Legal framework

People with mental disorders run a high risk of losing their basic personal and social rights. For that reason, users, their familes and all those associated with that person or who participate, directly or indirectly, in mental health promotion, need to be informed regarding the current legal framework for mental healthcare.
But first, some history...

From mandatory to voluntary internment

The first national legislation regulating psychiatric care," "Norms and regulations for asylums and the mentally alienated" was passed under the Giolitti government, in 1904, with the implementation act following in 1909. As public safety legislation, its main priority was protecting society from the mentally ill, with "custody" therefore taking precedence over "care". The criteria for internment in a mental asylum were set forth by the law as follows: "Persons affected with any form of mental alienation shall be interned and cared for in asylums if they constitute a danger to themselves or others or cause public scandal" (Italian Law n. 36/1904)

The internment procedure required certification by a physician and an order by the Questore; within 15 days (the observation period) the asylum director was then required to send a written report to the State Attorney and within 30 days the person would either be released or subjected to a "permanent internment". If interned, they suffered legal interdiction, with the loss of all civil rights and the appointment of a legal guardian. Permanent internment could only be ended by a certificate, issued at the asylum director's personal responsibility, that the patient was "cured", or if at the request of the inmate's family, a court authorised the "alienated person" to be released into their custody. Psychiatric care was administered by the provincial authorities and each province had to establish an asylum. Even if internment was voluntary, it was regulated by the same rigid rules.

This procedure remained in effect until 1968, when Italian Law n. 431 (known as the Mariotti Act) introduced voluntary internment and made it possible, at the patient's request, to convert a mandatory internment into a voluntary one. However, the real impact of the Law was to be found in the changes it enacted in asylum organisation and in the provisions it contained for prevention practices and follow-up care outside of the asylum itself.

From internment to the right to care: the Psychiatric Reform Act

The Psychiatric Reform Act, Regulations for voluntary and mandatory psychiatric evaluations and care (better known as Law 180), was approved on May 13, 1970 and subsequently incorporated into the National Healthcare Service Act (n.833, December 23, 1978). The Law established the principle that, as with general healthcare, psychiatric care would also be based on the individual's right to care and health, and not upon any presumed danger. Psychiatric care would now also voluntary, with mandatory treatment only for very exceptional and carefully regulated cases, and would be provided by services and facilities located in the community.

According to the Law, in the event of "altered mental states requiring urgent therapeutic intervention" and if all attempts to obtain the person's consent to such treatment have failed, then a Mandatory Healthcare Treatment (MHT) can be requested by the physician and carried out in any community-based psychiatric structure, or even in the patient's home. If hospitalisation is also required for medical reasons, the MHT can be applied in the Psychiatric Diagnosis and Care Unit (PDCU) within the general hospital.
The request for a MHT must be made by a physician and countersigned by another national healthcare service physician, and then submitted to the Mayor who, in addition to promulgating the actual order for such treatment, also has to notify a tutelary judge, whose function it is to guarantee the patient's civil rights. The Law further states that an MHT has the duration of one week only and can only be renewed following the same procedure as for the first instance. However, even after an MHT had been approved, every effort must still had to be made to obtain the patient's consent to voluntary treatment. The patient also has the right to communicate with whomever they wish and to appeal the MHT.

Law 180 also sanctioned that no new patients could be interned in psychiatric hospitals, (though permitting patients interned before May 1978 to continue to remain for an indeterminate period) and that existing psychiatric hospitals had to be closed (however, the definitive closure of all psychiatric hospitals in Italy would only be decreed by the Health Ministry in 1999, more than 20 years after Law 180).
Because Law 180 was promulgated as a framework law, it left "the criteria and goals to which the regional legislation for the organisation of fundamental services and personnel ... the general norms for the delivery of healthcare services and the national standards and indicators for the distribution of the National Healthcare Fund among the Regions' to a subsequent National Healthcare Plan." Unfortunately, the various Regional laws (Italy has 21 Regions) would be formulated only after considerable delay, and in a fragmentary and often contradictory fashion with respect to the national law, while the National Healthcare Plan was only drawn up and passed after many delays and difficulties. Because the first Mental Health Goals Plan was only passed in 1994, for many years Law 180 was inadequately financed and implemented.

However, the Friuli Venezia Giulia Region had the distinction of fully incorporating all of the indications of the reform law into its own Regional Law n.72/23 (December 1980), thereby initiating a positive transformation process. This Regional Law became a model for the correct implementation of Law 180 and many of its elements were incorporated in the Mental Health Protection Goals Plan of November 1999 (Dpr 274/1999).

