The Italian Experiment, fruit of ideological passion
Mario Di Fiorino
In the Age of deinstitutionalization the care with severe mental disorder has become one of the greatest challenges to public mental health and to society in general (Baum & Burnes, 1993). From a third to a half of all homeless adults in the United States have major mental illness (schizophrenia, schizoaffective disorder, bipolar disorder, or major depressive disorder) and up to 75 percent have major mental illness, severe substance use disorders, or both.
So probably we could conclude that we have been witnesses of a trans institutionalization: the passage of people from an institution, psychiatric institutions to another, penal justice institutions came up again, according the Penrose hypothesis.
Not only the lack of adequate support systems for persons with major mental illness in the community, also more formal and rigid criteria for civil commitment, contributing to the imprisonment of very large numbers of severely mentally ill persons.
Deinstitutionalization is generally defined as a shift in the locus of mental healthcare from hospitals to the community, and has been in operation for up to 60 years across many countries worldwide.
Since its introduction in the mid-20th century, critics have claimed a series of adverse effects, most notably increased homelessness and incarceration. Indeed, there has even been a recent call to ‘bring back the asylum’.
Another argument against deinstitutionalization is that it is linked to an increase in homelessness for people with mental illness. Indeed, from the early stages of closing psychiatric hospital beds in the USA, commentators expressed concern that where there was insufficient provision of accommodation in the community, homelessness would be the consequence,
When people with long-term psychiatric conditions who were included in the studies reviewed were largely discharged to residential facilities in the community with varying levels of support (e.g. to nursing homes, high support facilities, group homes or to semi-independent accommodation) of course the results were different.
In 1986 Stuart Whiteley of Henderson Hospital, London, adherent to the Movement of Therapeutic Communities, declared: ” I believe…. that there is for a certain proportion of patients, consisting of chronic schizophrenics, is necessary a possibility of “escape ” from reality, some kind of shelter needs. A small psychiatric ward in a general hospital, perhaps near the emergency room, is not good for these patients. These patients need space in which to move, a garden in which to stroll otherwise become restless and very disturbing. However, the problem is that hospitals are closed without the creation of an efficient community care. It is following a strange system: the government first sells hospitals and promises that then, with the proceeds, will build hostels and buy houses. In the meantime the discharged patients are often in big trouble: They live in makeshift accommodations, at the mercy of dishonest apartment owners or crowd the psychiatric departments of the general hospitals. There has not really been a particular creative effort to provide alternative solutions […] and I think that these solutions, of course, could be sought in the vein of therapeutic communities. ” (Macario, 1990).
Another critical voice towards how deinstitutionalization is implemented in Margaret Thatcher’s London is that of Robin Cooper, of the Philadelphia Association, collected in December 1986 by Macario: “A large psychiatric hospital north of London, Shenley Hospital, where David Cooper gave birth to Villa 21, is discharging patients to reintegrate them into the community.
There is no reflection on this “displacement”, there is no imagination, there is no passion; No one really reflects on what care in the community means. There is not that epistemological change I was talking about before and my impression is that in this country, and perhaps in Italy, the deinstitutionalization of patients is reduced to a move of people from the hospital to the community, supported by legions of Psychiatric nurses , who go around the houses to administer neuroleptics. There are few rumors that oppose this type of “therapy” […] ” (Macario, 1990).
In some countries, and especially in Italy, the only country where deinstitutionalization has been total, efforts to deinstitutionalize mental healthcare have been half-hearted not responsibly, with an emphasis on closing down psychiatric beds rather than on providing comprehensive community-based services. Where bed reduction is done responsibly, either in the context of closing hospitals or ‘down-sizing’ bed numbers, it has been shown that the overall costs of community care are about the same as for the previous hospital services for such patients.
