Abstract
The Italian psychiatric ‘revolution’ is the story of a range of flexible, changing formulas, exposed to many ‘contaminations’. Historical reconstructions have remained anchored to the lure of a founding myth and an eponymous hero. This essay aims to shed light on the multi-faceted concept of the Italian ‘moral management revolution’. We especially focus on: the circumstances which triggered the innovation in its various form; the ‘prototypes’ available in other countries which have been variously recombined in the different local contexts; the ‘special path’ of action strategies which has driven the change towards radical closure of the asylums; and the cause–effect relationship between the above ‘special path’ and several aspects of the current state of deadlock.
Keywords
Joshua fit the battle of Jericho
and the walls came tumbling down
Swimming against the tide
Law 180/1978 for psychiatric reform in Italy was the outcome of two formidable legacies left by 15 intense years of experimentation by the ‘anti-asylum movement’, taken so much for granted as to be almost forgotten, although they express an epoch-making change.
The first was that the ‘freeing of the mad’ proved to be possible in practice: ‘a population with a long history of illness and severe disability is able to undergo a radical change in its clinical and living conditions, if transferred to a local residential facility’ (Barbato et al., 2004). In other words, it could be done. The second major legacy was the change in the social mandate of psychiatry. When the relationship between the patient and the therapist was shifted outside rigidly hierarchical and regulated institutional contexts, the therapist had to come to terms with the suffering, without any protective screens, armed only with medical knowledge (including the powerful recourse to drugs). The doctor now ‘walked into the wind’: the doctor–patient relationship was no longer hierarchical but peer-based, closer to that of a wet nurse than that of a warder or controller.
What intermediate transitions led to this change in the movement’s objectives from mere rationalization of asylums to their abolition? What strategies, what co-operations and conflicts, what players led to this result? Was it really a compact, homogeneous movement, or was its greatest asset precisely the many innovative, but often conflicting, pieces of the mosaic? Italy of the 1960s and 1970s was called ‘Basaglia’s country’. Yet is it right to reduce a polycentric movement, effective precisely because it was equipped with several innovative local drivers, to the feat of a single protagonist?
Recently, Foot (1915) published a book about the psychiatric movement in Italy in the 1960s and 1970s, with Basaglia’s name featured in the title. However, the book involves a whole host of actors and groups from diverse walks of life who, in the 1960s, set out to transform the institutional landscape of Italian mental health care. Foot, as pointed out by Barham (2016), ‘embarked on his research with a focus that was initially Basagliacentric but soon discovered that the movement as a whole, in its rich and jostling diversity, were more complex and multi-balanced than this’.
Foot (2016) himself is explicit when warning that ‘by reducing the history of psychiatric reform to the life story of Franco Basaglia, we are doing the history of the movement a great disservice’. Indeed, two decades ago an Italian historian emphasized that ‘an Italian model of anti-institutional psychiatry does not exist; we should avoid the specific nature of the most profoundly studied cases being exchanged for their assumed exemplarity or for one of its kind’ (Guarnieri, 1998: 18).
So, the anti-asylum watershed in Italy is not the story of a one-man undertaking, but of flexible, changing formulas, exposed to many contaminations,
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in Italy and abroad. Yet in this creative complex, there is no trace of reflection endowed with historical rigour: There are various accounts, stories, ‘autobiographies of a movement’, discussions, many interviews of the anti-institutional era … which are too ideological, aimed at testifying to each particular experience with no critical comparison with others, or too concerned with the political correctness of their own strand so as not to slide into triumphalism. (p. 9)
In the new millennium, when the protagonists of the age of renewal and closing of asylums began to publish their thoughts on the period, there emerged equally invalidating limitations: ‘On reading them we have the sensation of a crystallized conflict’ (Fiorani, 2010: 16). In the past decade, half a century after the anti-asylum watershed, which would merit more attention, ‘memory prevails over history’ (p. 19).
Foot’s (2014) book on alternative Italian experiences, written for a major publishing house in Italy, recognized a ‘critical detachment’ (p. 343) in only two attempts at historical reconstruction (Legrand, 1988; Micheli, 1982). The fact is that critical detachment and an in-depth external approach encountered great hostility among a public of operators, experts and supporters, conditioned by the single thought of myth-making around only one eponymous hero. Instead, the period of radical asylum transformation (the 1960s and oft-neglected 1970s) was the fruit of original polycentric experimentation. One might perhaps think that this reductionist drive would come to an end, but this was not so. On reviewing the book by Foot (2014, 2015), Barham perspicaciously points out the major change in the significance of the title between the English and Italian versions: The book was first published in Italian under the playfully ironic title of La ‘Repubblica dei Matti’: Franco Basaglia e la psichiatria radicale in Italia, 1961–1978. Whilst Basaglia is announced as the main protagonist in the action, the book is evidently about a larger subject than him. In the English-language edition, however, the play of the Italian title is quite absent … . It is as though the revisionary Franco Basaglia of Foot’s text has been replaced by the soiled counterfeit currency through which his reputation has long circulated: an ironic demonstration of how resistant to eradication is the power of a legend once entrenched in popular culture. (Barham, 2016)
Foot (2016) cannot but confirm Barham’s lucid provocation: This work started out as a kind of biography of the Italian radical psychiatrist Franco Basaglia, but it turned into a cultural history of a wide-ranging and multi-faceted movement. But Basaglia’s fame is such that publishers would like him in the title itself. In Italy I managed to keep him to the subtitle, in the UK and the US this was a battle I lost.