The National Healthcare Service

In Italy, the right to healthcare was sanctioned in 1978. Healthcare was completely free until 1990, when a system of partial reimbursement, or the payment of a so-called "ticket" was instituted; however, despite this innovation, public healthcare remains essentially free. The national healthcare budget was 88.2 billion Euro in 2005, and while 5% of the total healthcare budget (4.4 billion Euro) is considered the minimum for mental healthcare, in fact only 3% is actually allocated for that purpose. Italy thus ranks 20th in Europe, together with Portugal, Slovakia and the Czech Republic, while Sweden, Great Britain and Germany allocate about 10% of their total healthcare budget to mental health.

In Trieste, the percentage spent for mental healthcare has remained more or less constant over the last decade, varying between 4.2-4.8% (in 2005, Trieste spent 16,057,739 Euro or 4.3% of the local Healthcare Services Agency – ASS1Triestina - budget).
In terms of organisation, national healthcare services in Italy were divided into Local Healthcare Units and then in 1995 into Local Healthcare Agencies. Each Agency has a catchment area which varies from a minimum 100k to a maximum of 500k, and provides all of the public healthcare services within its territory, including psychiatric care. The government allocates a healthcare budget to the Regions and autonomous provinces and the Regional governments in turn finance the Agencies within their territory based upon the annual national healthcare plans. Recent changes in the Italian Constitution have rendered the Regions even more autonomous in terms of healthcare programming and budgeting, and today local governments are essentially totally responsible for guaranteeing the quality and quantity of healthcare services for their populations.

Goals Project for Safeguarding Mental Health

The first National Mental Health Goals Project in 1994 represents a milestone in psychiatric care in Italy, with the second Goals Project (1999-2000) going even further and effectively modifying and emending the Psychiatric Reform Law of 1978 (Law 180) by specifying MHD structures and services in Italy and defining their functions. This Project ended a 20 year cycle of start-up and experimentation of the 1978 Reform, which had been characterised by strong and often bitter opposition and conflict involving operators, families, local administrators, politicians and public opinion.

The Goals Project was, and remains an extremely useful tool for the quantitative and qualitative development of psychiatric care because it:
| sanctions the definitive superseding of psychiatric hospitals;
| identifies the MHD, understood as an integrated whole of structures and services with a single management and coordination, as the organisational model best suited for guaranteeing therapeutic continuity and coherent interventions;
| specifies that the Psychiatric Diagnostic and Care Service forms an integral part of the MHD, even if located within a general hospital or a health care structure/agency which is not part of the community-based services;
| stresses the need to evaluate outcomes of interventions and the quality of MHD services;
| promotes a new phase characterised by the evaluation of the different types of services and intervention methods which are often in opposition or contrast with one another.

Mental Healthcare Policies and the Rights of Citizenship

Much of the world's population still lives in oppressive conditions due to various factors: extreme cultural and economic misery; lack of resources in the local territory or the social class to which one belongs; inequality between North and South and authoritarian and repressive political regimes which violate fundamental human rights. In a context already characterised by profound inequalities, persons who suffer from a mental disorder constitute one of the most oppressed minorities, and not only because they are denied basic rights more frequently, but because this denial of rights is legitimised by a scientific statute of "illness".

Because the majority of funds intended for psychiatry are still invested for the hospitalisation and segregation in closed institutions of persons who suffer from mental disorders, governments must give priority to promoting policies which provide for the immediate closure of all places of internment and reclusion and the development of community-based services. Of particular urgency during this transitional phase is the creation of mental healthcare services for defined areas, with the mandate of identifying operational choices, and strategies for the promotion of health and the real access to rights.

For methods of care to change, the places where care is provided must also be changed; changing one and leaving the other intact is a dead end. The focus must be shifted from the illness to the whole person: their needs and rights, but also their abilities and resources. Programmes must provided a wide range of interconnected services directed not only at the individual but also at their context, and the network and social groups to which they belong.

Thus, the political task (of both central governments as well as local administrators) must be that of promoting citizenship for the most disadvantaged and vulnerable sectors of the population, improving the quality of life and encouraging autonomy and emancipation (including from a dependency on the services) so that the real tangible exercise of rights leads to a greater ability to choose and act.
It is especially important to guarantee the following for persons with mental disorders:

• material and financial aid, even temporary, in order to guarantee an income that permits the person to live with dignity;
• adequate housing, meaning a home, but also the possibility of entering a protected or semi-protected apartment, community or residence during periods of particular need;
• employment, which is suited to a person's needs, abilities and inclinations;
• access to education, information and training;
• access to places and occasions for socialisation, both for specific activities and leisure time;

National governments and local administrations should also offer healthcare education programmes for the general public in order to promote a more positive image of the mentally ill which is free of labelling and prejudices.

