British Journal of Psychiatry (1985), 146, 208—213 Correspondence Understanding the Italian Experience DEAR SIR, Referring to Jones and Poletti's article on the Italian psychiatric reform (Journal, April 1985, 146, 341—347)I would like to point out some omissions and misreading of important facts. a. The Italian political context and the Mental Health Law (Law 180) The authors seem to be somewhat out of touch with the Italian social context, despite the fact that one of them is Italian. This is exemplified in omitting to mention the impact of 1968 on the whole of Italian society, in forgetting that the current income per capita is higher than in Britain, that Italy and Britain top the European league in unemployment rate together, and that one of the first achievements of the Psichiatria Democratica was to get an invalidity allowance for mentally ill people. As to the claim that “¿political no party in Italy supports Law 180, with the exception of the Communist party― it may be useful for the readers to know that as recently as 18 April 1985, Mr. Degan, the Minister of Health, stated in a con ference of European health ministers that the Italian law is the most advanced in the field and that the overall balance of its operation is positive (see interview with him in II Messaggero, a right-of centre paper). Of the 12 proposals for the modifica tion of the law currently before the Italian govern ment, none calls for the re-establishment of the psychiatric hospitals. The Italian Communist party has the consistent support of a third of the Italian voters since 1945. It is one of the two largest parties in Italy. Supporters of Law 180 are, however, to be found in all Italian parties, which is the reason why it was passed and why it has not been changed so far. b. The Italian experience The “¿ italian experience― is not based on Law 180. If any, the law is based on fifteen years of previous experience of changing radically the Italian psychiatric system in the North, the Centre and some parts of the South prior to 1978 by Psichiatria Democratica (PD) and its supporters. It is precisely this experience which led to halving the number of inpatients before 1978, a fact mentioned later in the article. To equate the PD with the personality of the late Franco Basaglia is like equating the British victory in the last war with the personality of Winston Churchill. Yes, Basaglia acted as a catalyst. But the PD is no more of a pressure group—as Jones and Poletti would like us to believe—than is the Royal College of Psychiatrists. It is a group whose majority are practising professionals of all ranks, who have demonstrated how a psychiatric system can be changed in their own practice. In their description of Trieste (which prisons has increased during the 1978—82 period by 55 (from 1580 to 1635, Giannichedda & Grassi, 1983). To call this increase “¿ sharp a increase― needs a considerable stretch of imagination. Not to mention that it is the PD which is now mounting a campaign, together with Magistratura Democratica, to change the conditions and treatment in these settings is a telling omission. Likewise the overall figure of homicide and suicide committed by people known to be mentally ill has not increased during the 1978—82 period, according to national statistics (CNR, 1982). On the basisof my own observationsover the last three years in Italy, including the South, I would agree with the authors that the psychiatric units in the general hospital are the least satisfactory component of the whole new system. In my opinion, this state of affairs is the result of the fact that they continue to operate in the traditional mould of psychiatry. Indeed, where no such wards exist (e.g. Cortona, Martina Franca, Trieste) the standard of care of people in an acute crisis is considerably better. Jones and Poletti do not mention ex-patients' work cooperatives, initiatives of the new centres to change local attitudes towards the mentally ill, and the imaginative use of hospitals' sites which typify the good examples of the reform and which are far from being confined to Trieste. One wonders why. 208 https://doi.org/10.1192/bjp.147.2.208 Published online by Cambridge University Press inaccurate they have avoided visiting) the authors omit to mention the fact that in a city of 350,000 inhabitants neither a psychiatric hospital nor a psychiatric ward in a general hospital exist now. Instead there is an eight-bedded emergency psychiatric service in the general hospital and 45 beds located in seven community mental health centres, all of them unlocked, which deal with all psychiatric admis sions, as compared to a 1,200 beds hospital in 1970. The number of inmates in the Italian psychiatric 209 CORRESPONDENCE References Examples of bad practice are to be found every where, including the UK and Italy. To claim that the majority of the Italian psychiatric services offer a poor service on the basis of a two-weeks visit, with a reference list which indicates that basic material has not been read, can hardly provide a basis for a sound judgement. 