On the other hand, where hospital bed closures are seen as a cynical method of making cost savings, without replacement investment in community services, then it is clear that the quantity and quality of care will suffer and may well lead to adverse outcomes for the people concerned (Salisbury & Thornicroft, 2016)
Pirella (1999) recognizes it: “less beds and more territorial intervention, it is in fact, for many years, a program widely shared, combining decrease in costs and defense of mental health. As we well know, however, it was the Reaganian right, in the USA, to support this programme only on the cost side, even before it was realised as de-institutionalization and rehabilitation.
This cynical attitude is not only dictated by the reduction of costs, but also to utopian and revolutionary dreams.
As Raffaello Papeschi (1985) concluded regarding Italian Reform Law: “Just as each revolution wants its own deaths, so the psychiatric revolution introduced by law 180, in line with the 1968 ‘Marcusian’ confrontation and its further development of Red Brigades has had and is still having its own ‘deaths’ among the many long-term patients, who are suddenly no longer taken care of by an organization.”
Also De Risio (2019) described the revolutionary connotation of the Italian Psychiatric Experience :
“The major diversity of the Italian experience in the care of mental disorder is that in this country – diversely form the others – psychiatric care faced a dramatic change that happened in a way comparable to a revolution, in which the patterns of care were abruptly modified with the total disappearance of mental hospitals.” No other developed country underwent such a change and today psychiatric care in Italy is totally different from the rest of the world. The impact of this radical change of perspective on the scientific community wasn’t harmless, however. The revolution in Italian psychiatric care also changed how mental health professionals operated.”
In other countries psychiatrists have moved with greater pragmatism, taking into account the context in which they were working:
“We have also learned that we are not ready to close all our state psychiatric hospitals, although their imminent demise was often predicted amid the optimism of the 1960s and 1970s “ (Lamb & Bachrach, 2001)
According to Lamb and Bachrach (2001) “it is not accurate to conclude that community services will result in substantial saving over hospital care “(Aldrich, 1993 ; Kovaleski , 1993; Okin, 1978, 1993).
From a third to a half of all homeless adults in the United States have major mental illness (schizophrenia, schizoaffective disorder, bipolar disorder, or major depressive disorder) and up to 75 percent have major mental illness, severe substance use disorders, or both (Baum & Burnes, 1993).
The increasing prevalence of homelessness and criminalization among mentally ill persons tells us unequivocally how important it is that we consider such factors in planning services for long-term severely mentally ill persons (Lamb, Bachrach, Kass 1992)
Borzecki & Wormith conclude that, in this era of deinstitutionalization, the criminal justice system has largely taken the place of the state hospitals in becoming the system that can’t say no (Borzecki & Wormith, 1985).
At the dawn of the new millennium Bachrach wrote “we have also learned that we are not ready to close all our state psychiatric hospitals, although their imminent demise was often predicted amid the optimism of the 1960s and 1970s” (Bachrach 1997).
Deinstitutionalization is not always a shift in the locus of mental healthcare from hospitals to the community, but often the real passage is to the condition of homelessness, incarceration or suicide
3.3 The Italian Psychiatric Reform Act of 1978
In the years 60, with the advent of psychotropic drugs, in Italy major reforms in the psychiatric care had occurred. In 1966 the record of admission to the psychiatric hospital on the penal certificate was abolished.
With the Mariotti Law (No. 431 of 18 March 1968), voluntary admission had been introduced. Over the course of a few months the number of patients with voluntary admission reached 60-70% (Cazzullo, 2000).
Mariotti also was successful in reducing the large concentrations of inpatients, setting the limit of 600 beds for hospitals. In Lombardy the hospitalized were reduced to half, going from 14000 to 7000.
The reduction of beds after the Mariotti Law covered the whole of Italy: in 1968, year of the Mariotti Law the beds in Psychiatric hospitals were 86.063, in 1978, year of the Reform Law, 54.284.
The Mariotti Reform also regulated the Mental Health Centers, always dependent on the provincial administrations, for the psychiatric service in the territory.
