By Pietro Pellegrini*, Anna Pellegrini**
From The Manifesto
December 28, 2022
The Agreement for the management of psychiatric patients with a safety measure approved on 30 November 2022 by the State-Regions Conference is the result of the interinstitutional dialogue held at the permanent consultation table on prison health. The document envisages the creation of two bodies: a “National control room” which joins the “Coordination body for the overcoming of the Judicial Psychiatric Hospital (Opg)” at the Ministry of Health; and a «Punto Unico Regionale» with the aim of supporting the Judicial Authority, of acting as a link with the Departments of Mental Health (DSM) and of promoting local Protocols. These have the objective of developing “shared care pathways” for which, in addition to the experts, the patient’s consent and participation are essential, as well as the activity of lawyers, support administrators and guarantors who will be involved at all levels.
The Agreement gives priority to care, within which the safety measure is placed, and overturns the vision according to which it is the safety measure that contains the therapeutic program until it coincides with it, in an obligatory and coercive way. The art. 1 confirms the principle of territoriality: people subject to security measures must be taken care of by the DSM of their territory. This contrasts with the forecast of the possibility of creating residences for the execution of national security measures (Rems), such as that of Calice al Cornoviglio (La Spezia). Choices that undermine the principle of territoriality, necessary for patients to be followed by the Centers that treat them, maintain relationships with their loved ones and be reintegrated into their own social fabric, given that many patients are without documents, residence, home, income .
The attention placed on the Rems must not make us forget that these structures represent the last resort and are part of the mental health departments, the true core of the system, which follow about 6,000 patients with judicial measures.
«Therapeutic rehabilitation activities, as constituent elements of the treatment process, even if carried out in a place outside the Rems (…) do not require further endorsement by the Judicial Authority» (art 8). A turning point to recognize the nature of “Residence” of the Rems, its integration with the territory and to go beyond the custodial aspects through Regulations, Charters of Services and Rights.
The criteria for managing the waiting list to enter Rems, in addition to the temporal oneare the “health characteristics” of the patient, “the current level of inappropriate placement” in a Penitentiary Institute or in a Psychiatric Service for Diagnosis and Treatment (SPDC) and the adequacy of “alternatives to Rems”, while the seriousness is not indicated of the crime.
The problem of temporary security measures remains open which concern 40% of people in Rems and are the cause of 80% of detentions sine titulo. The subject of probation, often extended indefinitely, has remained in the shadows as has the protection of mental health in prisons and in the Mental Health Protection Units, causing an overall view of the entire system to disappear.
The DSMs have the obligation to take charge of patients but they must do so with “unvaried expenditure”. A contradiction, a risk of denying rights and of default that weighs on psychiatric operators who, instead of a “position of guarantee”, should be granted a “therapeutic privilege”. There still seems a long way to go beyond the Rems, prioritize therapeutic programs with Health Budgets and create a community system of care and justice. An agreement made of lights and shadows, pending, as proposed by the Hon. Magi (pdln 2939/2021, of a radical reform of imputability.
* Psychiatrist
* * Jurist