Putting Diagnosis Into Brackets: Franco Basaglia,Radical Psychiatry,and Contemporary Mental Health Services

Introduction

At the time of writing, the death has just been announced of the leading American psychiatrist, Robert Spitzer (http://www.nytimes.com/2015/12/27/us/robert-spitzer-psychiatrist-who-set-rigorous-standards-for-diagnosis-dies-at-83.html). He had a key role in the progressive moves that resulted in the American Psychiatric Association declassifying homosexuality as a mental disorder. Spitzer will always be associated with the development of DSM 3. The compilation of DSM 3 occurred at a time when psychiatry was experiencing an existential crisis of confidence. Both the scientific basis of psychiatry and area of medicine and the institutional practices of the discipline came under critical scrutiny. The response of the psychiatric profession was such a powerful one that the roots of the criticisms of the anti-psychiatry have been subsumed in tokenistic approaches to service-users or lost entirely. Two important recent works—Scull (2015) Madness in Civilization: A Cultural History of Insanity and Foot’s (2015) The Man who Closed the Asylums—highlight the barriers that had to be overcome in the struggle to humanize mental health provision. Scull’s magisterial study of societal responses to madness demonstrates that there appear to be few, if any, indignities that societies have not been prepared to inflict on citizens in the name of mental health treatment. Foot’s fascinating study of Franco Basaglia makes very clear the essential political nature of the structure and delivery of mental health care. There is an implicit danger that, in examining the current crisis in community mental health services, the failures and abuses of the past are assigned to history. The response to the current difficulties in mental health service has to frame the debates in terms of questions of social justice if it is to be successful.

The 1960s Challenge to Psychiatry

Before considering the ongoing relevance of Basaglia’s intellectual career and work as a psychiatrist, it is important to place his work in a broader context. A note on the use of terminology is required here. The early 1960s saw a number of significant and highly influential works which have similar themes: the questioning of power—particularly that of the psychiatric profession, challenges to the supposed scientific neutrality of diagnosis and the dehumanizing nature of the asylum regime. These works include the following: R. D. Laing (1959): The Divided Self: A Study of Sanity and Madness, F. Fanon (1961): Les Damnés de la Terre—preface by Sartre—later published in translation as The Wretched of the Earth, M. Foucault (2006) : Folie et deraison: histoire de la folie a l’age classique—later published in translation as Madness and Civilisation, Szasz, T. (1963) Law, Liberty and Psychiatry. These radical critiques of psychiatry have come to be viewed under the umbrella term anti-psychiatry. The term anti-psychiatry is a problematic one—both Szasz and Laing disowned the use of the term. As Crossley (1998) notes anti-psychiatry is a loose term. Thinkers who were given this label often held contrasting or conflicting views. The radical views of Foucault have little in common with Szasz’s libertarianism. It best understood as a label for a series of critiques of 1960s psychiatry.

Anti-psychiatry can only be fully understood within the broader context of the social movements of the 1960s counterculture. Hobsbawm (1994) highlights that the postwar period was one of optimism, there was a widespread belief in the possibility of social progress and reform. These broader cultural tropes included challenging and questioning the basis of authority and power. As Nye (2003) argues, psychiatry has always had a role in the management of oppressed and marginalized groups—women, people from racial and sexual minorities. When the sexism and racism of the postwar period came under pressure, attention was also focused on the role of psychiatry. The challenge to the asylum regime can thus be seen as part of a campaign for civil rights by those experienced legalized and institutional discrimination.

One of the great novels of the period, Ken Kesey’s (2005) One Flew Over the Cuckoo’s Nest is a literary exploration of the corrupting influence of asylums. Kesey’s novel remains one of the most influential cultural portrayals of mental health services. The novel chimes with the themes of one of the most influential works in Goffman’s Asylums (1968). Goffman was concerned with the way that “total institutions” function. In such institutions, he argued that there was a strict divide between staff and patients. The staff exercised control over all aspects of the patients’ daily lives. The net result was that the organizational needs of the staff took precedence over any therapeutic needs of the individual patients. The processes and rituals of admission create the “spoiled identity” of the psychiatric patient. Goffman argued that patients need to maintain some sense of self, which they do by transgression or rule breaking—often in very minor ways. The staff then interpret these transgressions as evidence of illness or a lack of ability to stay within societal norms as justifying the original decision to admit the patient. This process ensures that the individual remains incarcerated. Rosenhahn’s (1973) famous pseudo patient experiment emphasized once someone has been diagnosed with a mental illness, there is a strong impulse to view all their behavior through the prism of that diagnosis.

