Involuntary Admissions, and Treatments (TSO) for Individuals Suffering from Schizophrenia: A Reflection on Patient Safety, and Quality of Care


Fabio Calzolari


     Introduction: Since the Italian Mental Health Act of 1978, public attention on the outcomes of Involuntary Hospital Treatment (TSO) for people struggling with Schizophrenia (SCZ) has increased. The practice is controversial because it goes against the Human Rights standards. Against this background, the author investigates factors linked to coercive measures, and personal experiences of acute care. He hypothesizes that limitation of freedom negatively affects the quality of the therapeutic relationship (TR). Materials, and Methods: Semi structured qualitative interviews (QIs) of individuals (n = 20) who were eligible for inclusion if the following criteria applied: [1] DSM-V diagnosis of Schizophrenia; [2] Having received at least one TSO; [3] Being outpatients; and [4] having emotional, and cognitional stability. The interview text was transcribed verbatim and analyzed by means of a phenomenological method. Results. The cohort described TSO as an unwelcome, and intrusive practice. Even if clinicians often justified the admissions, only a few patients gave an account of being told why their agency was eroded. Moreover, TSO damages Self-confidence, and trust in public services. Inasmuch, to prevent distress and avoid an outflow of so-called psychiatric refugees, the Italian government needs to improve joint crisis plans between patients, families, and medical equips. Discussion. The Republic of Italy does not have asylums but community-centers, and psychiatric wards within general hospitals. The Law No. 833 of 23 December 1978 established the possibility of a TSO for a period of 1-7 days in the simultaneous presence of [1] Psychiatric conditions that require urgent therapy; [2] Patient’s refusal of assistance; and [3] Circumstances that do not consent other less-invasive strategies. To author’s knowledge, this is one of the few qualitative reflections done on the pros and cons of adult Psychiatry, in Italy.  The survey adds valuable information regarding degree, and predictors of loss of autonomy, dignity, and the possibility of interpersonal contact.

Keywords: Schizophrenia, TSO, Human Rights, Therapeutic Relationship, Law No. 833.