In the present essay, I aim to expose the extraordinary wealth of such a golden age, much beyond the stereotype of a ‘one-man revolution’. Comparing the parallel history and contents of many experiences with those of Gorizia and Trieste is a salutary exercise in recovering historical perspectives which cannot but enrich reflection of both public opinion and psychiatric operators. In a period when we entrust pharmacology and neurology with the task of solving mental problems, it would be worth recalling (Dörner, 1975: 62); he wrote that, as early as the 1750s, William Battie, a pioneer of Tuke’s and Pinel’s ‘freedom from chains’, maintained in his Treatise on Madness that ‘management did much more than medicine’.
This essay aims to answer four non-trivial questions. What were the conditions triggering the Italian psychiatric revolution, that is, what management models, available in other countries, were drawn upon and combined into the Italian experience? Why does the success or failure of local experiences seem to depend on the implementation of a sort of pincer strategy, aimed at attacking asylums from both inside and outside their walls? Why, within the rationalization process of asylums, were the stakes raised so high and so sharply, until the very closure of the asylums? Finally, how can the peculiarity of such a ‘special path’ of reform design explain, at least in part, the current state of deadlock of the reform itself?
The pre-existing models triggering the Italian ‘DIY’
The range of 1950s prototypes
Legislation concerning psychiatric welfare in leading Western countries had already been reformulated in the immediate post-war phase in the UK, USA, Germany and France. Thanks to the pharmacological breakthrough in the 1950s, the concrete prospect of reformulating practice in psychiatric hospitals was then looming large. The asylum ceased to be a hallowed place, intangible and separate from the world: it was invaded by techniques of analysis of organizations according to the school of human relations, the same as those applied to factories or offices (Belknap, 1956; Caudill, 1958; Stanton and Schwartz, 1954). In 1955 the World Health Organization (
The drive to rationalize the functions and limit the competencies to be assigned to asylum structures involved all leading Western countries, but not yet Italy. The modernization of asylum psychiatry in Italy began in the 1960s, with the delay often attributed to self-isolation of Italian psychiatric culture, the partial result of two decades of totalitarianism and the legacy of autarchic positivism (Giacanelli, 1975: xvi). Both the emergence of Italy from its scientific isolation and the emerging pharmacological progress were decisive for the start of reforms.
A handful of exit strategies from the asylum dead end were available in those years for Italian reformers; all these strategies aimed to check the drift of a mentally ill person towards a state of no return, but without envisaging the abolition of the final place on this loop, the asylum. It was by looking at the choice of prototypes that the future modus operandi of Italy’s innovative experiments was found. Four models in particular would be combined.
The US model of Community Mental Health Centers: the Kennedy Act of 1963 approved the plan of progressive dismantling of the old asylum system, aiming to intercept the fall of individuals – often war veterans – towards the asylum black hole, by means of a safety harness of mental health centres, mostly arising from bottom-up solidarity movements.
The psychiatric sector, as used in Paris’s 13th arrondissement, shifted the axis of welfare from the asylum to the geographical unit on the basis of two rules: division of the asylum by geographical areas from which the patients came; and the principle of therapeutic continuity, through which a patient was monitored by the same team inside and outside the walls. A network of protected clinics and workrooms for rehabilitation and re-integration restored a bridge between patient and environment.
The French model of psychothérapie institutionnelle, ‘born’ in the psychiatric hospital of Saint-Alban, aimed to free patients not outside but within the walls, with a chiefly psychoanalytical psychotherapy approach and a marked pedagogical interest in training ‘new’ staff.
In the British model known as the Therapeutic Community, the organization remained closed and centralized, though attenuated by the democratization of internal rules and flexibility of release constraints. The best known experiment was that of Maxwell Jones (1970), first at Belmont Hospital in London (1947–59), and then until 1969 at Dingleton Hospital, Melrose. The distinctive characteristics were doctor–patient co-management and the possibility of patients leaving on a temporary basis under some control (revolving door).
One should not think of the Therapeutic Community in the same way as an official institutional model, but rather as a ‘showcase experiment’: in the 1960s it involved a dozen or so hospitals throughout the UK (Clark, 1976: 47). Yet the strength of the Therapeutic Community and sector models lay in their appeal for all those who wanted to innovate in that period, and especially in Italy.
Creative, innovative and multicentric DIY in Italy, 1963–78
It was the sector model which gained a consensus among Italian innovators in the 1960s. At the first National Conference of Social Psychiatry in Bologna in 1964, a legislative proposal inspired by the sector was put forward, and was presented in Parliament in 1965. The first major experiment in Italy was the work of Edoardo Balduzzi, who in 1964, as head of the Psychiatric Hospital of Varese, split the province into geographical zones assigned to distinct teams. He recruited young medical staff to take on the new work outside the hospital, leaving the hospital work to senior medics and paramedics. This was a generational divide between practitioners, intended to motivate those who were to immerse themselves in an unexplored dimension, the community outside. Indeed, according to Balduzzi (2006), who was thinking of the model of Saint-Alban, the most important problem was the involvement of staff. Yet he extended the new training only to the new operators recruited to work outside the psychiatric hospital. However, thereby fell the basic criterion of the sector: that of the continuity of the task force within and outside the walls. A change in the course of the Varese project fell through due to the opposition of staff union representatives, and the sector in Varese closed in 1968.
