An experience of deinstitutionalization at the start in Maggiano's Mental Hospital

Mario Di Fiorino

An experience of deinstitutionalization at the start in Maggiano's Mental Hospital *

Observer attached to Centres East Unit of the Cassel Hospital, with the grant n. 539 of General Hospital of Viareggio.

As an introduction to the report of the start of the experience of deinstitutionalization, I would like to give some information about the Mental Hospital where our attempt develops.

The "Spedale deн Pazzi", the old term for the Lunatic Asylum, was founded in 1773, in the ancient monastery of Fregionaia, a short time before abolished by a Papal bull. On the 20th April eleven mental patients, coming from the prison of the Tower, and other eight from all over the State of Lucca, wewr brought there.

In order to come to our intervention, it is sufficient to mention the late events of the Hospital-village.

The model of the Hospital-village

The Mental Hospital of Maggiano, sice 1959, under the direction of prof. Gherarducci, knows several interventions which began in the view of the theory of the Hospital-vullage.

The "Group of the advanced sociotherapy", constitued by psychiatrists, matrons, and founded on the "mixing of the roles", according to the principle that "what counts is not the titles but the degree of sharing in a programme and in its achievement", promotes musical activities (such as the Festival of Singing), sporting and artistic activities. A bar and a bank are opened, managed by the patients.

The Hospital-village represents the "attempt to give a cultural dimension to the Asylum, trying to insert it in the community, intersifying the in and out exhange, depriving the Hospital, where possible, of the prison features and doing all the activities typical of the people living in and out the Asylum, and of the class of origin". (Gherarducci, 1967 b).

"It is not a village in the village but a place where the tension of hospitalisation is relieved to the advantage of therapeutic interventions" (Ibidem).

As an example "to the Lunatic Asylum the villageнsquare of holidays and fairs (moves) so as the folkloric event, deep-rooted in the common culture of sound of mind and insane, allows a meeting -so to say- trans delirium, and for this the support is therapeutic (Del Pistoia et al., 1988).

There were years of animated discussions, which have left mark on the reports of various meetings (A.A.V.V., 1968, 1970).

Harsh criticism of the C.E.M.E.A., involved in the nurseнs training, quickens the ezhaustion of this experience.

The conviction of the uselessness of all this work inside the institution spreads, "because Maggiano retains of the most classic Asylum the lack of a new hope. The destiny of the patients remains as usual, almost of a good psychiatric zoo to show to the Sunday visitors the monkeys of madness" (Del Pistoia et al., 1988).

Dr. Tobino and "The last days of Magliano"

By the end of the Hospital-village, the task to repropose the certainty of the Lunatic Aslum, is accomplished by Dr. Mario Tobino, famous writer, poet of the sacred and paleopsychiatric view of madness.

The Elzevires of "Corriere della sera", took up again the themes of an unceasing verbal propaganda. Up to 1978 he critized the "territory", folly of young cubs of Psychiatry, then by the passing of the Law 180, the polemic thones climb: "They are pickaxing the House of mads!".

Still left at the age of 78 years in his "two little rooms" of the Asylum, Curator of the Library of Fregionaia", dr. Tobino has played the role of keeper of memoirs, flogging the utopias of the innovators.

In the best-selling pamphlet "The last days of Magliano" of January 1982 he gives the themes of a campaign which receives a certain agreement among common people.

The Law 180

Law 180/1978 closed the institutions, without having provided for alternative institutions for chronic mental patients (1).

A gap has been left, the place of Psychiatry has been, in one way, destroyed (Antonioli et al., 1985).

Defenders and critics of the Reform Law are of the same opinion in asserting its revolutionary and experimental character.

Confronted with this problem in Local Health Units (2) the old logic prevailed of postponing every choice, limiting theirselves to the administration of the status quo. No intermediate structure has been built, the regional funds have not been used, the "territory" has limited itself to a presence of psychiatrists in decentralized dispensaries, to the distribution ofsubsidies, without difference, as an organization, with no change from previous policy.

In the meantime, behind a curtain of chatters and slogans, an ultraconservatism in favour of clients prevailed, for the preservation of piace of work, against every danger of mobility.

The utopic "dazzle" of the destruction of Institution seems to leave the place, in the imagination of psychiatric nurses, to the "pickaxe" of the place of work evoked by Tobino.

