Written by Luca Castelletti (Medical Director, REMS Carlo Poma Mantova, Italy)
The whole Italian forensic sector is undergoing a radical process of renovation, as since 1st of april 2015 the 6 national forensic hospital have been closed down and are going to be replaced by small regional 20 bedded-units named REMS standing for Residencies for the Application of Security Measures. As the process is delegated to the 20 regional health systems, the institution of the residencies is at different speed of building up. In our contest, in the Lombardy region, with a catchment area of around 10 milion people including Milan area, the project is to refurbish and renovate the “old” Ospedale Psichiatrico Giudiziario (OPGs) into a system of 6 REMS for a total of 120 beds. In the regional and central political plans it’s going to be the main forensic centre serving the Country. At the moment we host around 180 patients, of whom 45 are women, as we supply the momentary lack of ready residencies of some other regions.
Forensic psychiatric field in Italy has suffered of a certain delay compared to other forensic systems in Europe. The great psychiatric Reform of 1978, named as Basaglia Law by the name of the psychiatrist who gave a fundamental impulse to overcome the asylums structure and replace it with new born community services left the forensic sector untouched.
This was deeply influenced by the ideas of Cesare Lombroso, a XIX century italian psychiatrist quite known for the development of “criminal antropology”, precursor of modern criminology. The establishing of the 6 OPGs from 1876 to 1939 were influenced by his ideas so the Rocco Penal Code, still in use in Courts, dated 1933.
Current consequences are the difficulties to update a whole sector scotomized for years by general psychiatric services, university schools of psychiatry, politics.
The old forensic system linked to OPG institutes produced the phenomenon of “white life sentences”: the patients were stuck and unable to progress to a lower level of security. As the forensic service suffered of isolation from general services, it has been difficult to develop a shared structured pathway for patients.
As the Laws 09/2012 and 81/2014 have defined that the old model has to be replaced by a modern system integrated with community psichiatry in a network including courts, correctional systems, services for addiction, social services, in the opinion of many there is an urgency to adopt a model that may include the needs of patients with a longer expectations of staying, in terms of staff (patient-staff ratio, training…), organization of structured daily activities, therapeutic climate and architectural solutions for indoor and outdoor spaces.
Training of professionals is a main aspect in forensic systems under renovation, as that was the case for the Irish forensic system in the near past. Now it is renovated and expresses one of the most well organized and feasible systems in the Continent. I visited the National Forensic Mental Health Service in Dublin during my STSM last July. The “Induction Programme“ for new staff I attended there represents a very interesting starting point to develop a structured and reliable pattern of education and training for all professionals interested in working in the forensic psychiatric field, and re-motivate those already working in the forensic sector but loaded by prevalent custodial culture. It’s held every six months, developed in two weeks, and dedicated to all those professionals, registrars, nurses, OTs, that are approaching forensic psychiatry, for a studentship training or new staff members. It is composed of classic frontal lessons for half of the day and practice training with multidimensional team for the remaining. It covers main topics of contemporary forensic psychiatry: structures and processes of modern forensic services, including prison in-reach services and court diversion, prison to community rationale, governance structures, ways of assessment and treatment assisting decisions on which level of security wards to set the theraputical program and on decisions about forensic hospital to discharge. Time is dedicated to improving structured therapeutic activities for patients daytime, focusing on development of individualized treatment programmes that should be supported by an active co-construction with service users to promote active engagement. His/her placement at the centre of care pathway in a recovery approach has thought to be essential to re-gain hope, control and opportunity.
How all this complex network of education, training, clinical knowledge can be imported into a different national system in a respectful form of history and comtemporary organization is now object of discussion at the REMS system of Castiglione delle Stiviere.