Another, less well-known, innovative experiment in psychothérapie institutionnelle was initiated in Italy at the same time: that of a group of young psychiatrists and skilled practitioners gravitating around the San Salvi Psychiatric Hospital in Florence; it was close to the thinking of Emmanuel Mounier’s community personalism, disseminated from the 1930s onwards through the journal Esprit. In the same months as Basaglia chose the Therapeutic Community as a ‘prototype’, Graziella Magherini visited Saint-Alban, convinced that daily hospital life in the modern sense was one of the more valid therapeutic tools for recovery of the patient. Parts of the organization in Saint-Alban were reproduced in San Salvi Hospital: the therapy art studios, a magazine run by patients, and attention to training of nursing staff. Babini (2009: 228) saw the reasons for the eclipse of the Florence experiment, at the end of the 1960s, in the emergence of Basaglia’s leadership at Gorizia. The guiding idea in Florence, that an ‘educational dimension involves carers and patients in a relationship of mutual human promotion’, did not seem to have any further influence (p. 229).
Appointed head of the psychiatric hospital of Gorizia in 1961, Franco Basaglia had already undertaken his training at Melrose, where Maxwell Jones had amassed 20 years of Therapeutic Community experiments. Basaglia decided to transpose the Scottish model, not to a clinic or ward for nervous disorders, but to an asylum. We know all that happened in Gorizia and then Trieste, and these are not the focus of this paper. The Gorizia project was not so different from that in Florence, albeit with some variants. Nonetheless, Basaglia was clear about the intrinsic limit of the Melrose model. L’istituzione negata, edited by Basaglia (1968), which recounted the Gorizia experience, made it clear what differentiated Gorizia from Melrose. Behind the adoption of a common practice, these were two distinct philosophies: on the one hand, a strategy of small steps, aimed at improving the therapeutic effectiveness of the institution; on the other, a contingent tactical choice within a longer-term strategy of total negation of the institution, closure being only one material facet of this category (negation). Humanitarianization of the Gorizia asylum made sense if, and only if, it targeted its own denial, with a shift in the centre of gravity towards community care.
A new and unexplored programme was set up by Basaglia in Trieste from 1971 onwards. Here, he initially took the Scottish model to its extreme forms, with choices and events that reached the public imagination via the media. Yet the most important step was not inside but outside the walls. Combining the Melrose model with the prototype of the sector (proving the creative DIY nature of the Italian ‘asylum revolution’), he planned the opening of mental health centres, which would intercept the flow of new in-patients (as in the Kennedy Act in the USA), favouring the re-admission of those who had been discharged into the community. The extraordinary ability of Basaglia to become part of the collective narrative (Pivetta, 2012: 244) ensured that by 1973 Trieste was designated by the WHO as a ‘pilot zone’ for mental health services in Europe.
Pincer strategy: a plurality of ‘special paths’ towards innovation
What happens when the centre of gravity shifts into the community?
If the exploration of innovative DIY were to stop at this point, we might identify the Italian anti-asylum revolution with the name of Basaglia. Yet in so doing, we would lose not only the lesson of models like those of Varese and Florence, but especially that of two eccentric experiments, which shuffle the cards of reflection. One of these anomalous projects was brief and ephemeral, while the other was able to transform itself in time.
From 1969 to 1977, Giovanni Jervis – Basaglia’s colleague and spokesman on the outside – accepted the proposal made by the Reggio Emilia provincial administration: that instead of managing the psychiatric hospital of San Lazzaro, he should set up an alternative network in the community through mental health outreach services and home contacts with problem cases. Venturini (1979: 78) reports that in Reggio, ‘double psychiatry has actually been created, one inside the psychiatric hospital and another outside’. This situation recalls the US experience of the circle of Community Mental Health Centres and that of Varese, which indeed shifts the barycentre of the struggle against the mental illness outside the walls of the asylum, yet without closing the asylum ‘buffer’. Without the adoption of a pincer strategy, the psychiatric circuit tends simply to stabilize around a double polarity: people confined in the asylum, fully detached from people living outside. The logical consequence was that the asylum institution remained ‘a traditional closed institution, with a few superficial changes’ (p. 78). (However, the number of residents at San Lazzaro decreased in eight years from 2400 to 150 and the number of outpatients rose from 150 to 1800, so either the data reported by Venturini do not add up or the ‘superficial changes’ were not so superficial.)
The Perugia experiment was the only one that set in train and achieved successful psychiatric renewal by tackling together the two aspects of the problem, within and outside the walls. It was the only one to undertake the whole Weberian ‘special path of development’ (Weber, 1922) peculiar to the Italian extramural psychiatric model, from the humanitarianization of the asylum to immersion and exploration in the local area, without the reassuring asylum safety net. The story began in 1964 as modernization of the asylum along the lines of the English Therapeutic Community model, but developed rapidly outside the asylum walls according to the sector model in 1968. In 1971 the provincial administration agreed to a network of outreach services, and 10 mental health centres were opened in the same year, equipped on the basis of the principle of the unity and continuity of care. ‘At the same time public meetings were organized [for] awareness-raising on critical issues like that of the dangerousness of the patient’ (Manacorda and Montella, 1977: 144).
In the seven years (1964–71) recounted soon afterwards by Manacorda and Montella (1977), the pragmatic syncretism of leading actors and the ability of a town to make itself part of Habermas’s (1971) ‘reasoning public sphere’ completed a 15-year journey undertaken between Gorizia and Law 180. At the beginning of the 1970s, while Trieste began to set up the sector, Perugia was already focused on community-based care, blocking new admissions to the asylum circuit.
On the threshold of the 1978 reform, nothing had been reported or published about post-1971 work of the Perugia teams. From the moment when Perugia began to move ‘in terra incognita’, exploring new processes of community-based treatment of mental illness, it also entered a media twilight zone. Yet the 1970s saw Carlo Manuali’s team at Perugia undertake not one but two fundamental steps forward in exploring the surroundings: one step every five years.