The deinstitutionalization feeds the worry to have to adapt theirselves to ambits different from that reassuring of Asylum.

The convention among Local Health Units

In this atmosphere Versilia's psychiatric services became in May 1986 the responsability of the versilian pavilions in Maggiano, with at that time 110 patients.

The definitive text of convention, which has required four years of carefui weaiving, assigns to L.H.U. of Versilia "the medical responsibility" of pavilions which treat patients from the Communities of Versilia, "with thc complex of activities of welfare and rehabilitation for the recovery of their mental health, and their discharge and reintegration into the community.

To the L.H.U. of Lucca remains the task of giving general medical assistance through to a pannel doctor of free choice specialized but not psychiatric assistance, emergency medical assistance, nightly and public holidays, and coordination of administrative hotel services. It is Lucca's responsability also to supervise general upkeep and extra for the departments assigned to Versilia.

The year before the signing of the convention, the psychiatric service of Versilia has already intensified its presence at Maggiano for preparing the programs of deinstitutionalization.

At the beginning we intended to know exactly the condition of the patients by using a researched questionnaire. We had to gather data from different sources, among the difficulties of consultation in certain cases, and of an unreliabie source, due to the non cooperation of nursing staff. Putting all the fragments together, the stories and profilies appeared. It was our intention to try to understand what remained, at a real and phantasy level, of the relationships with their family and country, after years, and decades of the Lunatic Asyium.

Naturally it was essential to be able to have up to date data of the family of origin, and of the pension and property condition of the patients. We had noticed a laboured cooperation of the social services: it needed more than one year to compile a single page of the questionaire.

With the signing of the convention the atmosphere was one of pretence. Our psychiatric service is responsible, but has no influence on the situation. Refusals and delays which our requests for change meet, soon show us that the passing of orders has been more formal than real, so that we go to work in the territory of another Locai Health Unit, with the impression that we work under the counter, without acknoiedgment, whilc the Chairman is in the uncomfortable position of the lightning rod.

The frustration of operators

The attitude of nurses is not only related to the corporative defence of the place of work, to the iron and not always underground will ofself-preservation which gives life again to the Lunatic Asyium.

We find a cultural element of Tobino's influence, which expresses itself in the appeal to the observance of unwritten iaws in comparison to the utopia of the law of innovators, with echoes which remember, in the best, Sofocie's Antigone.

The resignation showes up in seeing as inevitable and natural to the mental patients condition the development of a subhuman menagerie.

Our presence is demanded in order to have a medicai guarentee to "their" Asylum, in accordance to a view which awards to the psychiatrist the role of the double of the general practitioner, a powerless and disenchanted witness of the mechanism of the Mental Hospital.

This guarantee, repeated everytime signing in nurse's reports oozing Asylum, causes a mixed feeling of dislike and sorrow at the psychiatrists. It is a feeling of impotence and frustration for the impossibility to iet the programme take off for the Iack of alternative residential structures and for a nursing staff not willings to move.

The pavilions are characterized by a particuliar atmosphere. When I say that I am going to work at Maggiano, I realize that I stir up perplexities, because the common peopie know that Psychiatric Hospitais are closed, by a bill.

These ill men, which the bureaucratic lack of feeling designates "residue of the lunatic asylum" in official documents, are by now like ghosts.

The quality of life in the Hospital

Notwithstanding the letters of denunciation, the requests, the solicitations, the reports which have preceded the signing of the convention among the Local Heaith Units, the pavilions seem in a condition of distressing carelessness. They are crumbling structures, with spoiled fixtures and inadequate facilities.

During a visit of a group ofofficiais, the manager spoke of dangerous lighting systems. Now three years have passed. Only recently they have complied with the fire ilaws.

In the Summer of 1987, after a journaiistic campaign for a denouncement, in scandal-mongering tone, by a seif-styled Patients' Rights group, the L.H.U. of Lucca has decided to start, with an unknown diligence, the restoration of the facade. Make up has been spottered on the tragic mask of the Lunatic Asyium.

For a few months the collaboration with the Social Service has made it possibie to give ali the patients personal clothes.

Up to that time the clothes were not labelled: after washing them they were distribuited again, without the aknowledgement of the owner.

