Competence limits  
and regions' inefficiency  

This as well as other works have concretely hindered the observance of what the 662 law laid down, forced regions to regulate the closing process of the hospitals by adopting proper planning schemes within January 31, 1997 and fixed heavy financial penalties for defaulting regions. In this sense, the analysis of the regional plans ultimately suggested three different planning models that involved:  
a) the choice and the development of the closing plan of each mental hospital with a resolution of the county council;  
b) the choice of the closing plan of the mental hospital established by the Local Health Centre in question, with a resolution of the county council;  
c) the choice of the closing plan of a mental hospital established by the Local Health Centre in question, with a resolution of the regional council.  
Unfortunately, this administrative and corporate division that distributes different responsibilities among the Local Health Centre, the county and/or the regional council, is not efficient and seriously risks jeopardising the application of penalties for those who do not comply with the provisions of the law. On top of that, an analysis of the regional plans highlighted some dangerous tendencies that need a rapid change. What are these tendencies?  

What a bad way of doing things...  

The closing plans of the facilities do not always have precise closing times, a factor that makes controls and monitoring rather difficult. Many regions, furthermore, acted in extremis only to avoid financial sanctions. On top of that, many closing plans often consider the possibility of re-using the former mental hospitals' areas with the unclear and sometimes even questionable aim of building alternative facilities despite the high costs linked to the rebuilding of the premises and the evident clash with the concerned legislative policies.  
It is in this way, however, that the hospitalisations in mental hospitals are being carried out again. Finally, many “quick” closings - performed in order to avoid sanctions - are being carried out with no reorganisation projects pertaining psychiatric assistance.  

A couple of numbers  

According to the data collected by the survey, the closing process of mental hospitals concerns 62 public and 14 private hospitals, with a total of 20,292 beds, 12,951 of whom are public and 7,340 are private. It seems that the hospitals of Reggio Calabria, Arezzo, Collegno-Grugliasco, S. Ambrogio di Valpollicella, Rovigo, Salice, Noventa Vicentina, Monselice, Oderzo, Feltre, Treviso, Valdobbiadene, Perugia, Udine, Roncati and Lolli closed by the end of last December.  
'To seem' is the right verb here because it is not rare that some of those hospitals closed only “administratively” and turned their “patients” into “guests”.  
It is a worrisome situation, just like that of the state of the still working hospitals, now crumbling, disorganised and neglected, that are actually the survivors of themselves.  

The “human material”  

If the logistical and administrative problems seem now wrapped by a huge number of contradictions, the “human material” is far more in danger.  
The survey, in fact, dramatically highlighted a clear lack of reliable, detailed and uniform data pertaining what actually occurred inside the mental hospitals as from the 1978 reform and the lot of their former patients as from the same year.  
This alarming situation must have deeply affected the conclusive document's drafters as it pushed them to write: “The Parliament should ask itself and society what kind of life the thousands of people who lived in mental hospitals led, what happened to the patients who were discharged, what kind of assistance they received, how they were helped to settle in society, how many died and of what, how many are still surviving”.  Regions, then, actually failed to give precise information about the lot of the discharged patients, confirming that, apart from some happy cases, the enforcement of the 1978 180 law was but a makeshift operation, a tragic abandonment, that failed to provide the former patients with reintegration opportunities.  
The damage was huge: after 1980, some 80 thousand people left mental hospitals. One third likely died while the others probably ended up in... other institutions (sic!).  

