Reform of Italian forensic mental health care. Challenges and opportunities following Law 81/2014

• Pages: 1-3
• Published date: 12 March 2018
• DOI: https://doi.org/10.1108/IJPH-05-2017-0022
• Date: 12 March 2018
• Author: Gareth Hopkin,Ester Messina,Graham Thornicroft,Mirella Ruggeri
• Subject Matter: Health & social care,Criminology & forensic psychology,Prisoner health,Sociology,Sociology of crime & law,Public policy & environmental management,Policing,Criminal justice

Gareth Hopkin, Ester Messina, Graham Thornicroft and Mirella Ruggeri

Reform of Italian forensic mental health care. Challenges and opportunities

following Law 81/2014

Over the last decade, the Italian Parliament has committed to fundamental changes to the

pathway that offenders with mental illness follow through forensic mental health services.

Historically, six forensic psychiatric hospitals (Ospedali Psichiatrici Giudiziari (OPGs)) operated in

Italy but the quality of care delivered in these units was poor. Resources were heavily directed

towards custodial rather than therapeutic aims and a general consensus developed that major

changes were needed. Initially, Law 09/2012 was passed and required small scale therapeutic

facilities (Residenze per la Esecuzione della Misura di Sicurezza (REMS)) to be opened to replace

OPGs, but in response to delays, Law 81/2014 set deadlines and operational procedures to

conclude this process. Previous articles give a fuller account of the law change and highlight

some criticisms of Law 81/2014, including the lack of a strong clinical or economic evidence

base and reliance on th e amorphous concep ts of criminal respons ibility and social

dangerousness (Barbui and Saraceno, 2015). This paper therefore aims to present further

consideration of both the challenges and opportunities that this legislation presents.

The reform has rightly been recognised as an attempt to improve the quality of care for offenders

with mental illness, both through improving conditions for offenders who need detention in

psychiatric units and through increased use of diversion from court to community mental health

services. This reflects the call for strengthened diversion across Europe (Srivastava et al., 2013)

and conforms to international guidelines on good practice (World Health Organization, 2014).

Evidence supports this approach with smaller therapeutic units, like REMS, shown to be more

effective than larger custodial units or prison. Diversion from court increases the levels of

engagement with mental health services whilst decreasing contacts with criminal justice

agencies (Sainsbury Centre for Mental Health, 2009).

Yet there are a number of challenges presented by the reform that may undermine its beneficial

impact. First, there have been concerns about the preparedness of the Italian forensic mental

health system and REMS, especially in light of the deadlines enforced by Law 81/2014. Delays in

construction of REMS and lack of transitional arrangements raised questions about the

placement of existing patients from OPGs and the cost of building and running REMS may divert

resources from already stretched community mental health services. Similarly, if regions have

delays in providing REMS beds then newly referred patients may not be placed in the locality of

their community mental health service. In addition, there appears to be a lack of recognition of the

risk that this group of offenders with mental illness pose in secure settings and appropriate

training and security measures are needed to ensure that REMS provide a safe environment for

patients and staff. It has been suggested that if these issues are not considered then REMS

could become “little OPGs”and offenders with mental illness could continue to be treated

according to the inadequate standards that this reform seeks to replace (Casacchia et al., 2015).

Second, the pathways defined by the reform rely on the legal concepts of social dangerousness

and criminal responsibility, but the use of these terms may prove problematic. Initiatives in

England that merged legal and psychiatric concepts have been criticised on the basis that there

is a lack of evidence to support ratings of dangerousness and these assessments are not

predictive of future risk (Duggan, 2011). Similarly, criminal responsibility as a legal concept does

not explicitly relate to psychiatric definitions or practice (Wilson, 2009), and this conflicts with

human rights directives which require mental disorder for involuntary detention in psychiatric

settings (Council of Europe, 2004).

DOI 10.1108/IJPH-05-2017-0022 VOL. 14 NO. 1 2018, pp. 1-3, © Emerald Publishing Limited, ISSN 1744-9200

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