In the early 1970s, the idea that the asylum should be demolished was replaced by the hopeful idea of a ‘buon territorio’ (i.e. a ‘virtuous’ community outside the walls). Lengthy (and wearing) public debates among citizens, psychiatric operators and public administrators consolidated the flow of discharged long-stay patients, made the new cases emerging in the community shift from a strictly medical competence to a social one, and established in public opinion a new image of the relation between illness, health and medicine.
The utopia of the ‘buon territorio’ inevitably contrasted with the rocky terrain of everyday reality, so the late 1970s was a period of uncertainty. Without the support of the asylum, practitioners were exposed to distress arising once again in homes and families. The enemy was no longer the institution: mental illness was no longer a simplistic consequence either of asylum chains or social marginality. New complex formation mechanisms had to be explored. Precisely when the action shifted to terra incognita, the Perugia experience lost public visibility and went underground. The image that public opinion continued to perpetuate was that frozen from the 1960s: a model of militant and sociological intervention, grafted onto Basaglia’s dominant model.
However, below the surface much was changing. The patient was a subject who was no longer to be ‘recontractualized’, but whose voice needed to be restored. The Perugia practice had been consistent with the Basaglia standard, favouring ‘action with patients’ and aiming to reintroduce them to social work and the community fabric, but now the objective was to give patients a voice, to listen to them and especially to their more complex and articulate expression: delirium. Just before Law 180 was passed in 1978, the Perugia experience of Carlo Manuali drew attention to the new suffering emerging in the local area, and studied the strategies to intercept it before it became chronic. Knowledge was now elaborated and accumulated by the team, at meeting after meeting. The significant shift to community-based care in Perugia in the late 1970s (Micheli, 1982) was totally ignored, both in the anti-asylum movement and in public opinion.
Changing asylums only traps them in a ‘pincer’ movement
In almost all the experiences described, efforts were concentrated on changing the traditional framework, either within or outside the asylum walls. Yet changes were set in motion only if and when they attacked both the asylum and the surrounding area, like the pincers of a crab. The failure of the Varese experiment was due to the channelling of all investment into the community, rather than to the power struggle between unions, practitioners and politicians. The opposite occurred in the Reggio Emilia experiment.
The fact that the most important experiment of institutional psychotherapy in Italy – that in Florence – gave way to the Basaglian leadership at Gorizia might seem to be a simple case of Malthusianism among institutional models, with the model of greater character and effectiveness gaining the upper hand. Yet this shift of power can be explained by a flaw in the construction of the Florentine model rather than the greater strength of the Gorizia model. The Florentine road map was indeed the mirror image of its Varese counterpart: the latter project, based on the French model, incorporated only the interface within the asylum, and this could not evolve unless it was combined with work outside.
In his introduction to the Italian edition of the book by David Clark, chronicler of the pragmatic reformism of Maxwell Jones, Jervis (1976: 10) underlined the importance of the ‘good practice’ of the Therapeutic Community. Yet a year later he recognized that Gorizia was ‘something more than a copy of foreign models: it became an attempt to make asylum modernization less technical’ (Jervis, 1977: 20 ff.). ‘Making it less technical’, as expressed by the code of the movement in those years, was an attempt to exorcize the professional class of falsely neutral ‘technicians’, a target which Jervis strongly opposed. Yet in the meantime Jervis himself (p. 23) recognized that Basaglia had rapidly understood what had been overlooked by Italian promoters of experiments of the sector and of institutional psychotherapy: that the asylum philosophy could be overcome if, and only if, it was caught in a pincer movement from within and from outside. Only when the trumpets of Joshua resounded from outside the fortified walls of Jericho, together with a powerful war cry, did the walls collapse (Joshua, 6:4–5).
The six steps of a ‘Gradus ad Parnassum’ towards asylum revolution
Thus, the new Italian psychiatry was not a white elephant, but was subject to many contaminations from flexible, changing formulas. At Melrose in 1967, Maxwell Jones had subdivided the staff into three groups, to whom patients would be re-assigned according to their home geographic area: in other words, a sector. Without contamination, there is no innovation.
Although public opinion and the scientific community had scrutinized the Gorizia–Trieste epic, the change was the fruit of extraordinary cross-breeding of a range of models. Beyond the six experiments cited earlier in this article, which were significant organizational prototypes of change, there were many other instances in the history of anti-asylum psychiatry in Italy: the seed of Gorizia replanted in Ferrara, Arezzo and Pordenone; Piro’s adventure in Nocera Inferiore, Scotti and Brutti’s ‘second Perugia wave’; and the slow ‘fall of walls’ in a satellite psychiatric hospital in the metropolitan area of Milan. Yet the six main experiments previously discussed (Gorizia, Perugia, Trieste, Varese, Firenze, Reggio) deserve a general observation. Their brief review highlighted a sequence of steps that led from asylum psychiatry to that outside the walls ‘without a safety net’. These, with the final step (see below), were a sort of Gradus ad Parnassum, with psychiatry entirely in the community without the last resort of the asylum.
The first three steps (rationalization within the walls, partial opening of the entrances, two-way opening) occurred within the asylum organization, targeting its humanitarianization and a non-systematic connection with the surrounding community: the prototypes were Maxwell Jones and Saint-Alban. The next three steps (setting up a safety net of clinics for outpatients, initially non-systematic, and later systematically covering the whole community, up to the final closure of asylum structures) shifted the centre of gravity of the intervention into the community: the prototypes in this case were the sector and the US Community Mental Health Centers.