0. & GRASSI, L. (1983) Il Manicomio Guiziario:Problemie proposteper il superamento.Paper given at the conferenceon: La PsichiatriaIra Riformae Controri forma, Rome. CNR(l982) Progetto-finalizzato Medicine Preventiva. La Riforma Psichiatria, FOWLER, JONES, As late as 1979, Prof. Jones wrote: “¿ But we have plenty of evidence that such institutions [i.e. hospitals] M. Il Pensiero Scientifico, N. (1982) Opening Roma. speech. “¿ Working Together―, MIND Annual Conference, p. 5. c. Relevance to Britain psychiatric GIANNICHEDDA, can be damaging― (in K. (1979) Integration or disintegration of the Mental Health Service: Some reflections and developments in Britain since the 1950s. In New Methods ofMental Health Care(ed. M. Meacher). Oxford: Pergamon. Meacher, p. 3). Yet in the present article the authors can outline only negative outcomes appearance of such settings. to the dis In my view the Italian experience has demon strated more than once that: 1. It is possible to gradually dc-structure and dismantle the psychiatric hospital with the partnership of patients and staff. 2. Community mental health centres can offer a good psychiatric provided service without non-medical a hospital, asylum facilities are avail able. 3. It highlighted the conditions for successful as opposed to unsuccessful outcomes, including the desirability and possibility of a nearly full redeploy ment of the staff group. I fully endorse the point made by the authors that a psychiatric system cannot be changed by the law What Price Psychotherapy? DEAR SIR, Shepherd (Journal, May 1985, 146, 555—556) rebuts the suggestion that he ‘¿ latched on' to the paper by Prioleau et a! (1983) on the grounds that writers in two other medical journals did the same. But consensus, whether orchestrated or not, does not constitute evidence. An impartial observer would surely find it surprising that, out of the rash of meta-analytic papers, this particular one has been singled out for attention, based as it is on 32 papers describing untypical patients and therapies of NHS practice. almost wholly For example, psychiatrists were involved in only three of the studies, nearly half of the therapists were under graduate or postgraduate students and the patients community care policy. Not even one psychiatric were schoolchildren in 13 cases and university hospital has closed down since then, despite the students in nine. considerable reduction in numbers of in patients One's suspicion that it was the conclusions of the (Fowler, 1982). study rather than its merits that gained it such For a real, non-cosmetic, change of the notoriety is heightened by the account given ofit in a psychiatric system there is a need for a changed fourth article, an editorial written by Prof. professional and political attitude, a fact which the Shepherd's .registrar in a journal he himself edits Italians, for one, have understood perfectly. (Wilkinson, 1984). In language not usually asso It is the very lack of a real change in Britain which ciated with professional or scientific discourse, this attracts to the Italian experience professional and article calls for the ‘¿ protectionof unhappy and at lay people here who are unhappy with the stalemate times desperate people' from ‘¿ unscrupulousprac of our psychiatric system, without necessarily titioners ofpsychotherapy' and describes the growth wishing to imitate the Italian format. in the number of consultant psychotherapists (to a If Jones and Poletti assume that an “¿ ante figure still well below College recommendations) as diluvian, imperialist― approach which stresses the a ‘¿ disturbing piece of information'. impossibility of comparing “¿ backward― Italy to Shepherd depicts the debate about psychotherapy “¿ enlightened― Britain will convince anyone in 1985, in terms of two extreme vocal groups with a large alone. The nearest example is provided by Britain, where officially we opted in 1959 for a fully fledged they may be in for a rude surprise from the natives and other inhabitants of the British Isles. SHULAMITRAMON Acting Course Director, Social Work Studies, The London School ofEconomics & Political Science, Houghton Street, London WC2A 2AE https://doi.org/10.1192/bjp.147.2.208 Published online by Cambridge University Press silent majority. This is the picture which his style of argument, and also that of Eysenck (Journal, 1985, 146, 556—557) (which has indeed remained unchanged for 30 years) would tend to perpetuate. Fortunately, in both the UK and the USA, there is a large and growing body of vocal practitioners and researchers who have long tired of polemics and