Already in full Fascist era in 1924 the Italian League of Mental Hygiene and prophylaxis, promoted by Tumiati, was founded in Italy.
In Florence, for example, the Center for Mental Health Care and Prophylaxis was instituted in 1937 by the director of the Psychiatric Hospital of San Salvi, Gino Simonelli, to promote a social dissemination of psychiatric treatment and improve the service of “domestic custody” of patients started from 1866. He ensured outpatient care and home visits throughout the province (Acocella & Sacchettini, 1961)
Moreover, Tuscany has never known large concentrations of patients in the Grand Duchy of Tuscany and in the Duchy of Lucca there were psychiatric hospitals on a provincial basis. In addition to Florence there were psychiatric hospitals in Siena, Arezzo, Volterra, Pistoia and Lucca.
The Grand Duke Pietro Leopoldo of Lorraine in 1785 opened in Florence one of the first psychiatric hospitals in Europe, renewing the ancient Hospital of San Bonifacio, in Via San Gallo, with the psychiatrist Vincenzo Chiarugi from Empoli, who graduated in medicine in Pisa in 1779. In the hospital of San Bonifacio were transferred psychiatric patients, hospitalized until then in the hospital of Santa Dorotea.
We are in the same years that in Paris Philippe Pinel worked in the Asylum de Bicêtre
In Italy the attack launched against psychiatric discipline and institutions had meaningful success. when the ideas and the anti-institutional struggles reached the goal of inspiring the Reform Law with a radical closure and dismantling of the mental hospitals in the whole country.
It was one of the most radical attempts in history to abolish the practise of custodial psychiatry using legislation (Pycha et Al, 2011).
In May 1978 Franco Basaglia inspired Psychiatric Reform Act (Law 180), and the anti-psychiatric Utopia came to power. In December 1978 the law merged in Law 833, that introduced National Health Law.
According to Basaglia placements, the law 180 decreed the end of the psychiatric institutions, with the gradual closure of existing. The first admissions of patients were prohibited in May 1978, and then in January 1982 all the admissions were blocked. Finally all the inpatients left the Mental hospitals and the construction of new hospitals was banned.
Some lines should be dedicated to what happened in the meantime in these hospitals “at the time of termination of active functions”, called “residual” (Slavich, 1985) I voice to Slavich, one of the most important supporters of the Reform (Slavich, 1985):
“I think it is superfluous to re-list the factors, known to all of us, which have led to this collective scotomization of the conditions of the OO.PP. in Italy: suffice it to say that there was a singular consonance between inexperienced neo-administrators (of the USL), technicians progressive but tired of madhouse, conservative technicians but interested in new opportunities, distracted politicians, guilty public opinion, concerned legislators to reduce the area – and the sphere – of social security, and then to cut off the supposed “dry branches” of the reform rather than to let the cultural and social sprouts develop.”
The representative of the Tuscany Region Romano Percopo in September 1996 declared in the “Commissione permanente Igiene e Sanità” of Senate:
“The Tuscany region still has 5 psychiatric hospitals compared to the 6 that existed at the time of the approval of the law of 13 May 1978, n. 180.
The psychiatric hospital of Arezzo has been definitively closed in
1994; there are still 5 psychiatric hospitals with a total of 803 patients: Lucca with 112, Volterra with 183, Florence with 134, Siena with 283 … and Pistoia with 91 patients.
We expect that, compared to the current 803 patients, at the end of the year one hundred probably can be discharged because there are structures, loans, structures in progress, while for about 700 of them it is unthinkable that they can be discharged from psychiatric hospitals in 1996 (Percopo, 1996) “.
Crepet (1988) wrote that 9 years after the Reform more than 30,000 inpatients were still in psychiatric hospitals and “little was known of the fate of those discharged in recent years”. As Morzycka-Markowska et Al. (2015b) stated, the existing researches explored administrative parameters, such as the reduction of hospital bed, we have no data concerning patients forced to quit hospitals or patients never admitted (De Risio, 2019).