The degradation of the buildings combines with the atmosphere of inertia and neglect, with the lack of hope in a different future.

Days follow one another with an oppressive monotony. Many patients collaborate to clear the tables, to wash the kitchenware and the rooms, without even earning the pocket money which the "littie bank" of patients in the past secured.

The pavilion "Primo Misto" functions as a residentiai structure with an open door system, for the relative seif-government of patients, many of whom are psychotics, but with a sufficient adjustment to reality.

Before the start of the programme of deinstitutionalization, there were no activities of animation and socialization apart from the parties on occasion of the most important religious holidays.

The only residual expression of the sociotherapic season is knitting and sewing of some patients, stimulated by two nurses.

In the last two years a patient, with a diploma from School of Art, has changed a washroom into his studio.

The initiative of a painter, who works voluntary in Asyium, has founded a painting group. Recently.the members of the group have also visited a picture-gallery at Fiorence.

For the rest animation is entrusted to television, always on in the pavilions.

Alcohol represents for many, also women, a possibility of escape, socially tolerated.

Programme for the future

After trying to show a description of the lunatic Asyium in its dark colours, but also the delays and in large part cultural insufficiency of politicians and managers, I should finish speaking about the programme which we have started to put in practice (5 discharged out of 95 patients).

We think that psychiatrists have to accomplishe the task to lead again the patiens in the generai community.

This is possible if a psychiatric service works in the community, with the necessary means: an emergency ward, Crisis Centres, offering support with initiatives of animation and socialization, and again the Day Hospital in addition naturally to residential structures.

In the last years we have engaged ourselves in this direction. The deinstitutionalization is in psychiatry's competence and may not become a demagogic operation, a dilettantish initiative of sociologists and psychologists, put in practice on the skin of mental patients and of their families.

We may not make up for an uprooting by uprooting in the other direction.

Our model provides the weaving of a net of relations, through a firm connection among the crisis centres, the residential structures and homes where the patients have gone back.

Regular trips organized for small groups offer a new possibility of life to the patients. In this period because of the lack of public residential structures (3) (in few months the opening of a residence mixed for eiderly and mental patients, with rooms for 16, is foreseen), the only possibility offered by the present rules has been the collaboration with boarding houses, managed by private persons. The Social Service has attended the convention with L.H.U. for the pay of charges (4).

In order to nurse the patients (from 2 to 10 according to the structure) a social staff, employed by the public service, collaborates with the personnel of the boarding house.

These structures are periodically visited by the psychiatric service and the patients are inserted in the activities of animation.

In our case the coilaboration has deveioped for new chronic mental patients, because we had not any place for a long term stay.

The collaboration with the net of the boarding houses, proposes the confidence of mentai patients to the structures managed by private persons, confidence which so many polemics have made in the past (5).


(1) Law 180/1978 has been resumed by Law 833 of the same year, law of the institution of the National Health Service. The article 64 prohibits the building of new Mental Hospitals and awards to the regions the rule of gradual overcoming of those existing, not allowing new hospitalizations.

(2) The Local Health Unit (L.H.U.) is the public Organization for Health, formed by an Association of Councils.

(3) When the President ofL.H. U. asked the Mayors of 7 Councils to find buildings to design intermediate structures, he received 4 negative answers and 3 silences, which carry on still today.

(4) The Regional Law of Tuscany 'i. 70 of 6 December 1984, Regionai Health Plan 1984-1986 and the Regionai Plan of Sociai Services 1984-1986 show the picture referencefor the stipulation ofconvention between LH. U. and private.

(5) At the end of Nineteenth-century in Italy the Freniatric Society, the old materialistic term of Italian Psychiatric Association, guided by positivist psychiatrists, polemized especially against the institutions managed by religious orders.

A phrase of Livi is famous: "Charity has had his day. It is reason's turn to buitd her buildings".



I would like to thank dr. John D. Denford who has given me this opportunity of a period of stay at the Cassel Hospital.



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GHERARDUCCI D.: "A proposito dellнorganizzazione manicomiale attuale: alcune riflessioni sulle nostre esperienze". Riv. Sper. Freniatria, 91/5, 1242-1253, 1967 b.

TOBINO M: "Gli ultimi giorni di Magliano", Mondadori Ed. Milano, 1982.

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