Association of Social Anthropologists of the Commonwealth. (1999). Ethical guidelines for good research practice. Retrieved from
Barbui, C., Papola, D., & Saraceno, B. (2018). Forty Years without Mental Hospitals in Italy. International Journal of Mental Health Systems, 12,43 .
Basaglia, F., Scheper-Hughes, N. E., Lovell, A. M., & Shtob, T. T. (1987). Psychiatry inside out: Selected writings of Franco Basaglia. New York: Columbia University Press.
Bergen, B. J. (2000). The banality of evil: Hannah Arendt and'the final solution'. Lanham: Rowman & Littlefield Publishers.
Biggerstaff, D., & Thompson, A. R. (2008). Interpretative phenomenological analysis (IPA): A qualitative methodology of choice in healthcare research. Qualitative research in psychology, 5(3), 214-224.
Byrne, P. (2007). Managing the Acute Psychotic Episode. BMJ: British Medical Journal, 334(7595), 686-692.
Burns, T. (2019). Franco Basaglia: a revolutionary reformer ignored in Anglophone psychiatry. The Lancet Psychiatry, 6(1), 19-21.
Casacchia, M., Malavolta, M., Bianchini, V., Giusti, L., Di Michele, V., Giosuè, P., ... Roncone, R. (2015). Closing Forensic Psychiatric Hospitals in Italy: A New Deal for Mental Health Care?. Rivista di Psichiatria, 50(5), 199-209.
Cohen, B. M. (2008). Mental health user narratives: New perspectives on illness and recovery. New York: Springer.
Davies, C. (1989). Goffman's concept of the total institution: Criticisms and revisions. Human studies, 12(1), 77-95.
Ebisch, S. J. H., Salone, A., Ferri, F., De Berardis, D., Romani, G. L., Ferro, F. M., & Gallese, V. (2012). Out of Touch with Reality? Social Perception in First-Episode Schizophrenia. Social Cognitive and Affective Neuroscience, 8(4), 394-403.
Groeben, N., & Scheele, B. (1982). Einige Sprachregelungsvorschläge für die Erforschung subjektiver Theorien. Analyse und modifikation subjektiver theorien von Lehrern, 13-39.
Horwitz, A. V. (1982). The Social Control of Mental Illness. NY: Academic Press.
Iversen, K. I., Høyer, G., & Sexton, H. C. (2007). Coercion and patient satisfaction on psychiatric acute wards. International Journal of Law and Psychiatry, 30(6), 504-511.
Kaiser, K. (2009). Protecting respondent confidentiality in qualitative research. Qualitative health research, 19(11), 1632-1641.
Kallert, T. W., Mezzich, J. E., & Monahan, J. (Eds.). (2011). Coercive treatment in psychiatry: clinical, legal and ethical aspects. Hoboken, NJ: John Wiley & Sons.
Kaltiala-Heino, R., Korkeila, J., Tuohimäki, C., Tuori, T., & Lehtinen, V. (2000). Coercion and restrictions in psychiatric inpatient treatment. European Psychiatry, 15(3), 213-219.
Kaufman, J., Birmaher, B., Brent, D., Rao, U., Flynn, C., Moreci, P., Williamson, D., & Ryan, N. (1997). Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL): Initial Reliability and Validity Data. Journal of the American Academy of Child and Adolescent Psychiatry, 36(7), 980-988.
Kinderman, P., & Tai, S. (2008). Psychological models of mental disorder, human rights, and compulsory mental health care in the community. International journal of law and psychiatry, 31(6), 479-486.
Kinderman, P., & Butler, F. (2006) Implementing a Human Rights Approach within Public Services: An Outline Psychological Perspective. London: A Report for the Department for Constitutional Affairs. Department for Constitutional Affairs.
Kuosmanen, L., Hätönen, H., Malkavaara, H., Kylmä, J., & Välimäki, M. (2007). Deprivation of liberty in psychiatric hospital care: The patient's perspective. Nursing Ethics, 14(5), 597-607.
Larson, M. K., Walker, E. F., & Compton, M. T. (2010). Early Signs, Diagnosis and Therapeutics of the Prodromal Phase of Schizophrenia and Related Psychotic Disorders. Expert Review of Neurotherapeutics, 10(8), 1347-1359.
Leung, A., & Chue, P. (2000). Sex Differences in Schizophrenia, a Review of the Literature. Acta Psychiatrica Scandinavica, 101(401), 3-38
Lehto, E. (2018). Applicability of Article 3 of the European Convention on Human Rights at the Borders of Europe. Helsinki Law Review, 12(1), 54-77.
Lora, A. (2009). An Overview of the Mental Health System in Italy. Annali dell'Istituto Superiore di Sanita, 45(1), 5-16.
Lidz, C. W., Hoge, S. K., Gardner, W., Bennett, N. S., Monahan, J., Mulvey, E. P., & Roth, L. H. (1995). Perceived coercion in mental hospital admission: Pressures and process. Archives of General Psychiatry, 52(12), 1034-1039.
