Is mental illness still “in brackets”?
Reflections on recent bills for discussion in the Italian Parliament, on the current psychiatrisation of society and on possible remedies
By Pino Pini, 11 August 2024.
In the current 2024 bills on mental health, presented by various political forces, there is a clear emphasis on the clinical aspects linked to new diagnoses and, at times, also on new restrictive measures. However, shared projects of a psychosocial nature managed equally together with all the subjects directly involved, starting from user and family associations, local authorities, and services, do not appear equally clearly among the functions of the services. The latter projects are not primarily oriented towards the disease, but towards interpersonal relationships and community development and which should be considered as important as the clinical ones.
Basaglia’s historic statement, according to which the concept of mental illness should be put “in brackets” due to the uncertain nature of mental illness itself, is perhaps even more valid today. In fact, despite the great technological progress in various sectors of science, we do not have sufficiently objective evidence on the scientific validity and reliability of psychiatric diagnoses (old and new), which always remains descriptive and not causal despite what we are led to believe by important organizations in the sector (+a).
Law 180, especially through the closure of the psychiatric hospital, which was considered the greatest emblem of marginalization/medicalization/coercion, emphasized the need for a return to the territorial communities to which people belong, underlining the social aspects as well as the health nature of the problems.
Almost in those same years, however, a completely opposite movement was strengthened also thanks to the diffusion of the third edition of the Diagnostic Statistical Manual (DSM). It was stated that the problems were not in the relational context of the community but above all in the individual person. People therefore had to be treated mostly individually in a specific way thanks to new diagnoses and new scientifically validated therapeutic tools. Without a doubt, this was a strong message contrary to that of Basaglia.
The aforementioned Diagnostic Statistical Manual (DSM), published worldwide since 1980 by the American Psychiatric Association, includes over 300 diagnostic frameworks in the most updated version. If we consider that in the first edition of the DSM dating back to the post-World War II period there were only about a hundred diagnostic categories, the result is an impressive numerical increase over the last few decades. The WHO’s International Classification of Diseases (ICD) has had a similar development and therefore does not differ much from the DSM.
Unfortunately, scientific evidence to date can only explain a small part of the universe, both at a macro and microscopic level; not to mention that in addition to scientific evidence we must consider other types of evidence linked to myriads of other aspects of life.
Nowadays, probably due to the tendency towards excessive use of diagnoses and the related large market of therapeutic remedies, priority is given to clinical aspects, often underlining their chronic nature and resorting to clinically dominated health care. The psychosocial aspects are usually considered a mere extension of the clinical moment to be managed with personnel from various backgrounds, trained in a psychoeducational sense (operators, family members, carers, former patients, etc.), to follow the progress of the disease step by step for its entire duration. Therefore, the disease, considered to be the basis of the abnormal functioning of the individual, has emerged from Basaglia’s “brackets” and has returned to the center of attention with all its might and even greater power. Relational, psychosocial, cultural and educational factors would no longer have significant relevance in determining mental suffering. Society is simply required to welcome people affected by these diseases and support them during treatments, which are often chronic.
The clinical approach proceeds from the concept of individual disease (medical or psychological), is implemented in specific places, makes use of a standardized global language based on scientific evidence (global knowledge +b) and there are well-defined settings and responsibilities to which professionals and users are tied.
The shared psychosocial model, on the other hand, is implemented in communities outside the location of the services; it does not look primarily at the disease but at the person within their local context; equal relationships are fostered, overcoming discrimination of all kinds and valorizing diversity and native languages (local knowledge +b). Professionals with a clinical background participate as people on an equal footing with others in the construction of common projects, giving their contribution as people, and avoiding methods linked to the clinical context.
These are, therefore, two approaches of a different nature, which must not be confused, and which should develop in a parallel manner without mutual abuse. The clinical moment certainly remains important and is the responsibility of the professionals in the sector who are linked to the responsibility of the various standardized interventions. The psychosocial moment of shared projects instead sees the various local actors, including service professionals with clinical skills, involved equally and with equal responsibility in the construction and management of the aforementioned projects.
Among the shared psychosocial projects of various nature, both internally and externally centered and in relation to the characteristics of the different communities, meeting groups where one reveals one’s personal experiences of suffering and shares them with the other participants are of particular importance. Free relationships, in a context in which everyone sees themselves as equals, proves in itself to be very useful for gaining self-confidence and identifying appropriate solutions. In these groups the service professionals also participate as equals without resorting to diagnostic judgments and prescriptions. Instead, they will have to listen and perhaps help facilitate the circularity of interactions, they will have to refrain from giving answers, but they will have to ensure that the group itself gives answers. The location outside the service environment and the participation of people from the local community, who are in some way interested in mental health, requires the use of understandable and meaningful language that adapts to each community context. By listening to the points of view of others, the person who has revealed her/his problem will have the opportunity to reflect in complete freedom on the possible interpretations and solutions to be adopted, as expressed by the other participants. Through the interactions of such a group we realize how things can be narrated differently, and everyone is free to choose the narrative that best suits them. From these groups, further activities and projects can arise more or less directly managed by the former users themselves together with other community subjects and the support of health service professionals will no longer be appropriate. It should also be underlined the fact that meeting in a public place within the community, outside the headquarters of the services, induces the participants to feel like citizens of that community, all on equal terms with equal rights and duties and as such, co-responsible for the development of the community of which they are a full part.
The shared psychosocial projects are in continuity with historical experiences of transformation into communities of some psychiatric hospitals, in various countries, but especially in the United Kingdom, since the Second World War. Such experiences also inspired various Italian psychiatrists such as Basaglia. The development of psychiatric self-help and mental health associations in Northern Europe and North America, which spread in Italy between the 80s and 90s, gave further impetus to the transition from the clinical model to the community model, now no longer understood as transformation of a hospital into a community, but as work disseminated into the actual territorial communities, outside the hospital.
Several other kinds of relationship alternative to the patient-therapist dyad were proposed and saw the users themselves becoming supporters of the construction of new paths which called into question many other subjects in society, i.e. the cocreation approach c+.
Shared psychosocial projects exist both in Italy and in other countries and the creation of an intermediate area +d jointly managed by associations, services and local authorities has been hypothesized to coordinate these projects and ensure appropriate relationships with services and the territory in general.
The disease should still remain “in brackets” and only a frank dialectic between the clinical moment and the shared psychosocial moment will be able to appropriately balance individual interventions with collective ones. The risk of further abnormal expansion of more or less forced clinical interventions on the individual in the name of diseases, that are often of little consistency even from a scientific point of view, will be avoided. This is something that is happening in many Western countries, and which can be considered as a form of new institutionalization in continuity with the mental hospital philosophy which unfortunately is always present in a large part of society +e.
Law 180 already offers abundant space for the aforementioned psychosocial projects shared between associations, local authorities and services, but these projects should be further promoted and implemented at a local level so that they are truly effective.
+b https://philpapers.org/rec/BRAPMH
+c https://www.mentalhealtheurope.org/library/co-creation/
+dhttps://www.ecologiadellamente.it/archivio/2136/articoli/23144/
+e https://mhe-sme.org/wp-content/uploads/2018/01/Mapping-and-Understanding-Exclusion-in-Europe.pdf