Almost a decalogue  

These as well as other data provided the Parliamentary Commission with the opportunity to understand that the closing project has just been started in an extremely ambiguous context.  
Consequently, the Commission decided to make a list of mistakes not to be repeated and of dangers to be avoided in the future.  
Avoid “damping” the people who still live inside former mental hospitals to their lot (or damping them to their families, if they exist), to formally demonstrate the closing of mental hospitals and neglecting a customised cure, rehabilitation and a way to re-integrate into society.  
Avoid adapting to “false closings”.  
In many former mental hospitals, there still is a re-organisation process that merely envisages to renovate the old wards and to keep the old patients, sometimes paradoxically aiming at re-opening a series of new admissions through the so-called rehabilitative communities.  
Avoid always using the same facilities and areas for old patients and the handicapped of former mental hospitals.  
Avoid starting closing plans without properly preparing the transfers to alternative facilities. Avoid “damping” former mental hospitals' patients to public facilities bereft of requirements alternative to mental hospitals. This loophole is often used either to formally close former mental hospitals or to sadly guarantee local interests aiming at transforming the closing into a turnover.  
Avoid using the former mental hospitals' property for speculative purposes or abandoning them to themselves neglecting an income necessary to be re-invested in the mental health field.  
Avoid favouring the tragic contrast between the interests of the patients currently living in former mental hospitals who will certainly resort to the weak and neglected alternative facilities of the region, and that of the new patients who are many and have few opportunities to be cured and rehabilitated.  

Some points for the future  

If the above-mentioned hints indicate what should be avoided - but was actually widely done so far - what follows indicates a method for closing mental hospitals in a proper way. The XII Commission itself outlined the following points in order to set a support scheme for closing mental hospitals.  
1 - Monitoring the patients, wherever they live, coming from former mental hospitals as from 1994.  
2 - Customization of discharge schemes and of the admission into alternative facilities, providing the patients with a proper social and working reintegration.  
3 - Development of a network system of the services, beginning with the Mental Health Department.  
4 - Promoting a strong integration of the interventions in the social and health fields which cannot be separated in the various stages of prevention, cure, rehabilitation, social and working re-intregration. To such end, it is fundamental to establish a relationship with local bodies to develop common strategies to strengthen their respective roles within a logic of an integrated work.  
5 - Recognizing the strategic role of the relationship with the social private field that should participate in the project phase and in the examination of the results and that should not be considered as “low-cost labour”.  
The social associations can be a relevant and serious answer across the country because they offer a wide range of services, in particular in terms of working reintegration.  
6 - Starting a re-qualification programme of the workers coming from former mental hospitals, allowing them, if they request it, to work in other health care service facilities; strengthening of the professional training of health care and social workers of the mental disorders field in order to enhance services and improve quality.  
7 - Change of the interdiction discipline of former mental hospitals' patients, making it possible to use their income, that are often kept in bank or postal deposits, for their assistance and personal needs.  
8 - Adopting a new objective project in order to determine methods and times of intervention to support the regions and the local health centres.  
It should indicate the minimum uniform levels of assistance in order to avoid intolerable inequalities throughout the country and provide precise guidelines to strengthening alternative facilities.  
9 - Re-setting the historical expenditure, adjusting financing systems to cure mental disorders and freeing the resources laid down by the 1994 724 law, then changed by the 1996 662 law, avoiding the use of former mental hospitals' areas for other facilities.  
10 - The 1998 financial law should establish provisions that on the one hand penalize those who have not complied with the existing provisions yet and on the other favour those who actually closed the facilities. The supervision and control over “false closings” will continue to be performed.  
11 - By-yearly reports from local health centres, the regions and the ministry about the situation of the closing and other interventions' implementation.  
12 - Re-examining the Observatory for mental health's organisation and functioning, adapting its operating and support structure to the possibility of carrying our some tasks, such us supervision and control; enhancing national and regional conferences to support the monitoring activity.  
13 - Development of a new project for judicial mental hospitals in order to overcome the logic of classical mental hospitals, keeping due levels of security for the citizens and guaranteeing the humanitarian nature of the sentence and the prisoner's social rehabilitation.  
14 - Establishing some guidelines on psychiatric therapies, avoiding to resort to electroshocks and to the abuse of drugs, in particular of retard drugs, especially in private facilities where controls are less strict.  
15 - Supporting families that should not be left alone to tackle mental disorders, at the same time developing discharge plans that should consider the patient's precise will.  
16 -Ensuring an easy way for the political and parliamentary control of the closing plans.  
The Commission will probably set up a standing committee to keep close tabs on mental disorders-related questions.  

Conclusion 

It is difficult to draw conclusions. After more than a year's work, the Parliament is trying to launch a plan to achieve these goals. Who knows, maybe in the end even 1998 will deliver its sentence.  
Sure: 20 years of waiting to hope for a little more than normal life... this seems a sheer madness!