So it was the only model of total deinstitutionalization, as in the other countries admissions to the Psychiatric hospital were still possible.
The Antipsychiatric Utopia went to power and transformed Italy into a great Geel.
On the one hand the Italian Law was a success of deinstitutionalization
if we measure the success in terms of reduced hospital population, on the other side the Reform Act inspired by Basaglia, represented
a compromise. The first signer was Bruno Orsini, a Christian Democrat deputy, chief
of psychiatry. The law provided for small psychiatric wards for emergencies in
general hospitals. Many witness that Basaglia did not want even these small
departments (Corbellini & Jervis, 2008, Fargnoli, 2018).
The conviction of Tancredi Falconeri, nephew of the prince of Salina in “The Leopard” “If we want everything to remain as it is, everything must change”, has marked the choices of the leading group of Italian psychiatrists, who obtained psychiatric units in the General Hospitals at the price of the renunciation of psychiatric institutions for severe disorders. (Di Fiorino, 2019).
One of the most important Italian university psychiatrists Cazzullo (2000) thus narrates this compromise ( and partition) “The relationship (of the Italian Society of Psychiatry) with the Association of Democratic Psychiatry was of mutual consideration, even in relation to the two areas, university and services”
Relatively few studies in this area appeared in the published literature, and the existing works has several important limitations. We do not find quotation of Penrose’s hypothesis about the direct association between deinstitutionalization and increasing of prison populations. It means that the deinstitutionalization process in Italy was implemented without sufficient evaluation of possible health risks.
All psychiatric hospitals, over a few years, were closed and the law also prevented the building of new hospitals2. 80 E’
“It is in any case prohibited to construct new psychiatric hospitals, to use those currently existing as psychiatric specialist divisions of general hospitals, to establish in general hospitals divisions or psychiatric sections and to use as such neurologic or neuropsychiatric divisions or sections. “
Not only have psychiatric hospitals been demonized and closed. Not only has the law 180 prevented any hospitalization, even for the most serious patients, not only has banned in the future to build new hospitals, but the curse has covered the same places, as it has prevented the use of buildings for other purposes assistance. Only Carthage, after its destruction in the Third Punic War in 146 B.C., experienced such measures so imbued with hatred and resentment. On the ruins of the Phoenician city, furrows were drawn with the plow and salt was spilled on the ground, so that nothing could be reborn.
There is no doubt that “Italian anti-psychiatry” has led to the most radical experiment in deinstitutionalization in history (.Morzycka-Markowska et Al, 2015a).
Some supporters of the Reform Act has attacked the critical reports. Thus, for example, an Italian scholar, Michele Tansella (1985), stripped an article of Jones and Poletti (1985) published in British Journalof Psychiatry, that dares to describe “the negative effects of the 180”.
Jones and Poletti have cited the point of view of prominent academics like Sarteschi and Cassano:
“The most precise and authoritative account of the view against Law 180 comes from the University Medical School at Pisa, where the professorial psychiatric team writes;
“The new law completely disoriented physicians and psychiatrists; there was a sudden disruption of the previous system of psychiatric care… so far no programme has been devised for the re-integration of the patient into the social milieu, and this vital point.. has been left to uncoordinated dabbling . . . it may be asserted that none of the objectives of this law have been attained. but that there has actually been a severe decline in the quality of psychiatric care . . . ” (Sarteschi, Cassano et al, 1983).
It is argued in this paper that a moderate reform movement had been in progress in Italian mental hospitals for some years, and that the population had been halved before the new law took effect. The reduction since has been only of the order of 10,000 and at least 35,000 patients are still in hospital (a fact confirmed by a national survey: CENSIS 1982). Many of the changes are no more than semantic patients remain in hospital as “guests” (ospiti), but do not count in the official fìgures. Psychogeriatric patients do not appear in the fìgures because they have been re-classified as “geriatric”. Many of the so-called “alternative structures” are in old mental hospital wards re-named as “family homes”. but substantially the same as before. (Sarteschi, Cassano et al, 1983).
