In-patient mental health care is regrettably often carceral to some degree. Any system built on forcing care upon a person “for their own good” is not going to be patient-centered. All of my experiences with mental health hospitalization in the United States have been traumatic.
As a teenager, I was strip-searched, kept alone in a room for hours on end, and prevented from contacting anyone aside from immediate family. One one occasion a close friend was able to see me, to check I was alright, only by masquerading as my partner. Once I was even transported to a hospital in handcuffs, because a social worker incorrectly believed I was suicidal, due to a sarcastic remark I made while under stress.
I would often fear that I was one autistic meltdown or misplaced comment away from losing my freedom and my shoelaces.
In the US, depending on the state, a dizzying array of people—medical and mental health professionals, social workers, relatives, friends, law enforcement and others—can initiate emergency involuntary commitment processes. The time someone can be held in this way ranges from 23 hours to 10 days, or an “unspecified” duration, and a number of states don’t require a court order for the period to be extended.
There, I would often fear that I was one autistic meltdown or misplaced comment away from losing my freedom and my shoelaces. More recently, I learned first-hand that things are different elsewhere.
In Italy, where I live now, involuntary commitment is not wholly absent, but it is significantly more difficult to impose. It takes far more than a therapist or doctor finding one’s comments concerning. The criteria for involuntary psychiatric hospitalization in Italy are as follows:
“(a) the patient is suffering from psychic alterations that need immediate treatment; (b) the patient refuses the treatment; and (c) the patient cannot be adequately treated by other non-hospital-based means.”
Two doctors, a mayor and a magistrate have to be involved in such a decision. The person is required to remain hospitalized for seven days, after which the doctors would have to reapply to the local authorities for an extension.
Despite the fact that I had attempted suicide, I did not meet the Italian criteria because I never refused treatment. Even if I had, the process is so complex that it’s used infrequently. Less than 5 percent of psychiatric hospitalizations in Italy in 2015 were involuntary. There are also no dedicated mental health hospitals in Italy, only wards within more general hospitals.
That’s not to say psychiatric care in Italy is great. I saw restraints used on one patient in the ward. People went in and out of each others’ bedrooms without being noticed by the staff, sometimes at night, which made me nervous because of my past experiences of sexual assault. I awoke one night to see a woman, a patient who’d wandered in from another room, nonconsensually kissing my roommate while he slept.
The doors to the bathroom and shower room did not lock. There were cameras in every single bedroom, meaning we couldn’t even dress in private unless we hid beneath our blankets.
Critically, I always retained the legal right to sign myself out, albeit against medical orders, at any point.
I was prescribed antipsychotics, even though I had explained to the nurses that I could not take them on account of having suffered a bad reaction in the past. They also prescribed me what my doctor in the States called a subtherapeutic dose of lithium, which was more pointless than harmful.
The doctors were reluctant to let me leave until I had an appointment with the town psychiatrist, and a friend or relative to take me home. But critically, I always retained the legal right to sign myself out, albeit against medical orders, at any point.
The doctors’ requirements were quite easy for me to meet, however. So I followed them, and was home within 72 hours. Plus, there was no hefty bill to worry about; the hospital is part of the Italian socialized health care system.
Despite all the issues I’ve mentioned, the experience was vastly better than my previous hospitalizations in the US.
There, I’d only ever been committed to wards in which we couldn’t go outside. In one hospital, even fire drills were conducted indoors. In the event of a real fire, we would have gone to a room within the ward, which was on the third floor, and waited. The nurses assured us that the firefighters knew which window to break.
Nor could we see anything from the windows aside from gray concrete walls. In Italy, the hospital had a small courtyard where nurses and patients alike smoked, from which one could see the hospital garden. I spent a fair amount of time reading there. In US wards where we couldn’t go outside, no one could smoke or vape. For people who were dependent on nicotine, it must have been incredibly stressful to go through withdrawal on top of everything else they were experiencing.
In one private hospital in the States, everyone was strip-searched for cutting marks upon arrival, including young teens. Nobody searched me at the Italian hospital, though they did take my backpack and look through it. Still, this was significantly less traumatic.
The US hospitals typically had something called a quiet room, where people who were upset were isolated until they calmed down. Those who didn’t calm down were held down by nurses and given a shot. As an autistic person, being isolated in an empty, windowless room is absolutely the last thing that should happen to me when I have a meltdown, because there’s no way for me to calm myself—no music, no books, no distractions, nobody to talk to me.
This served as a deterrent for me; I was as well behaved as possible because I feared seclusion. Still, seeing the quiet room used in a manner that seemed punitive, especially against children when I was only a child myself, was deeply disturbing. There was nothing like this in the Italian ward.
This focus on my support system and a safe home environment, as opposed to a cure, reassured me.
The Italian hospital allowed any of my friends to visit me. That was a huge improvement on most US hospitals I’d experienced, where I could only speak to or see close blood relatives—and that fake boyfriend one time. Banning people from speaking to those who care for them is hardly therapeutic, especially when so many people—notably queer people and drug users—tend to be closer to their friends than their relations.
One local friend was there to help me translate when my Italian wasn’t quite up to the task. I was released into his care specifically, because none of my relatives live in Europe. The doctors urged him to stay with me for a few days to ensure I was safe.
This focus on my support system and a safe home environment, as opposed to a cure, reassured me. US hospitals, in my experience, are much more focused on making someone “normal.”
When I was first hospitalized as a child, the doctors wanted me to remain until my “problems”—which turned out to be then-undiagnosed autism, along with social anxiety—were fixed. Their attempt to essentially make me neurotypical through heavy doses of psychotropic drugs naturally didn’t go anywhere, and I remained there long enough that my school wanted me to repeat fourth grade.
Under the less-carceral system here, with a greater emphasis on community-based care, I believe my early life would have gone better.
Due to the lack of “progress,” I very nearly found myself committed to a long-term ward—the plan my doctors favored. My parents’ inability to afford this saved me. But after this experience I never fully reintegrated into my family, and remained isolated from my peers.
Italian mental health care has plenty of issues, for sure. But under the less-carceral system here, with a greater emphasis on community-based care, I believe my early life would have gone better.
Overall, Italian doctors seem to trust their patients more and treat them more like human beings, capable of collaborating and making decisions for themselves. Most of the patients I spoke to in the Italian hospital were there by choice. The food was horrible and some of the prescribing choices questionable. But the environment seemed less hostile, and patients, accordingly, less stressed.
Photograph via Pickpik