There are clearly a range of critical perspectives on psychiatry (Foucault, 2001; Scull, 1977; Laing, 1959, 1967; Szasz, 1971). It should be noted that Szasz stands apart here. He is essentially a right wing libertarian committed to a small state. He views mental illness as a form of social malingering—his views are neatly summed up in the 1995 article Idleness and Lawlessness in the Therapeutic State. Laing has much more in common with existentialism—he did not share Szasz’s view of the mentally ill. They were victims of the forces of an uncaring capitalist society. Within the other perspectives, there are a range of views. However, a number of common themes can be identified. The first is a questioning of the assumption that mental illness exists in the way that psychiatrists and medicine suggests. In these critical accounts, there is a skeptical approach which sees mental illness as largely socially caused by the injustices of a capitalist society: poverty, racism, gender discrimination, and social inequality. Whereas treatment is seen as a therapeutic intervention in progressive accounts, from a critical perspective, it becomes part of the means by which capitalist society maintains social order and manages difficult populations (Cummins, 2012).

For Foucault (2001, 2003, 2008), the investment in the asylums was justified because of the role they played in social control not because of the humanitarian zeal of the builders of these institutions. Both approaches argue that what later came to be seen as the failings of the asylums: cruelty, squalid living conditions, and inhumane treatment are, in fact, inherent features of their design. For example, while most commentators see the development of the retreat at York as a progressive measure, Foucault (1982) essentially sees it as the exercise of power by other means. He describes the “moralising sadism” of the Yorkshire Retreat and its Quaker founders. In Foucault’s terms the outcomes for the inmates are the same, exclusion and subjugation. Stone (1982) argues that there is nihilism at the heart of Foucault’s thinking that means that he sees all relationships in terms of power or subjugation. Stone concludes that this makes it impossible for Foucault to accept that there might have been a humanitarian root to the development of these institutions.

Franco Basaglia

One of the key virtues of Foot’s (2015) outstanding biography of Basaglia is that it places his work in the context of Italian intellectual and political arguments of the postwar period. Foot argues that Basaglia’s work is part of a Gramscian, radical, and anti-fascist tradition which reached its height of influence in the turbulent politics of 1968. Basaglia can be understood as a charismatic intellectual guru, who worked in the field of psychiatry but might have easily had a role in other areas. His most famous contribution is the passing of Law 180 (Basaglia’s Law) which led to the restructuring of Italian mental health services and the closure of asylums. After his death at the age of 56 in 1980, his wife fellow psychiatrist Franca Angora, continued to campaign for reform to the Italian mental health system.

Foot’s nuanced portrait of Basaglia is a counterbalance to the extremes that portray him either as a secular saint or as a man responsible for destroying mental health services and putting the wider population at risk. In 1944, the student, Basaglia was arrested and imprisoned for his anti-fascist activities. After the war, he resumed his studies. A brilliant student, Basaglia, seemed destined for a glittering academic career. Any ambitions that he had in this field were thwarted by the bitter internecine world of academic politics.

In 1961, he moved to take a post as Director at the Asylum at Gorizia, and he remained there until 1970. He then spent a brief period in Padua before moving to Trieste in 1971 where he worked until 1979. He was head of mental health services for Lazio at the time of his death.