According to Jones and Poletti (1986) the Italian anti-institutional psychiatrists had intended to apply a Marxist revolutionary process, as the existence of asylum would symbolize the covert inpatients needs of freedom and justice.
Political affiliation played a role in these oppositions. The conclusion of Tansella attack seems significant:
“I would like to conclude by quoting the words ofAntonio Gramsci, a leading Italian politician and a famous writer: ‘In order to change for the better one needs to balance the pessimism of reason with the optimism of will.’ There is still a long way to go, but we feel we are going in the right direction. “
Tansella did not present fully to the English reader Antonio Gramsci, forgetting to write that was a founding member and one-time leader of the Italian Communist Party.
Psychiatric care in the hospitals was very difficult, imposed by the small number of beds available: The mean length of stay in psychiatric units in Italy was 12 days, compared with about 47 days in other industrialized countries, except the USA (WHO, 1980) (Papeschi, 1985).
In Italy, one the few voices opposed the reform was Mario Tobino, psychiatrist, known to the general public for his novels. He collected in the pamphlet “The Last Days of Magliano ” (1982) articles already published in Corriere della sera.
“Some news come, it becomes known that different patients, discharged from mental hospitals, driven out into the world, in society, in order to heal, as proclaimed the innovators, to fit, they are already in jail, in prison arrested for acts they committed. No one will protect them, advise them, prevent them. No one will keep you with loving kindness and firmness, will lead them to hand over their possible way. And now fall, opens to them the Forensic hospital. The madness is not there, does not exist, derived from the society! Hooray! “
Tobino, in his polemic against the Reform, seized the most original, and relevant utopian aspect of Basaglia’s ideology, the rejection of the entire psychiatric residential facilities.
“They are destroying the House of Fools ” was repeating Tobino.
Among the consequences of the Reform Law there was the entry of many mental patients in the judicial circuit (jails and Forensic Hospital) and an increase of suicides.
Williams and collaborators studied the trend in suicide in five years before the Reform law and the post reform quinquennium. The suicide rate in Italy increased consistently over the past 10 years, especially in the northern central regions (Williams et Al, , 1986).
In order to assess the reliability of Italian suicide data derived from different sources, they compared regional suicide data from returns made by the Police and Carabinieri with those based on medically certified cause of death for the years 1973-1980 (Williams et Al., 1987). Rates of medically certified suicide were found to be higher than those derived from the Police/Carabinieri returns, a difference which increased steadily over the years of study.
They found a negative correlation with the number of general hospital psychiatric beds: the increase in the suicide rate was less in regions with more beds per population, a correlation which persisted after controlling for the pre-reform trend in the suicide rate (Tansella et al., 1987). This correlation also remained stable when studying suicide statistics based on death certificates (Williams et al., 1987).
Other Authors reported an increase of suicide and of deaths induced by mental disorders. In the five years after the Law (1978-1983) the suicides had a 19% increase (Palermo, 1991), the deaths a 43,5% increase (Crepet, 1988).
Compared to the significantly different evaluation of Palermo (1991), the Tansella group papers had investigated the trend in suicidal increment, rather than the increase in their absolute number.
In any way, in the end, even the Tansella group admitted that the suicide rate had incremented since 1978 in Italy.
We address the following limitations in the literature to inform policy in the era of community-based treatment.
I will cite some observations .
“Psychiatric care in the hospitals is now extremely difficult, if not impossible to obtain; the very high turnover rate of patients, imposed by the small number of beds available, means that they can only stay for a very short time. The mean length of stay in psychiatric units in Italy is now about 12 days, compared with about 47 days in other industrialised countries, except the USA (WHO, 1980) (Papeschi, 1985).
