Forty years of the Law 180: the aspirations of a great reform, its successes and continuing need.

Abstract

Italy pioneered deinstitutionalisation over the past 60 years and enforced a famous mental health (MH) reform law in 1978. Deinstitutionalisation has been completed with the very closure of all psychiatric hospitals over two decades. After 40 years of implementation, this article presents the main achievements and challenges of the Italian MH reform law, including its long-term effect and impact in Italy and abroad. The Legislation of 1978 was based on the discovery of rights as a key tool in mental healthcare. At the climax of crisis of psychiatric hospitals as total institutions in this country, through the new community-based system of care, it has fostered the lowest rate of involuntary care and gave back the full citizenship to people with MH disorders. This act was also part of a social movement for expanding civil and social rights, and a promise of a true paradigm shift not only in psychiatry, but also in the way of providing an adequate welfare community for all citizens. According to the WHO, the Italian city of Trieste, together with its region, is a practical example of how the Italian movement achieved deinstitutionalisation, intended as a complex process resulting in the gradual relocation of the economic and human resources and subsequent creation of 24 h services together with the development of social inclusion programmes. Even if the great principles of the Italian reform law were anticipatory (e.g., the UN Convention on Rights of Persons with Disabilities - CRPD), the law application has been poorly provided with resources and did not follow those avant-garde experiences as models. Limitations are evident today especially at the organisational levels, such as services capable to take up the challenge and transforming the field, left free from the imprint of total institutions. These endemic critical aspects concerning to implementation policies, together with the financial crisis of the Italian healthcare system, must be taken into consideration for a re-launch of this historical law. The rights-based approach opened by the Law 180 should now take into consideration the new legal situation caused by the CRPD worldwide in the area of individuals' human rights, especially about the issue of legal capacity and related involuntary care.