Benedetto Saraceno
In Italy we continue to bond and not only in Diagnosis and Treatment services but also in the many types of residential care, from the insane to the old through to disabled minors, everyone is exposed to the risk of one day finding themselves immobilized in a bed by bands of hemp
Italy signed the United Nations Convention on the Rights of Persons with Disabilities (CDPD) in 2007 and ratified in 2009. (1). Ratification solemnly expresses the consent of a state to be legally bound by the provisions contained in the treaty or convention. The rights affirmed by the Convention are already present in international treaties on human rights but in this specific convention the general principles of dignity, equality, non-discrimination and full social inclusion are applied to people with disabilities, with the concern that disability should never constitute a factor of weakening of rights. The CPDP establishes a fundamental and historic paradigm shift by affirming the rights of people with disabilities, whether physical or mental.
To prevent the Convention from remaining a dead letter, an intergovernmental body was established which constitutes a sort of permanent secretariat through which States discuss and examine the status of implementation of the Convention. This body is called the Conference of States Parties. An eighteen-article Protocol establishing a Committee on the Rights of Persons with Disabilities was annexed to the Convention. This Committee has two functions, that of monitoring the implementation of the Convention, examining the reports sent every four years by the States, and that of examining all reports of violations of the Convention. It is made up of eighteen independent experts who meet three times a year and who are elected by the Conference of States Parties.
At the end of 2022, the Committee produced guidelines on deinstitutionalization thanks to a participatory process which involved over five hundred people with disabilities and survivors of institutionalization. Finally today the Italian version of the Guidelines was also published (2). It is very important that the notion of deinstitutionalization has become part of the language of the United Nations and that institutionalization is recognized as a form of violence against people. It is a radical evolution of UN thought that makes deinstitutionalization practices transition from an innovative experiment promoted by a few visionary reformers (and Franco Basaglia first of all) to an obligation of States.
The language used by the Committee is unambiguous: “Institutionalization contradicts the right of people with disabilities to live independently and to be included in the community. States parties should abolish all forms of institutionalisation, put an end to new placements in institutions and refrain from investing in institutions” (2).
The Guidelines provide a sort of glossary that defines numerous terms and first of all the term “Institutionalization” (and lists numerous places that must be considered as institutions, well beyond traditional psychiatric institutions and among others: long-term hospitals, nursing homes, protected dementia wards, special colleges, rehabilitation centers other than community ones , rehabilitation homes, forensic psychiatric facilities).
Furthermore, it defines fundamental deinstitutionalization processes such as
Respect for the right to choose and individual wishes and preferences, Support at community level (which includes home support services!), Allocation of funds and resources (“Investments in institutions, including renovation, should be prohibited. Investments should be directed towards the immediate release of residents and the provision of all necessary and appropriate supports to live independently). reasonable prices in the community, through public housing or rent subsidies….…The reference to residential services in Article 19 of the Convention shall not be used to justify the maintenance of institutions”). Involvement of persons with disabilities in processes of deinstitutionalization (“States parties should establish open and inclusive planning processes, ensuring that the public understands Article 19 of the Convention, the harms of institutionalization and exclusion of persons with disabilities from society and the need for reform” ).
It should certainly be remembered that these Guidelines, unlike the Convention whose ratification is legally binding, are recommendations to States and do not have the same value as the articles of the Convention. However, they should be hailed as an authoritative attempt to moral suasion towards states that still consider deinstitutionalization as a dangerous and excessively libertarian adventure.
Let’s remember how Matteo Salvini’s League would like to review the Basaglia law and maybe, why not, reopen the mental hospitals. After the killing of the psychiatrist Barbara Capovani, at the hands of one of her patients, “the belief is strengthened that a profound reflection on law 180 is necessary and can no longer be postponed”, official sources from the League said. On the other hand, already in 2018 the then Minister of the Interior proclaimed: «We are working for a better Italy. I think of the absurd reform that has left thousands of families with psychiatrically ill relatives in poverty… This year there is an explosion of attacks caused by psychiatric patients”.
On the contrary and against these positions, at best fearful, and at worst decidedly retrograde and repressive, the Committee addresses in depth the issue of regulatory and policy frameworks that favor deinstitutionalisation and social inclusion: the right to legal capacity (i.e. the promotion of the exercise of decision-making capacity), the right of access to justice (i.e. the abolition of environmental, attitudinal, legal and procedural barriers that hinder access to justice for people with disabilities), the right to freedom and security (i.e. the promotion of the repeal of those legislative provisions that deprive people of their freedom and attack their personal safety).
The Guidelines go into the very important details of the elements that must constitute alternative services to institutionalization and describe the need for Support Services and Networks with much emphasis on peer support. Income support is also analyzed and recommended as a key component of the deinstitutionalization process. Finally, the question of preparations for leaving the institution and the importance of training processes for operators and users to actually experience what has been defined as “the risk of freedom” (4) is addressed. It would be useful to be able to describe the Guidelines in detail here but suffice it to remember that they represent a decisive step forward in the international debate on forms of liberation from the biomedical and repressive model of current psychiatry. Land people with long-term mental disorders and some kind of disability, are no longer a separate vulnerable group with diminished rights or placed under special protection. The common belonging to the universal social contract of rights constitutes a substantial progress compared to the time in which mental disability was relegated to a legal limbo, not only separate, but substantially regulated by laws that had to do with social danger instead of, rather, with the right to social inclusion.
However, in Italy ties continue (5) and not only in Diagnosis and Treatment services but also in the many types of residential care, from the insane to the old, passing through disabled minors, everyone is exposed to the risk of one day finding themselves immobilized in a read by hemp bands (6).
Therefore, if the application of the United Nations Convention cannot be considered an optional but a moral and legal obligation, knowledge of the Guidelines of the Committee on the Rights of Persons with Disabilities is strongly recommended.
Benedetto Saraceno, Lisbon Institute of Global Mental Health
References
United Nations. Convention on the Rights of Persons with Disabilities. http://www.un.org/disabilities/convention/conventionfull.shtm. New York, 2006.United Nations. Committee on the Rights of Persons with Disabilities. Guidelines on deinstitutionalisation, even in case of emergency. CRPD/C/27/R.1Fabris A. The specter of Basaglia haunts Salvini. Jacobin Italia. 13 Dicembre 2018.Cohen A., Saraceno B.: The Risk of Freedom: the Mental health Services in Trieste. In: Cohen A., Kleinman A., Saraceno B.: World Mental Health Casebook. . . . Academic Club/Plenum Publishers, New York, 2002.Del Giudice Giovanna. And you untie him right away. Edizioni Alphabeta Verlag, Merano, 2015.Saraceno B. (2021). International conventions and denied rights. International Health. May 24th. Barbara Capovani, CDPD, restraint, United Nations Convention on the Rights of Persons with Disabilities, deinstitutionalization, Disability, mental disorders, Institutionalization, Basaglia Law, Guidelines, Mental health