Gorizia is a small town in Northern Italy on the border with modern day Slovenia. This physical, political, and intellectual isolation meant that Basaglia was in a position of relative freedom to develop and employ a new approach to mental health services. An approach that came to be known as Psichiatria Democratica (Democratic Psychiatry). Basaglia was appalled by the conditions that he witnessed on his arrival at Gorizia. He stated that they took him back to his period of imprisonment under the Fascists. Primo Levy’s work (1991) was an enduring influence on Basaglia who frequently compared the asylum to a concentration camp. Levy rejected such comparisons. However, Basaglia was not the only one to make such a comparison. Scull (2015, p. 366) highlights that the images of male incontinent patients at the Byberry State Hospital taken in 1944 were not dissimilar to those about to appear in newsreel footage of the liberation of Auschwitz. The photographs were taken by Charles Lord a conscientious objector, who was sent to work at the hospital. As Scull notes that the next door ward for violent men was known to Lord and other attendants as the “death house.” Barton (1959) in describing the impact of “institutional neurosis” had made an explicit comparison between the psychological damage that concentration camp survivors and asylum patients had suffered.

Basaglia viewed the asylum as a morally, ethically, and therapeutically bankrupt institution. If the question was reform or revolution? The answer was clear—a revolution. He did not want to create an Italian version of therapeutic communities. He saw these as a liberal reformed version of asylums but failed institutions nevertheless. Oregano had translated Goffman’s Asylums. As Director, Basaglia began moves to dismantle the total institution. He gathered around him an equipe of similarly enthused radical pioneers. Foot outlines the incredible commitment and energy that was expected and demanded from the staff. In a sense, Basaglia has been banished to Gorizia. It was certainly not expected that it would form the base for a radical challenge to the wider psychiatric profession. Previous directors had presided over regimes of benign neglect. The focus was on a relational rather than a coercive or custodial approach. The reforms at Gorizia included a series of open meetings for “patients” and staff as well as the end of using ECT. Basaglia saw the reforms as part of much needed wider social reform movement. Gorizia was very much in tune with the radical anti-authoritarian spirit of 1968. Foot argues that the asylum was one of the key sites of the 1968 protests emphasizing that the reform of mental health services was not a narrow technical issue. The reforms are part of a clear political project. L’Istituzione Negata (The Institution Denied) a collection edited by Basaglia which outlined the work at Gorizia was widely read. In addition, a TV documentary Sergio Zavoli’s The Gardens of Abel was shown in Italy in 1969. Zavoli a left wing Catholic was broadly sympathetic to the thrust of the reforms and the film reflects this.

As Foot (2014) notes events at Gorizia reflected the broader political movement of 1968 at its best and worst. The radical shift in attitudes that included the recognition of the fundamental human dignity of those incarcerated in the asylum, the removal of many of the casual brutalities and indignities of daily life, and a focus on relationship building, all stem from the anti-authoritarianism of the 1968 protests. Against this, the new regime reflected a number of the weaknesses of the protest movement. These include a focus on almost interminable theoretical debates.

As with the policy of community care in the 1980s and 1990s (Cummins, 2010), damage was done to public standing of the reforms by violence committed by patients or former patients. Giovanni Miklus, on day release from Gorizia in 1968, killed his wife with a hammer. Basaglia and one of his colleagues were accused of manslaughter, although both were eventually cleared. In February 1972, Giordano Savarin murdered both his mother and father after he had been released from the asylum in Trieste where Basaglia was the director. Basaglia and another colleague were again tried for manslaughter and, again, both were cleared. As with similar events in the UK, the coverage simplified the complex nature of these events in attempt to discredit the basis of the whole reform movement.

Foot (2015) concludes Basaglia and his work has been consistently misinterpreted in the English-speaking world. His magisterial biography is likely to change this. As he notes, two leading historians of psychiatry Porter (2002) and Scull (2011) make a number of factual errors or marginalize his work in their accounts. These errors are partly due to the lack of English translations of Basaglia’s work. As noted earlier, there are two poles of interpretations. At one extreme, Basaglia is seen as a Gramiscian Marxist theoretician—a criticism in itself—whose ideological beliefs allowed him to condone patients being made homeless. At the opposite end, Basaglia and his work at Trieste has taken on an almost mythic status. As Foot (2015) nuanced analysis shows both extremes are essentially caricatures that obscure the potentially ongoing significance of his work and ideas.

Contemporary Mental Health Services

The origins of community care lay in an attempt to improve the care of one of the most marginalized groups in society. By the 1980s, it was clear that the asylum regime was coming to an end. The reasons for the shift toward community-based mental health services are complex (Pilgrim & Rogers, 2013). The challenges to psychiatry outlined earlier were an integral part but other factors such as the discovery of new medications and treatments, changing social attitudes, and wider government policies all played a role. In England and Wales, the NHS + Community Care Act (1990) made clear that the economic policies of the government of the time meant that new funding arrangements were demanded.