The framework of the psychiatric assistance after the reform emerged from the research “project Residences”, which sought to assess the conditions of assistance, measuring the outcomes and efficiency of services (De Girolamo et al., 2002 )
In Italy, where all mental hospitals have been phased out since 1978, psychiatric patients requiring long-term care are being treated in non-hospital residential facilities (acronym NHRFs).
However, detailed data on these facilities are sparse. The Progetto Residenze (PROGRES) residential care project is a three-phase study, the first phase of which aims to survey the main characteristics of all Italian NHRFs. On 31 May 2000 there were 1370 NHRFs with 17 138 beds; an average of 12.5 beds each and a rate of 2.98 beds per 10 000 inhabitants. Residential provision varied ten-fold between regions and discharge rates were very low. Most had 24-hour staffing with 1.42 patients per full-time work (de Girolamo et Al, 2002). There is marked variability in the provision of residential places between different regions; discharge rates are generally low.
Psychiatric patients requiring long-term care have been treated in non hospital facilities. According to a research, in 2002, 25 years after the Reform law, there were in Italy 17.138 beds in 1370 non hospital facilities, ‘homes for life’, being populated by long-term users whose discharge is not easy (de Girolamo et Al, 2002).
According to De Risio (2019) the Italian NHRFs guests were a ‘hard core’ of users whose outcome is severely dysfunctional, along with findings in other western countries (Lelliott et al., 1996). De Risio (2019) outlined how the Italian psychiatric reform ended in a ‘zero sum’ game, in which the hardest patients that were custodied in an institution, there remained, as in many cases were just moved from an ‘asylum residual’ to a rehabilitation facility.
After the high price paid to the revolutionary utopia, “Democratic psychiatry” denounced the sabotage of the reform, because the alternative structures at the Psychiatric Hospital would not have been built (Di Fiorino, 1998),
The number of beds in the alternative residences at the hospital was higher than the projected target project of 19994 Also there was a large number of patients guest in the nursing homes and handicap facilities (RSD), a population difficult to survey.
Regarding the quality of care, considering the low turn over (the low rate of discharge: in 1999 more than one third of the structures did not resign patients) the structures seem to have a modest curative and rehabilitative impact.
Many are “houses of civil habitation”, with a staff in shifts sometimes with one or two operators, places not suitable to manage conditions problematic of disease.
Morzycka-Markowska et Al (2015b) that Reformers have underestimated the difficulties of treating patients with severe disorders in General Hospitals or in the context of community care.dx
The conception of therapeutic community was also disrupted, as Tom Main (1957) had defined it.
The British Therapeutic Communities have developed for patients able to offer a real and valid consensus, while the residential therapies of the other patients, when there is insufficient awareness of disease and adherence to the cure, take place within Psychiatric institutions.
In the Italian Therapeutic Communities non-hospital facilities many problematic patients with poor insight and no compliance, do not offer a real consensus for the admission into the community. So Italian Therapeutic Communities cannot be compared with the British: the absence of the psychiatric hospital does not allow rigid admission criteria in therapeutic community. They are the final common pathway for complex patients who have kept in check the other modes of intervention.
After Basaglia’s law the most problematic patients, who would need more prolonged therapy, are placed in structures with ten beds, more private affiliated, which often cannot keep them within the programs. They also welcome patients undergoing community safety measures, in “Therapeutic Communities” where theoretical reference model emphasizes consensus.
In “End of an illusion” Andrea Angelozzi questions himself, analyzing some focal points, forty years after the law of that reformed psychiatry in Italy (Angelozzi, 2017).
The antipsychiatric movement placed emphasis on the Institution’s processes in creating chronicity (Goffman, 1961; Basaglia, 1968).
The law closed hospitals, and there was such an identification of chronicity with the Psychiatric hospitals, that by law the use in any form of old hospitals was forbidden.