The final step of this second round tends to be viewed as the closure of the asylum, as the target of the Italian model. Yet the great change did not stop there. Building a network of outpatient clinics was merely a precondition, not sufficient to create a new intervention profile for tackling the new suffering originating from the homes of local people. Going ‘beyond asylums’ was not enough: roots had to be planted in the community. Of the six prototypes described, at the time of Law 180 (1978) a few had reached the stage of asylum closure, but hardly any had reflected on the meaning of psychiatry ‘with no safety net’. The seventh step of the ascent of Parnassus had been taken by few of them and, with the sole exception of Perugia, remained terra incognita.
What ‘game of chicken’ made the Italian asylum walls tumble down?
Dissipative structures, resource externalization and the role of communication
The organizational and logistic inadequacy of the Italian asylum system, the backwardness of the legal apparatus, and cultural and scientific isolation help us to understand why the psychiatric response in Italy in the 1960s was more resilient than elsewhere. Yet they fail to explain why it was channelled in the radical direction of asylum closure. It is useful to follow the strands of events and motivations with which a handful of innovators wove a strategy of action, consisting of a continuous game of raising the stakes: from mere rationalization of asylums to their opening up, then to a systematic re-integration of in-patients ‘outside the walls’, then to intercepting potential new long-term patients, and then from continuing to operate with their backs covered by the antiquated asylum system to their feet being firmly set in the community.
This begs another question: why was the golden age of challenges followed, after Law 180, by a long period of theoretical deadlock and dragging delays in the new circuit outside the asylums? One certain answer to this second question comes from the unanticipated consequences of the chain of raising the stakes, which had nevertheless led to the closure of asylums. Let us try to reconstruct how it all unfolded.
In the late 1960s, it rapidly became clear to those working at the front line of psychiatric modernization that the problem of backwardness in Italian psychiatry was not only the disgrace of ‘asylums like concentration camps’, nor would it be solved by simply closing them. In this phase, the dialectic still involved stressing a project’s positive traits, and rejecting what was antithetical to it. The therapeutic rapport was only possible ‘outside the walls’, with the institution being rejected.
As early as 1968, Jervis suggested that this widely shared conclusion was too general, and maintained that rejecting the institution involved not the rejection but the modernization of the doctor’s role (a view not widely shared). In the movement, a dialogue on impassioned reformism developed. For all concerned, focusing on the community meant allowing ‘the doctor and patient to face each other and seek new roles, forgetting that one is the doctor and the other the patient’ (Jervis, 1968: 315). Yet for Jervis, ‘forgetting to be a doctor’ did not mean the elimination of the therapist, ‘who is called upon as such by the suffering itself’ (p. 315).
It was really nothing more than a change in syllogism. What underpinned the innovation in the 1960s may be summarized as follows: (a) psychic suffering of single individuals cannot be viewed apart from the pathogenicity of the institution and (b) alleviating the psychic suffering consists in restoring the patient’s meaning-giving function, ergo (c) recovery of the capacity of a patient to attribute meaning to his surroundings is possible only in a doctor–patient peer relationship outside the asylum safety-net.
Something changed with the passing of the decade on the winding road from Gorizia to Trieste. Perhaps it was the need to remain in line with the bywords of those movements, struggles and protests which increasingly used up resources and energy so that the Trieste project could survive. This was the moment in which a shift took place in the argumentation, no longer against the contradictions of the asylum but against those of society.
Only by bearing in mind the extreme ambiguity of the situation we are experiencing will we manage to avoid the construction of a new ideology: that of the open hospital, of therapeutic communities, proposed as a solution to the problem of mental health. Our reality is rooted in profoundly contradictory soil, and achievement of the patient’s freedom must coincide with achievement of freedom for the whole community. (Basaglia, 1973: 11)
The new approach corresponded to a new syllogism: (a) psychic suffering of single individuals cannot be viewed apart from the oppression of an unjust society and (b) treatment of suffering lies in empowering the patient to have alternatives to action, ergo (c) the patient’s conquest of freedom is only possible palingenetically, with the conquest of freedom for the whole community. The key to interpreting this change lies in the sense of the word ‘freedom’, which now became the availability of alternatives rather than restoring the capacity of a patient to attribute meaning to his surroundings.
Thus, the 1970s witnessed a quantum shift in critical thinking and in grammar, both being transposed from concrete subjects to abstract categories: it was no longer the person who suffered but society, which was unfair; no longer pain but struggle. Was all this part of the Zeitgeist of the 1970s? Undoubtedly. Yet if conformism and the drive to belong may be ascribed to the foot soldiers of the revolution, the responsibility of the protagonists of that season weighed heavy. As early as 1979, Gianfranco Minguzzi drafted the following critique of that period: ‘We talk too much and too often to have the time to come up with ideas which are a little different from those just mentioned, to have the time to metabolize the events which unfold around us’ (Minguzzi, 1979: 268). However, to understand the change in register in the dialectic of the movement, it is essential to take account of an aspect that is far from secondary. The pincer movement against the asylum – to empty from within, and to intercept from the outside – required an outlay of economic resources and human energies which the Trieste provincial authority would be unable to supply. The ‘killing’ of asylum psychiatry and its ‘resurrection’ in the community was an improbable sequence in nature, insofar as it involved ‘the emergence of ordered structures far removed from the system’s [previous] equilibrium conditions’ (Micheli, 1984: 15). Like Prigogine’s ‘dissipative structure’ in thermodynamics (Prigogine and Nicolis, 1977), the anti-asylum psychiatric experiments – and every other organization shifting towards a different system – would succeed in achieving the objective only if, by opening up and interacting with its own environment (the region, the community), they drew energy from it to grow. Demolishing the walls of an asylum and opening it to the outside community required far more resources than routine bureaucratic structures (whether asylums or ministries). Hence they had to absorb energies from their own ‘environment’ to add to routine resources.