It is impossible to separate institutionalized and community-based responses to mental illness. Scull (2015) suggests that the past 40 years should not be seen as a departure from patterns of provision. It is the period of the asylum that represents a departure from the abandonment of groups of the poor mentally ill and private provision for the wealthy. The policy of community care can be seen through this prism as a modern variant of long standing approaches. The impulse behind community care was to improve the standards of mental health provision. Even in the most radical work, such as Laing, part of the recovery process involves a period in a therapeutic setting of one sort or another.

One of the most important arguments put forward in support of community care is that prolonged periods of institutionalized care are in and of themselves damaging. Alongside this, it is argued that services need to exist to intervene at early stage to provide support to those suffering from any form of mental distress. This is a public health model of service provision that ideally develops tiers that will meet individual and community need. The asylum system resulted in a complete imbalance in that services such as they were almost all concentrated in this sector. The focus of modern mental health services is similarly unbalanced. The actuarial risk dominated model of service provision focuses on smaller population groups. There is a danger that this means that the social determinants (http://www.who.int/social_determinants/en/) of and the impact of mental illness become obscured or marginalized. This focus on audit, compliance, and regulation has been termed bureau-medicalisation (Nathan & Webber, 2010).

In England and Wales, the media portrayal of community care in the 1990s have a very clear impact on the loss of popular support for the policy. This legacy remains today. The focus of the media was on cases of homicide or serious injury. The issue was thus cast in terms of law and order and public safety rather than social justice (Author, 2010, 2012). The response from Government in England and Wales was a series of more coercive policies. The thrust of mental health policy in the past 15 to 20 years can be viewed as a political response to the agenda created by a media focus on homicides and other serious events. A range of policies and legal changes such as the Care Programmed Approach (CPA), Supervised Discharge, Supervision Registers, Modernising Mental Health Services, and National Service Frameworks concentrated on essentially bureaucratic responses of audit and surveillance of service users and workers culminating in the introduction of Supervised Community Treatment Orders in the reformed Mental Health Act (2007).

Moon (2000) argues that there is a geographical paradox at the heart of the development of community care services. As several commentators note (Philo, 1987; Scull, 1989), the asylums were based on seclusion and concealment. The institutions served to cut off this group from the wider population. As Goffman (1968) suggests the experience of being a resident and the stigma attached were potentially so damaging that there were huge barriers to the resumption of former roles. The move toward community care has not challenged this. For a variety of reasons, economic, social, and political, the modern communities have not proved up to the task of providing humane and effective services for those with the most complex needs. The overall picture is a very bleak one, so bleak in fact that the asylum system appears to have some advantages in that it was, at least, a community of sorts (Gittins, 1998).

Discussion

The justification for the development of community-based mental health services is based on moral and clinical arguments. It is a combination of idealistic and pragmatic approaches. The idealism can be seen in the human rights arguments that were put forward. Community-based services, it was argued, would be by definition more humane. Lamb and Bachrach (2001) argue that this was based on a moral argument with little evidence to support it. Clearly, the supporters of community-based mental health services did not argue that asylums should be replaced by jails. Deinstitutionalization, a progressive policy aimed at reducing the civic and social isolation of the mentally ill, did not achieve its aims. Wolff (2005), Moon (2000) and Knowles (2000) shows the ways that asylums have been replaced by a fragmented and dislocated world of bedsits, housing projects, day centers, or increasingly, prisons, and the criminal justice system. This process of “transinstitutionalisation” incorporates the ideas that individuals live in a community but have little interaction with other citizens and major social interactions are with professionals paid to visit or increasingly monitor them. Other social outcomes such as physical health, which can be used as measures of citizenship or social inclusion, are also very poor indicators. Kelly (2005) uses the term structural violence, originally from liberation theology to highlight the impact of a range of factors including health, mental health status, and poverty. These trends are likely to increase as the state withdraws from even the most basic forms of welfare provision (Wacquant, 2009).