Lysaker, P. H., Roe, D., & Yanos, P. T. (2007). Toward Understanding the Insight Paradox: Internalized Stigma Moderates the Association between Insight and Social Functioning, Hope, and Self-Esteem Among People with Schizophrenia Spectrum Disorders. Schizophrenia Bulletin, 33(1), 192-199.
McLaughlin, P., Giacco, D., & Priebe, S. (2016). Use of coercive measures during involuntary psychiatric admission and treatment outcomes: data from a prospective study across 10 European countries. PloS one, 11(12), e0168720.
Medawar, C., & Hardon, A. (2004). Medicines out of control? Antidepressants and the conspiracy of goodwill.
Messias, E. L., Chen, C. Y., & Eaton, W. W. (2007). Epidemiology of schizophrenia: review of findings and myths. Psychiatric Clinics of North America, 30(3), 323-338.
Mezzina, R. (2018). Forty years of the Law 180: the aspirations of a great reform, its successes and continuing need. Epidemiology and psychiatric sciences, 27(4), 336-345.
Moore, W. H. (2000). The Repression of Dissent: A Substitution Model of Government Coercion. Journal of Conflict Resolution, 44(1), 107-127.
Nelson, B., Parnas, J., & Sass, L. A. (2014). Disturbance of Minimal Self (Ipseity) in Schizophrenia: Clarification and Current Status. Schizophrenia Bulletin, 40(3), 479-482.
Paksarian, D., Mojtabai, R., Kotov, R., Cullen, B., Nugent, K. L., & Bromet, E. J. (2014). Perceived Trauma During Hospitalization and Treatment Participation Among Individuals with Psychotic Disorders. Psychiatric Services, 65(2), 266-269.
Pelto-Piri, V., Kjellin, L., Lindvall, C., & Engström, I. (2016). Justifications for coercive care in child and adolescent psychiatry, a content analysis of medical documentation in Sweden. BMC health services research, 16(1), 66.
Peralta, V., & Cuesta, M. J. (2001). How Many and which are the Psychopathological Dimensions in Schizophrenia? Issues Influencing their Ascertainment. Schizophrenia Research, 49(3), 269-285.
Petrila, J. (1995). Ethics, Money, and the Problem of Coercion in Managed Behavioral Health Care. Louis ULJ, 40, 359.
Rose, D., Perry, E., Rae, S., & Good, N. (2017). Service user perspectives on coercion and restraint in mental health. BJPsych international, 14(3), 59-61.
Scheper-Hughes, N., & Lovell, A. M. (1986). Breaking the circuit of social control: Lessons in public psychiatry from Italy and Franco Basaglia. Social Science & Medicine, 23(2), 159-178.
Schroter, S., Plowman, R., Hutchings, A., & Gonzalez, A. (2006). Reporting ethics committee approval and patient consent by study design in five general medical journals. Journal of medical ethics, 32(12), 718-723.
Sicilianos, L. A. (2014). The role of the European Court of Human Rights in the execution of its own judgments: reflections on Article 46 ECHR. In Judgments of the European Court of Human Rights-Effects and Implementation: Nomos Verlagsgesellschaft mbH & Co. KG.
Sjöstrand, M., & Helgesson, G. (2008). Coercive Treatment and Autonomy in Psychiatry. Bioethics, 22(2), 113-120.
Sjöstrand, M., Karlsson, P., Sandman, L., Helgesson, G., Eriksson, S., & Juth, N. (2015). Conceptions of Decision-Making Capacity in Psychiatry: Interviews with Swedish Psychiatrists. BMC Medical Ethics, 16, 34.
Smith, J. A., & Osborn, M. (2004). Interpretative phenomenological analysis. In G. M. Breakwell (Ed.), Doing social psychology research (pp. 229-254). Leicester, England: British Psychological Society; Malden, : Blackwell Publishing.
Szmukler, G., & Appelbaum, P. S. (2008). Treatment Pressures, Leverage, Coercion, and Compulsion in Mental Health Care. Journal of Mental Health, 17(3), 233-244.
Tarricone, R., Gerzeli, S., Montanelli, R., Frattura, L., Percudani, M., & Racagni, G. (2000). Direct and Indirect Costs of Schizophrenia in Community Psychiatric Services in Italy: The GISIES Study. Health Policy, 51(1), 1-18.
Zeppegno, P., Airoldi, P., Manzetti, E., Panella, M., Renna, M., & Torre, E. (2005). Involuntary psychiatric admissions: a retrospective study of 460 cases. The European journal of psychiatry, 19(3), 133-143.
Zinkler, M. (2016). Germany without coercive treatment in psychiatry—a 15 month real world experience. Laws, 5(1), 15.

Research Articles


How to Cite
CALZOLARI, Fabio. Involuntary Admissions, and Treatments (TSO) for Individuals Suffering from Schizophrenia: A Reflection on Patient Safety, and Quality of Care. Naresuan University Journal: Science and Technology (NUJST), [S.l.], v. 27, n. 4, p. 75-86, oct. 2019. ISSN 2539-553X. Available at: <>. Date accessed: 29 may 2020. doi: