Roberto Catanesi, Stefano Ferracuti

This issue of the Journal of Psychopathology brings together an array of national and international experiences aimed at providing an integrated perspective of current forensic psychiatric problems. Credit should be given to Prof. Rossi for his sensitivity and attention for proposing a complex and difficult subject such as that of psychopathology in the forensic field. What happened in Italy in the last 10 years certainly establish an important moment of discontinuity with the past, as reported by various authors. Several authors of this issue have been promoters and organizers of the process of closing the judicial psychiatric hospitals in Italy, and the difficulties that have arisen and the current perplexities are well represented in the various contributions.

The assessment of the risk of possible future violent behaviors emerges as a central theme, especially in relation to the possibility of applying or prolonging measures limiting personal freedom to individuals identified as being at risk for antisocial behaviors. Other aspects of violence related to psychopathology are thematized, such as intra-family violence and possible specificities of violent behavior in relation to diagnostic categories, demonstrating the breadth of the theme. Elements of more strictly medical-legal assessment are also inside the issue, in reference to the general framework of risk assessment from a risk management perspective a novelty theme in forensic evaluations.

We believe that the current situation of forensic psychopathology in Italy, and generally in Europe, shows very clearly that few areas of psychiatry and psychopathology are more linked to social and legal choices. Forensic psychiatry is a discipline of strategic importance in the context of the study of human behavior that combines, in a not always linear and coherent form, purely clinical dimensions with the methods of organizing the control of deviance and, in particular, of the violence linked to mental illness. In this sense, the problem in Italy today is a system of different instances and philosophies, which have stratified over the course of almost a century.

In fact, in the same clinical-social-juridical scenario there are rules that establish the responsibility of the person entrusted with the supervision of the incapacitated in case of damage caused by the latter (art.2047 of the Civil Code), an evolved and refined doctrine on informed consent (Law 319/2017), a legislation on coercive treatment which excludes the possibility of recourse to it due to the risk of violent conduct and in any case strongly limits its duration. This last aspect must be related to a legal doctrine which, on the other hand, has progressively extended the psychiatrist’s “position of guarantee”, attributing ever greater responsibility to the healthcare professional in relation to possible future violent behaviors of his clients, provided that they are “predictable “. Certainly it becomes paradoxical and in any case unmanageable on a practical level, a situation where a psychiatrist can be accused of an omission if he has not been able to prevent a violent act of his client when there is another legislation that prevents coercive treatment except for the need for treatment and does not allow involuntary treatment as a possibility for limiting action on the client’s conduct.

Even the lack of intermediate civil treatment, other than compulsory medical treatment, is a strong limit to a correct practice aimed at protecting patients and potential victims. We take this opportunity here to highlight that all the choices of the legislator with respect to the closure of the Judicial Psychiatric Hospitals were exclusively aimed at the perpetrators and there was no attention to the possible victims of crimes committed by patients, even knowing that for the most part, their violence is exercised within the family or towards close relatives. This legislative vacuum certainly does not help to reduce the elements of social friction: the victims of crimes committed by psychiatric patients seek compensation to the detriment of the health professionals, increasing a spiral of conflict of which the limit is not seen.

The lack of an overall perspective is reflected in confused proposals for the abolition of the not-guilty for reasons of insanity legislation tout-court, often advocated by those who believe that problems can be solved with a work of social-legal engineering without considering that, on the other hand, these problems belong to an anthropological dimension. much deeper culture and in any case they seem to ignore many years of juridical (and also medico-legal) reflection on the subject.

It is not a case that the debate reported in this issue of the Journal of Psychopathology is completely lacking the voice of the prison dimension. In fact, if it is true that on the one hand the criminal asylums have been closed, thus achieving the “political” objective, on the other hand very little has been done to improve psychiatric treatment in prison institutions, nor does this problem seem to be of concern to the General Managers of the local health authorities, if not for sporadic exceptions. Prisons have become the new containers for a large number of psychiatric patients who often do not have sufficient economic protection to have an adequate lawyer or to pay for a consultant. The set of rules that governed the closure of the criminal asylums envisaged, at the same time, the development of “health articulations” in the penitentiary environment, that were conceived as authentic psychiatric structures, separated from the prison context and with treatment and environmental standards comparable. Today this health resource is available in a scattered way in the different areas in Italy and is absolutely residual inside the department organization.

Many of the problems highlighted in the REMS interventions reported in this issue are related to the presence of a subgroup of people with high rates of psychopathy and mental illness. It is a limited number of people, who nevertheless absorb considerable energy and resources from the staff working in REMS, in addition to exposing them to the risk of suffering violence. The rule originally envisaged the establishment of two types of REMS, one for stabilization and one for treatment, and certainly the problem of the existence of a subgroup of people who appear resistant to treatment and a continuous source of social alarm cannot continue be neglected or treated as a speciousness of forensic psychiatrists, deserving instead an appropriate organizational reflection.

In our opinion, a serious comparison with reality must be implemented: how many people, suffering from mental illness, are currently included in the system of security measures? The number certainly cannot be assessed only with REMS inmates. These form the tip of an iceberg whose immersed volume is completely ignored. Furthermore, the security measure of probation, unlike the custodial one, does not have a defined time limit and some of these subjects can be in charge of the departments of mental health for many years, in situations that appear problematic if evaluated from the point of view of the freedom of the single. It is also common knowledge that sometimes people assigned to REMS are sent to community treatment with a revision of the safety measure only because there is no bed available in REMS, thus finding themselves in conditions of community management that can last for a much longer time of the original measure.

The solution, at least the first step towards a solution, passes in our opinion from the establishment in each Region of an Observatory for a standardized and capillary data collection. In fact, only by having a vision of the actual dimension of the problem, that is, of how many offenders are actually affected by mental illness, where they are allocated, how they are treated, etc., will it be possible to adequately calculate the level of capacity necessary to deal with this problem in dignified terms, central to human rights. Having a dimension of the problem, it will be possible to think of a treatment system differentiated by structures and programs, more able than the current one to balance personal freedom, health protection and the interest of the community. It is time to abandon ideological prejudices and tackle the issue of the protection of psychiatric patients who are offenders scientifically and concretely, without forgetting however the protection of their possible victims.

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