Healthwatch’s annual national survey, based on reports from 152 local groups, has identified mental health as its number one issue for 2016 (http://www.healthwatch.co.uk/news/peoples-top-five-health-and-care-issues-2016). It is widely acknowledged that mental health services face a number of serious challenges. Like all public services, they face a period of retrenchment. The wider austerity agenda has a double effect. It reduces service provision at a time when demand is increasing. There is a now a significant and developing literature that documents the impact of austerity and the withdrawal of the social state (Bourdieu et al., 1999; O’Hara, 2015; Slater, 2012; Tyler, 2013). As Garland (2001), there has been a punitive turn in approaches to both penal and welfare policy. Mental health services straddle these two broad areas. As Hall, Critcher, Jefferson, and Roberts (2013) so presciently recognized, the response of progressive parties has been a form of populist social authoritarianism. New Labour under Blair is the prime example of this (Butler & Drakeford, 2001).

These trends have been exacerbated by austerity. The following example highlights the inter-relationship between poverty, mental health, and changes in Government policy. Barr et al. (2015) recently published research highlights the impact of the Governments Work Capability Assessment (WCA) scheme. The WCA is an assessment process that determines whether an individual is eligible for Employment and Support Allowance. There are three possible outcomes that the person is

Fit for work;

Unfit for work but fit for pre-employment training; or

Fit for neither work nor training.

Across England as a whole, the WCA was associated with:

590 suicides

725,000 additional prescriptions for antidepressants

279,000 additional cases of self-reported mental health problems

This is the context within which mental health services have to work. The pressures on community mental health and other services than work with people in crisis reached breaking point. This is explicitly acknowledged by the signing of the Mental Health Crisis Care Concordat (http://www.crisiscareconcordat.org.uk).

Conclusion

There is a danger of approach in Basaglia’s work as an interesting historical episode or period which no longer has relevance. Mental health services in England and Wales are as far from the community-orientated systems that Basaglia championed, as it is possible to imagine. As the pressures on services increase and retrenchment continues, the emphasis on coercive institutionalized care remains. The rather bleak analysis of the economic and political landscape that forms the backdrop to the current provision of mental health services would not seem to indicate that now is the time for a revival of interest in Basaglia. I would argue that the opposite is the case. Here, I am strongly influenced by the late Stuart Hall’s revival of the term, from Marx and Gramsci, of conjuncture. Conjuncture is simply a combination of events. However, Hall uses it as a tool for the analysis of the current political and cultural trends. Hall was seeking to move away from the rigid economic determinism of Marxism and argues that it is important to consider cultural developments. An economic analysis, Hall suggests, only takes one so far. Using Hall’s approach, forces us to look at economic and cultural factors.

Basaglia’s reforms took place during a period of relative economic affluence. However, an economic analysis does not fully explain the reasons for his initial success. As outlined earlier, his ideas were in tune with much broader cultural tropes and attitudes. I would argue if that the fundamental principles of the Basaglian approach that can be used by mental health social workers and others to form the basis for a restructuring of services. This is not to ignore the clear difficulties that currently exist. It is rather to suggest that there is a need to look for new ways of working. There are indications that approaches focusing on recovery models and the building of social capital and networks can provide alternatives to an over reliance on coercive institutionalized care (Newlin, Webber, Morris, & Howarth, 2015).

The achievements of Basaglia have been, to a certain extent, lost in the excesses—the interminable open meetings and the Maoist slogans. When we strip that away, we see that the most important messages of his work remain very relevant to contemporary mental health services. As Foot (2015) notes, one of Basaglia’s greatest achievement was to reassert the fundamental human dignity of the patients at Gorizia and Trieste. A relational approach was to be the key to revolutionizing the regime. The asylum at Trieste was closed and is now a public park. In England and Wales, by contrast, many former asylums have been converted into those modern temples of consumerism—apartments or supermarkets.

Foot (2015, p. 238) concludes his analysis as follows

The basis of his work lay in existentialist philosophy – in particular the work of Jean-Paul Sartre. He believed in trying to understand mentally ill patients by building up a relationship with them, and by ‘putting into brackets’ the diagnosis that prevents a proper relationship being formed.