It seemed, implicitly, to solve the problem of chronicity with the limitation of institutional chronicity (Angelozzi, 2017).
At the time of the Reform there would have been 78,538 patients admitted to Psychiatric Hospitals in Italy 5. “Over 50% of long-term patients with physical and psychic disabilities. In an important reality such as the Psychiatric Hospital of Collegno according to a research carried out in 1972 (Sini, 2005) only 1/3 of the patients were affected by a psychiatric disorder, while the others would have been demented, disabled and marginalized not able of adequate accommodation (Pascal et al., 1978).
This is also the esteem of Piazzi et Al (2011), at least 30% of the beds of Italian psychiatric hospital in 1970s were occupied by “serious” psychiatric patients with ‘sound’ psychopathology, while the remaining 70% suffered for psycho-organic disorders or showed severe psychosocial problems that involved the need for a shelter.
In the SISM Report of the Ministry of Health for 2015, with over 30,000 people in Italy in residential facilities, to which are added 5,000 patients admitted to the acute wards that in 1978, after the Mariotti Law, were admitted to psychiatric hospitals.
This population is very similar to 1/3 of 78,538 of actual psychiatric relevance.
The closure of the Psychiatric Hospital did not change the chronicity.
Angelozzi concluded that the goals of the Italian Law on Psychiatric Reform have not been reached because of “intrinsic limits of the Law itself, deep limitations of Italian psychiatry in building new models and its difficulty in becoming a real counterpart in negotiation within increasingly fragmented and hospitalized healthcare management (Angelozzi, 2017).
The conditions in which psychiatrists were forced to work have been described
“A city of 5 million people such as Rome, in 1988, had only three psychiatric units for emergency cases. These psychiatric units are housed within general hospitals and have a capacity of 15 beds each. The hospital stay ranges from one day to 14 days, with an average stay of 3 days. The patient turn-over is very high. Professionals are overworked and most of the patients, once diagnosed and medicated, are discharged to the family, to the Mental Hygiene Clinics (CIMs), or, if necessary and possible, directed to a private psychiatric clinic” (Palermo,1991).
The conditions of patients after the Reform Law are well told by Henry A. Nasrallah (2011).
“A major impact of the antipsychiatry movement is evident in Italy due to the efforts of Franco Basaglia, an influential “psychiatrist-reformer.” Basaglia was so outraged with the dilapidated and prison-like conditions of mental institutions that he convinced the Italian Parliament to pass a law in 1978 that abruptly dismantled and closed all mental hospitals in Italy. Because of uncontrolled psychosis or mania, many patients who were released ended up in prisons, which had similar or worse repressive conditions as the dismantled asylums. Many chronically hospitalized patients died because of self-neglect or victimization within a few months of their abrupt discharge.”
In the following decade many Italian doctors complained that the prisons had become depositories for the seriously mentally ill, and that they found themselves “in a state psychiatric-therapeutic impotence when faced with the uncontrollable paranoid schizophrenic, the agitated-meddlesome maniac, or the catatonic”(Palermo,1991). The increase in the admissions to forensic psychiatric hospitals and jails was contested by other Authors (Williams et Al, 1986; Williams et Al. 1987, Tansella et al, 1987)
Palermo stated that “demographic, sociocultural and economic factors are historically important determinants in the actuation of any new idea”.
And Caparrotta (1989) commented that “a detached epidemiological evaluation should have preceded any planning and the primary care should have in the forefront of any community care”
Angelozzi wonders “How was it possible that the first national data about the psychiatric reality post-reform have been drawn up to forty years away, and above all there is no work that really compares them outcomes before and after the psychiatric reform? How is the lack of reliable studies possible? on the actual use of proven methods in therapy and rehabilitation? It seems as if the doubt should not be raised, certainly not by scientific evidence, but by an ideological or partly ethical assumption.