How did Basaglia manage to cope with this need? In two intimately connected ways: on the one hand by attracting and involving voluntary, motivated staff worldwide, and on the other by stirring up, within the international scientific community and public opinion, a strong sense of participation and empathy with what was happening in Trieste. To achieve these two results, Basaglia activated two strategies, one conscious, the other less so: taking advantage of communication and gradually raising the stakes, to keep the attention well held.
Let us start with the first strategy. Why did volunteers come to Trieste from many parts of the world? The care devoted by Basaglia to communication and image channelled the expectations of a targeted public sphere. As Pivetta (2012: 129) wrote succinctly: ‘Basaglia was a marvellous image man . . . . He was all too aware of the value of communication.’
Basaglia was not the first Italian psychiatrist to understand the importance of pandering to public opinion. According to Babini (2009: 137–8), when the film ‘The Snake Pit’ – a crude Hollywood representation of the ‘asylum regime’ in the USA – was shown in 1949, the Italian psychiatric community closed up like a clam, fearing a tidal wave of discredit on institutional psychiatry. Ugo Cerletti (1949) supported the full airing of the film, underlining the strategic role that the media could play in influencing public opinion in favour of mental health reform. Cerletti understood the potential force of the new lever of mass communication; Basaglia used it, fully aware of this.
‘Mad’ strategy: raising the stakes and mutations in objectives
The second strategy was to retain the attention of the media and the scientific community and maintain the level of attraction towards innovative yet dissipative structures. An effective way of doing this was to gradually raise the level of objectives given to the movement. Thus, there was a shift from an argumentation strategy based on targeted rejection (‘the institution’), with limited objectives to pursue and means to do so, to a generalized denial or ‘disconfirmation’. Alongside confirmation and negation, disconfirmation is the third logical procedure of human communication, which allows an individual to exit from a cul-de-sac, not rejecting an object but denying value to the framework of (practical or symbolic) reference which contains the object. ‘While rejection amounts to the message “you are wrong”, disconfirmation says in effect “you do not exist”’ (Watzlawick, Beavin and Jackson, 1967: 192).
The transition from rejection to disconfirmation occurred in the second half of the 1970s, with the unexpected and traumatic realization that the newly mentally ill were becoming chronic outside the asylums. At times, this trauma was resolved by shifting from the just fight against asylums to the rejection of a ‘community’ itself viewed as ‘asylumizing’, with its quarters for the calm and for the agitated, for practitioners and for patients, for the old and for the young, with its warders and regulations, its specific treatment modes; control or abandonment, it seems there was no way out.
Either asylums or ‘asylumizing’ communities: there was no third way. Espousing such an argumentation strategy was consistent with an inevitable constant raising of the stakes – as in the game of ‘chicken’, a configuration of game theory which many of us recognize in a famous James Dean scene in the film ‘Rebel without a Cause’ (1955). Two teenagers decide to settle a dispute by way of a near-death experience. Each races a car towards a cliff, and the first to jump out of his car is the chicken and – by universally accepted social convention – concedes the object in dispute. The second to jump is victorious, and appropriates what is at stake. If neither jumps, a fiery death is assured – quite a negative payoff, for both players.
During the Cold War, it was thought that peace in Europe – that is, the difficult point of equilibrium in the game – could be guaranteed by the strategy of ‘mutual assured destruction’, the
The feeling that the bidding game might not have a desirable outcome began to spread among the more mature and reflective members of the anti-asylum movement, who perceived an increasingly clear-cut detachment from the concrete reality of mental suffering: ‘For some time I have been struck (I cannot say surprised) by the gap between what is said and what is meant or what one does. At times … I even think that the order of the discourse is pure fiction, whereas the reality, action or simply the thought is elsewhere’ (Minguzzi, 1979: 261).
Minguzzi was not the only one of Basaglia’s supporters and ‘fathers’ of the anti-asylum movement to appear to have lost his way. Michele Risso, shortly before his death, finished a book on the connection between the uprooting of migrants, ‘nostalgia’ and mental illness. Risso (1982) recalled the Heideggerian metaphor of the rock climber stuck half-way up a cliff face, where ‘it is no longer possible to go back or continue, where disorientation and fixation make ascent impossible’, citing in particular Binswanger’s (1978: 18) ‘situation of Verstiegenheit, this present which appears to lack an escape route’. When Risso (1982) talks about the ‘disproportion between the breadth of experience and the depth of the issue between something and something else, between the capacity to construct and the capacity to climb up’, perhaps he leads us to a second plane of reference: that of psychiatric denial which, taken to the limit, also proves to have no escape route half-way up the cliff face, and one is unable to climb up or down. In his final years, Risso personally experienced the deadlock of Italian anti-institutional psychiatry: no longer being able to go back or forward.
Competition for dominion: taboo, fatwah and the courage to be homo duplex
The deadlock in the climb affected the nature of communication – not with the rest of the world, but within the movement. Pivetta (2012: 245) later explained, with disenchanted realism: ‘Propaganda perhaps, yet it breaks the isolation, stirs public opinion, creates currents of utopia but also of reforming concreteness, against many enemies.’
