biases of popular psychology (which are the foundations of stigma), which should be modified by rules, and instead are much stronger and serve to constantly reabsorb attempts at change, to rearrange everything around something central. Cases that have always been marginalized and controlled. I am thinking of Law 180/78 that instituted compulsory health treatment to protect a person’s health, which has been gradually reconverted – also in the rulings of the Court of Cassation – into protection from danger.

And what about the focus on rehabilitation that eventually determined with the housing investment, again the institution’s proposition? From psychiatry that wanted to tear down walls and now identifies activities instead with the separate and specific spaces of DSM structures? I am thinking of the right examples of a different management of offenders which ends up bringing all psychiatry back once more to anchor itself under the sword of the guarantee center and hand over services again to the stigma of being dangerous.

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And what about the SPDCs in general hospitals that have ended up being marginalized in terms of places and life in the hospital as an integrated care community? When I think of the primacy of territory, I’m reminded of how Foucault describes the passage from control of leprosy, centered around institutional segregation, to control of plague, centered on dividing the city into sectors and sectors into streets, each entrusted to “operators”. Who made the call every day and took those who did not answer.

Even economic events are not new, given madness as an expense that must be contained. The ships of madmen that have carried the sick since the thirteenth century elsewhere are associated with policies that agreed to spend money only on the inhabitants of that region; Same home care for the insane was born in England in 1600 more as an attempt to contain costs than as a moral and therapeutic ideal. The construction of the well at the Salpetriere Sanatorium also enabled patients to do “therapeutic” labor (which later turned out to be useless), paid for by negligence. In the end, should we be surprised that the 2001 commitment of the Heads of Regions to allocate 5% of the health fund to mental health was never achieved?

Attempting to construct somewhat distinct pathways to psychiatry in the form of set rules or reserved budgets risks only affirming diversity, reaffirming stigma without delivering the benefits promised, in the same way as creating ostensibly distinct pathways for patients at work or at home, He ends up reaffirming it again as “different”, oftentimes without even keeping his promises.

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It is as if the social demands that have historically affected psychiatry, beyond the will of the legislators and motives of psychiatry, provided its conditioning, turning all attempts into the pesky prep-school tasks where it was necessary to reckon with infinite time. with which the snail reached its leaf, a few centimeters ahead, and then immediately slipped past the others.

Ultimately, the suspicion is that there is an intrinsic link between psychiatric practice and finding marginalization and control in response, as if the two sides were necessarily related.

And maybe just looking at the roots of what it means to do psychiatry allows us to break this mechanism.

Andrea Angeluzzi

June 14, 2023
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