The Helsinki Declaration

In January, 2005, the WHO organised a 3-day European conference on mental health in Helsinki. At the end of the conference, the health ministers of 52 countries in the European geographic area, including Turkey and Uzbekistan, unanimously approved a significant document in which the signers declared their adherence to a shared analysis and evaluation regarding mentally ill persons living in their countries. According to the WHO Director for Europe, this agreement is the result of years of experience and work in defense of human rights and the right to care, treatment and prevention in mental health, and represents a historic achievement and point of departure.
The document was prepared by doctors, psychologists and researchers, as well as mental healthcare service users and their families from different European healthcare systems.

The Helsinki conference also approved a Plan of Action which is binding for European governments. The principles expressed in these documents are the same ones which have sustained and driven the transformation process in Italy, with the "Trieste system" representing a real concrete experience of renewal.

But what does the Helsinki Declaration say? It begins by stressing that there is no health without mental health, that a person's mental health and mental wellbeing are fundamental to their quality of life, impacting on their productivity, the family, the community and the nation as a whole. Mental health enables a person to experience the true meaning of life, permits them to express their own creativity and be active and participatory citizens.

The Plan of Action provides for increasing investments for mental healthcare and establishing healthcare policies and laws based on current knowledge and human rights. The document further states that mental healthcare policies and practices should focus on promoting mental wellbeing, fighting discrimination and social exclusion, providing effective and adequate services and promoting prevention and the social reintegration of persons with severe mental disorders.

The WHO Declaration places mental health at the centre of the human, economic and social potential of the participating countries and exhorts all countries to consider it an integral part of their social policies, together with the defense of human rights, education and development.

The Declaration also establishes the following priorities for the coming decade:

• publicising the importance of mental wellbeing;
• fighting together against stigma, discrimination and inequality and working to empower and support persons with mental health problems and their families so that they can actively participate in this process;
• planing and building complete, integrated and effective mental healthcare systems that deal comprehensively with promotion, prevention, therapy, care, rehabilitation and social reintegration;
• training competent and effective operators;
• recognising and valuing the experience and knowledge of persons who have experienced or are experiencing mental illness and their familes as being able to make an important contribution to planning and developing mental healthcare services.

The Green Paper

In May 2006, based upon the Helsinki Declaration the European Community prepared a "green paper" entitled: "Improving the public's mental health. Towards a mental healthcare strategy for the EU."

The mental health of European citizens is a resource for achieving a number of the EU's declared strategic goals, such as long term prosperity, a greater commitment to solidarity and social justice and a real improvement in the quality of life of European citizens.
The following factors make improving the mental health of Europeans a priority:

• one citizen in four suffers from a mental disorder, with the possible risk of suicide;
• mental disorders result in significant costs and a major burden for the economic, social, educational and legal systems;
• stigma, discrimination and the violation of human rights and dignity of persons with mental disorders or handicaps are still widespread, in clear contrast with fundamental European values.

Improvement is possible in all of these areas and numerous initiatives have been launched. Further development is necessary, together with a consolidation of existing projects.

Appeal of Pope Benedict XVI

On February 11, 2006, on the occasion of the 14th World Day for the Sick, Pope Benedict XVI made an appeal to persons around the world in order to stimulate and promote attention, solidarity and effective action in favour of persons suffering from mental disorders.
In his message, Pope Benedict XVI wrote: Many countries still lack legislation in this area, while others have no specific mental healthcare policy. In addition, the prolonging of armed conflicts in various regions of the world, the succession of immense natural catastrophes and the spread of terrorism have not only resulted in an incredible mortality, but have also caused often irreparable mental trauma for many of the survivors. In economically developed countries, experts point out that at the origin of new forms of mental illbeing is a crisis in moral values, which impacts negatively by increasing the sense of solitude and undermines or even destroys traditional forms of social cohesion, beginning with the family, and marginalises the ill, especially the mentally ill, who are often considered a burden for the family and the community. I should like to render homage all those who, in different ways and at different levels and inspired by human and evangelical ideals and principles, work to maintain the spirit of solidarity and provide care for these our bothers and sisters.
I therefore wish to encourage whoever operates in order to guarantee that the mentally ill receive the necessary care. Unfortunately, in many places around the world, the services for the mentally ill are inadequate, insufficient or degraded. The social context does not always accept the mentally ill with their limitations, which is another reason why it is difficult to obtain the necessary human and financial resources. Appropriate therapies must be integrated with a new sensibility and awareness for the mentally ill, so that mental healthcare operators can work more effectively with ill persons and their families, who otherwise would be unable to assist their loved ones properly. The upcoming Worldwide Day for the Sick is an excellent occasion for expressing solidarity to those families who must provide care for a member who suffers from a mental illness.