‘[A]gainst many enemies’: here was a third escape route for psychiatric modernization, that is, close ranks by warning of the risk of deviation from the line. This meant not only head-on opposition to the old asylum psychiatry, but also ‘fuoco amico’ in search of an enemy, in order to close ranks by driving them to brand the opposing party as a Schmitt (1981) ‘non-value’. Thus it is explains why the sights were raised to take aim at a ‘certain alternative community-based psychiatry’ that ‘rationalizes suffering’, or against the sector as ‘new clothes for the dominant psychiatry’ (De Salvia, 1977: 33). The target of this criticism was not the sector, but the experiments in which community-based work had gained the upper hand over that within the walls, as in Reggio and Perugia. Jervis (1976) responded in kind, attacking therapeutic spontaneity: A psychiatry based on ingenuous common sense, on ignorance of therapeutic techniques (or on the pathetic illusion of ‘destroying all the techniques’) or, still worse, on more common after-hours publicity-seeking paternalism of ‘the mad on a special visit’ or taken on a boat excursion, not only is short of breath, but contributes to creating illusions and distracting ideologies. (Jervis, 1976: 9)
The higher the stakes, the stronger the temptation of the fatwah became, and the more extensive would be its power. The stake of asylum closure did not require the indiscriminate slaughter of bodies, but the excommunication of minds, being shielded behind a passage from Gramsci’s prison notebooks, reported in Crimini di pace (Basaglia and Basaglia Ongaro, 1975: 3 Intellectuals are commissioned by the dominant group to exercise subordinate functions of social hegemony and political government, i.e. a) of the ‘spontaneous’ consensus given by the large masses …, b) of the apparatus of state coercion which ‘legally’ ensures the discipline of those groups that do not ‘consent’ either actively or passively… .
In many contributions to Crimini di pace, a new awareness seemed to emerge among ‘practitioners’: that of being (only) officers of consent, where ‘the consent of the controlled and segregated is obtained a priori via mystification of the therapy and rehabilitation’ (p. 5), bracketing not the illness but the suffering. The book collected together some of the most widely aired stories of ‘traps of oppression’ in the West. Many of the writers ‘toed the line’ in terms of thinking and linguistic code. No one withstood normalization, except for a few who had already dialectically smoothed the harshness of the fatwah in the book, for example Castel (1975). Some contradicted themselves, at times adapting to the prevailing linguistic code, at other times keeping their distance, embodying the problematic status of homo duplex (Durkheim, 1912). This applies to Michele Risso in two essays in the last year of his life (Risso and Repetti, 1981, cf. Frigessi Castelnuovo and Risso, 1982), and to Carlo Manuali (1979, cf. Manuali, 1978). Finally, some were opposed head-on, in real time – ‘better to deal with an honest official than with a false revolutionary’ (Jervis, 1976: 11) – before formulating, post hoc, a scathing condemnation of that sort of Julien Benda’s (2012) ‘trahison des clercs’, which was the hallmark of many intellectuals in those years.
They were the years of normalization of reflective elites, although reducing the prospects of this movement. Basil Bernstein (1971) distinguished two codes of language: a restricted code, shared by people of the same circle, abbreviated and syncopated, which creates inclusion and a sense of belonging, but entails – strictly consequentially – a collapse of project capacity; and an elaborate code, more universal and able to ‘stand on its own two feet’. Bernstein was referring to the uneducated majority of youth, but the curse of a restricted language code also applied to cohorts of ‘practitioners of psychiatry’ starting their careers in the 1970s. The race to limit the language to a stereotyped, mandatory code could not but produce, in the long term, the drying up of project effectiveness – scientific and practical – of generations of techniques involved. This is perhaps what happened.
From the pre-1978 unfinished revolution to two major challenges (not yet) met by Law 180
Acknowledgement of a new chronic phase and its consequences
There are defeats and normalizations at the end of every revolution, even when it is won. All things considered, Law 180 has weathered the impact with reality quite well, but obviously not without a few shortcomings.
The enlargement of the circuit of services and facilities coping with mental illness (private, public, for short-stay or long-stay) led to an increase in the numbers of those in search of treatment moving from one agency to another; a chronic phase at asylums was replaced by a chronic phase of commuting between agencies, which is manifested in a large increase in the number of relapses. The number of elderly, long-stay patients decreased due to the block in hospital admissions, but they were replaced by an army of new long-stay patients, characterized by an intermittent but prolonged rapport with psychiatric services. The law reform resulted in an increase in the number of in-patients in short-stay wards in general hospitals, especially with the major psychiatric diagnoses. Many residential facilities that opened in the 1990s are equipped for long stays.
In turn, the change in service users with time led to a change in approach of the services themselves. One of the cornerstones of the philosophy of reform atrophied: the use of home visits for therapeutic purposes. The exponential increase in the number of interventions by the health services mostly consisted of intra moenia action. The entrenchment of services ‘within the walls’ also standardized home-based care, which was, increasingly often, routine administration of drugs performed by paramedics. The very term ‘home-based care’ became misleading, because this was, mainly, routine standardized management of psychic disorders which, by definition, should not be treated as routine or standardized. Scotti (2009) speaks of an ‘increasingly defensive medicine’ in which ‘to avoid responsibility for omission of custodianship, omission of care will be developed’. This scenario was already prefigured in Jervis (1977: 39): We were pushed with force (under the pressure not of enlightened central administrators, but of those at the periphery, preoccupied with following bureaucratic guidelines) into quantitative state support: many clinics, many patients, many allowances, many tranquillizers, fewer home visits.
Yet behind this strategic deceleration, there were two real changes in Gestalt.