When the authors comment that the law 180 had insufficient programming and the facilities were not prepared, evidently they are photographing what has happened, but not always this seems to consider that these are consequences of the thought of Basaglia, of the revolutionary elements and the utopian aspects. These elements are so clear is the antipsychiatric current of thought, demonizing the psychiatric institutions.
We have noticed the relevance of the utopian dimension underlying the alienistic approach, when the “Asylum” has re conceptualized as a machine for recovering.
It is noteworthy that a utopian point of view supports these two points of the parabolic trajectory of the asylum: the rise and fall (Di Fiorino, 1987).
The long wave of law 180 then closed even Forensic Psychiatric Hospitals (OPG). There has been a continuity between the dismantling of Psychiatric Hospitals and the closure of the OPG, which has been the characteristics of a farce. To our event well draws the commentary of Karl Marx (1852): «Hegel notes in a passage of his works that all the great facts and the great characters of the universal history arise, so to speak, twice. He forgot to add: the first time as tragedy, the second time as farce» .
Commenting on the modalities of closure of OPG, after “hygienic sanitary instances
Suddenly discovered with inspections induced by approximate information”, Angelozzi (2015) wonders whether we would close the heart surgeries and decree the absorption of this field in cardiologies for the unhappy hygienic outcome of the visits of the Anti-Adulteration Nuclei (NAS) in some of them» (ibidem).
The closure had aspects of a farce, first because it was postponed from year to year and was finally implemented in a precipitous, little meditated manner. Even in Bra, in Piedmont, the execution of detention security measures, for which a patient is deprived of freedom, was entrusted to private facilities. In Castiglione delle Stiviere, instead of small structures with 25 beds, they limited in the change the name of OPG:
Then the survey was made, there were hospitalized between 140 and 160 guests. But the most worrying aspect is that in the face of the 596 hospitalized in the Rems there are 289 patients in waiting list for entry. About 30% of the detention security measures are not applied.
An isolated and radical position has influenced the Law 180. This ideological stance, which profoundly marks psychiatric care in Italy, it continues today, after decades, to remain even in a changed cultural context, made more dramatic by the closure of the Forensic Psychiatric Hospitals (OPG). The custodian security measures of patient, who have committed crimes, unable to find
application in the existing Residences for the Execution of Security Measures (Rems) (Montanari, 2013), with the result that they persist for months in the Psychiatric wards in General Hospitals, “Psychiatric diagnosis and care services” (SPDC).
And that this has taken on an almost religious dimension testifies to that sort of secular pilgrimage accomplished by a papier-mache horse, “The animal of the good conscience, “dragged through Italy in a visit to all the OPG before the closing, with the awarding of the medal to Marco Cavallo, officiating President of Italian Republic Napolitano 
According to Suetonius,
neither Emperor Caligula honored his
loved horse Incitatus (Incited) with a distinction.
 Annuario Statistico Italiano.
 “The Venetian psychiatrist did not want psychiatric wards in general hospitals: he would have preferred a < network of anti-crisis apartments>, based on the style of the English family houses created by Ronald Laing and ended in a resounding failure.” (Fargnoli, 2018)
 Cassano G.B.: Interview. L’Espresso 27January 1985, Milan
 P. 487 of the edition of 1966
 Newspaper La Stampa, September 18, 2017 . “The dark side of Rems half patients locked up before judgment. Just six months after the abolition of the psychiatric hospitals, the system threatens to unload the limits of prisons on the new residences “.
 Suetonius says: «Because to his horse Incitatus (Incited), because it was not disturbed on the eve of a rush, he (Emperor Caligula) used to notify by soldiers to the neighbors to keep quiet, besides having for the horse made build a stable of marble and a manger of ivory, he gave him some purple blankets and harness decorated with gems, and even furnished house and servants, to receive with greater dignity the people he invited in his name. It is said that he wanted to honor him with a distinction » (Vite dei Cesari, 121 d.C.).