Franco Scarpa, Luca Castelletti

The italian reform of forensic treatment: the Community Mental Health Network and the new facilities for patients not guilty by reason of insanity and dangerous.

Italy reformed the system for treatment of patients not guilty by reason of insanity, dangerous for society, and according penal code sentenced to a security measure. Last 2014 was approved the Law n. 81 stating the principle that patients had to be treated out of prison system, i.e. the big asylums called Judicial Psychiatric Hospitals, but in a new national residential network managed by the national health system and Psychiatric Departments.  This new system for subjects in security measures is now trying to develop and share common good practices of care, according to the contents of the new legislation.

The definitive closure of the forensic hospitals in Italy began since april 2015 and was concluded last January 2017. Currently the national mental health system is developing a system of new procedures for the care for mentally ill peopole.

New facilities, Residence for Sercurity Measure (REMS), have been done for each Regional Administration. Each REMS must provide not more than 20 beds and basically the admission is reserved only for the treatment of most dangerous patients.

On the other hand, the main goal of the Law was adressed to allow that less dangerous patients should be treated by the network of the community services and residences of the Mental Health System. We need to remind that In Italy, after the Basaglia reform of 1978, don't exist asylums for mental health people but only community residences, flat or ambulatiorial treatments. The acute patients are hosted in Psychiatric  wards inside the ordinary Hospitals for the necessary time.

The REMS aren’t like prison or asylums but they work, according principles recognizing the rights of the patients, acquiring patient’s consensus to the treatment, plan individual therapeutic plans centered on the patient’s needs, perceive a rehabilitation goal.

At the moment there are in Italy 34 REMS for a number of 600 patients that can be there treated in a secure and restricted environment. There is a high turn-over of the patients and many of them are discharged to be admitted in less security level facilities. Actually, some of the Regions have set up peculiar facilities that can admitt and treat less dangerous patients.

The number of beds of the REMS seems not to be sufficient and several patients (almost 300 hundreds) are waiting to be admitted to this secure facilities.

Beyond the REMS, the most part of the NGRI are treated inside the ordinary facilities because the Judge can apply a “non restrictive” security measure called “libertà vigilata”, i.e. freedom under prescription. The new system of treatment will be described and the main problems will be analyzed.  The new forensic system has to be underpinned by reformism of correctional health services, establishment of psychiatric services and units inside the prisons, by more developed forms of collaboration with Courts and his experts, who still  decide in autonomy the referrals to forensic units.

The reform must tackle many other questions including changes in penal legislation, that remained unmodified, relationship between law system and care for people, mental health services inside the prisons and finally the possibility to reform the legislation regarding security measures. What Italy is currently doing is without any doubt a new step towards a treatment of the patients who have committed crimes without prisons or ayilums in a less restrictive environment, without the walls and gates, if not really necessary, inside the community services.   

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