Retreat from community-based to area-based psychiatry
Behind the regression of area measures to a mere defensive bureaucratic strategy, Olivetti Manoukian (2008) saw the responsibility of ideology as being a ‘response to needs’, the hallmark of the golden age of psychiatric innovation, and one which identifies its fundamental task as the satisfaction of user needs. If a psychiatric service within a community is reduced to a machine for routine standardized provision, the service will be disconnected from its community of reference. As expressed by Scotti (2009), ‘there are no longer services for an area (i.e. devoted to a certain community) but in an area: the paradigm of community-based psychiatry which succeeded that of asylum psychiatry has disintegrated’.
Corlito (2007: 144) also wrote of the same need (‘there is community-based psychiatry while there is no community-based mental health’), with a surprising note of regret for the untimely demise of Carlo Manuali, the only person in the golden years of the new psychiatry who had reflected on the sense of the word ‘community’: … place of the family, of men, of women, of children, of the elderly. Of the infirm. Place of extreme concreteness and maximum abstraction at the same time . . . . Area within an area, invisible space, which traditional services and ideological apparatuses continue to keep secret. (Manuali, 1978: 33)
Yet Manuali had no voice in his own time. Since the anti-asylum experiments freed patients from their traditional places of confinement, there is today sometimes a tendency to reduce the management of suffering to mapping ‘circuits’ of regulatory and control agencies. The Department of Mental Health is compared to a knot of macramé, woven together by patients, family members, practitioners, local authorities and associations. As one of the pillars of the philosophy of the reform weakens – the therapeutic use of extra moenia interventions – it is the responsibility for the demand for area-based treatment which begins to waver.
Removing the focus of crisis intervention
Shifting the centre of gravity outside asylums brought to the surface, in experiments in the late 1970s, a new setting in the practitioner–patient relationship, which could neither be standardized nor routinized. To make the relationship effective, the need was felt to bring contact forward to the onset of the crisis that causes the person to come into contact with the services. The evident advantage of this model ‘is that the crisis can be managed where it occurs; the drawback lies in having to operate in a setting in which there is no chance of having the mastery or certainty of emergency treatment’ (Ciompi, 1999: 98).
In the USA, in 1942 almost 500 young people died in a fire at a Boston nightclub, the Cocoanut Grove; the survivors were given psychological assistance to help them find their way in the jungle of sentiments of guilt, grief and aggressiveness. Two years later, Lindemann (1944) published the results of a study on approaches to coping with grief in a catastrophe, as adopted by these survivors. His observations led, at the end of the decade, to the opening of the first Crisis Intervention Centre.
Twenty years later, Gerald Caplan (1964) proposed a model of intervention and carer–patient relationship, since then taken as a starting point for practice. His model is structured in six steps. The second block of the sequence (re-activate strategies of habitual behaviour and restore comparison with reality; seek new solutions; carry out a retrospective analysis and draw up a budget) fell within the normal rehabilitating routine. However, the first block involved a major breakthrough in how to conceive intervention without reducing it to mere containment, whether physical or pharmacological. Caplan invited practitioners to understand the reason for the crisis and to elaborate a definition shared by patient and carer, with each party opening up and expressing their respective sentiments.
In Italy, outreach experiments, with a specific team of consultants, or taking over an office in the Accident and Emergency (A&E) department, remain isolated cases, like that of Cancrini et al. (1981). In contrast, this approach became a well-established practice in English-speaking countries, starting from the research of Leonard Stein and Mary Ann Test (1978) in the psychiatric hospital of Madison, USA, and their Programme in Assertive Community Treatment, now the model of case management most widely adopted in treating mental disease (Burns and Firn, 2003: 9ff.).
In planning their intensive intervention model, Stein and Test had in mind Caplan’s approach, with the fulcrum being post-crisis intensive assistance. However, do the US model of Assertive Community Treatment, the Mobile Support Teams common in Australia and Canada, and the team of Assertive Outreach launched in London satisfy the first three steps of Caplan’s sequence? Do they respond to that need to ‘understand, elaborate together a response, open up and express their respective sentiments’? In reality, taking care of demand for therapeutic support presupposes a ‘philosophy of listening’:
Crisis intervention was the most costly item in the budget of several advanced services. The intensity of the intervention required a deployment of forces alongside the patient, to assist and control his/her social disruption. Experiencing a crisis together with the patient, avoiding any outrageous actions that might give him/her a public stigma, attending while his/her aggressiveness unfolded, involved a great psychological and physical effort. Yet the outcome was extraordinarily positive: ‘they understand that you understand; and this is already therapeutic’ (Carlo Manuali, interviewed by Micheli, 1982: 114). Scotti and Brutti (1981: 164–5) – companions in the rich experience in 1970s Perugia – arrived at similar conclusions: Psychotic crises are either tackled, assumed and elaborated at their onset, or they are destined to be sucked into the patient’s subconscious. Accepting the cancellation of the psychotic experience is a choice that excludes the possibility of an evolution and that leaves the patient totally disarmed against the risk of the phenomenon being repeated.
Reducing crisis intervention to home-based interventions strictly to ‘establish the first contact, subsequently entrusted to various institutional moments’ (Gozzetti and Cappellari, 1993: 207) is no more than or different from the duty-bound rule of triage, or rapid sorting of patients according to the form and intensity of their discomfort. Yet in this organizational model, demand for the patient’s therapeutic support is not heeded. There is no exposure to risks of confrontation on ground that is familiar to the patient but unknown to the carer, far from the protective niche of psycho-social centres or of any other centre in a community-based network. There is no opening up of an unrepeatable space of empathy between patient and carer (‘he/she understands that you understand, and this is already therapeutic’), which opens doors to possible ways of resolving the crisis.
Footnotes
Funding
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.