The Man Who Closed the Asylums: Franco Basaglia and the Revolution in Mental Health Care
by John Foot
When Basaglia’s academic career reached an impasse in the face of
reactionary networks in Italy’s universities, he accepted a surprising position
as director of an enclosed and oppressive asylum in Gorizia, a small, out of
the way and very reactionary town, literally situated on the border between
Italy and Yugoslavia at the height of the Cold War. With staff who were actively
Fascist and a reactionary town council, the institution was expected to sustain
its unpleasant and often violent regime without scrutiny or question. From his
first day, Basaglia was determined to bring this regime to a complete halt, and
his first act was to refuse to sign approval forms for patients to be tied up
for the night. He had no support for this stand from staff, the profession
generally, from the politicians or from the people of the town. What he
achieved made him famous.
Basaglia was hugely influenced by
books. “...texts Basaglia came
across in the early 1960s, especially those by Erving Goffman, Frantz Fanon and
Michel Foucault. Goffman’s Asylums. Essays on the Social Situations of Mental
Patients and Other Inmates unpicked the perverse workings of what he dubbed
‘total institutions’, a phrase which would soon become a key part of the
Basaglian lexicon. Foucault, meanwhile,
provided a historical and philosophical focus on the workings of asylums and a
theoretical and methodological approach to the study of madness (The History of
Madness) and the containment of deviance. Both of these books first appeared in
1961, the year Basaglia took over in Gorizia...” [p30] “Laing’s classic study The Divided
Self came out in 1960, although it took some years for it to become a seminal
text.” [p34] “Meanwhile David Cooper, a South African–born
psychiatrist, ran an open, experimental ward from 1962 to 1966 within an asylum
on the outskirts of London, and later described his experiences there in
another classic text, Psychiatry and Anti-psychiatry.” [p35]
Primo
Levi was a constant presence in Basaglian texts from the 1960s onwards. His
work was important to them. The Basaglias made sure their children read If This
Is a Man at a young age. It was a key text for their understanding of the
world, and the world they worked in. [p127] To Basaglia and to others, the most persuasive analogy to describe
contemporary mental”asylums” was that of the concentration camp. “Asylums looked like concentration camps.
They had high walls and bars, forbidding entrance-ways, long corridors, locks
everywhere. They cut the hair of their inmates, took away their clothes and
possessions and wedding rings, and gave them (sometimes striped) uniforms to
wear. Lobotomies were routine. Inside, patients were often tortured and
sometimes beaten, tied up, electrocuted, sexually abused, experimented upon,
denied basic human and political rights or even killed.” [p125] In Italian asylums, the analogy with the Nazi camps was further enhanced
by the reality that many of their employees and senior managers were committed
Fascists, with regimes stretching back to long before the Second World War. “Of course, Franco and
Franca Basaglia did not believe that the asylums were exactly the same as
concentration camps or death camps. If they had done, their position of
authority inside these places would have been untenable. They would have been
the equivalent of concentration-camp guards. The use of Levi was symbolic,
allegorical, a powerful political and literary tool, a provocation, and, at
times, a crude propaganda weapon.” [p129] Nevertheless, the movement
for change was brought to a head by individuals who, like Basaglia, saw what was happening within asylums as a
“vision of hell” and made the decision that they could no longer be tolerated.
It was
inevitable that any attempt at change would have a political dimension. Asylums
were, in any case, public institutions under the control of elected authorities
and regulated by a law dating back to 1908.
They existed in the form they did because this served a function for at
least some part of society. To secure change, the political parties and their leaders
would have to be enlisted.
The big asylums
were significant economically, with many people relying on them for a
livelihood and for a career. Colorno’s psychiatric hospital was a
city within a city, and was a vast political and economic resource for that
tiny town, able to support hundreds of jobs and services (and provide votes).
In fact, it was more or less the only large-scale source of employment in
Colorno itself. As Tommasini said, ‘The hospital was the only source of work,
the only “industry” in Colorno … the town lived off the asylum.’ [p325]
They
served a local population and it was local people who made up their
population. For better or worse, the
lives of people within and outside the asylums were interlinked in countless
important and often very personal ways. Not
every patient would be at all welcomed home and some were feared or hated, but
they were not non-people; they had identities. The media could and did play on fears that mad
people were dangerous, relishing any incident of violence that could be blamed
on such people. Conversely, there were people who would be shocked and
concerned to be properly informed of the fate of people they knew who were
trapped within these asylums. Mario recognized people and
was recognized by people.’ They had been his comrades in arms, both during and
after the war. He had fought by their side. They were his friends, and they had
ended up there. He knew they weren’t mad. What was going on? How had it come to
pass that ‘dozens and dozens of comrades, people who used to live in my
neighbourhood and who were well known to me’ were locked up in such a terrible
place? It was heartbreaking, just twenty
years after the triumph of the liberation struggle of which they had been part. [p312] Tommasini
had been in prison, and, like Basaglia, he saw the asylum as a scandal and its
inmates as people who needed to be liberated. He used the word ‘kidnapped’ to
describe what had happened to them. The people inside were prisoners who had
committed no crime. [p312]
It would seem that the town of Gorizia never
really adjusted to the radical changes imposed by Basiglia on their local
asylum. In Parma, Basiglia influenced a
mirror image of this process, in which political leadership imposed radical
change against the reactionary opposition of the professionals in their asylum,
establishing resources in the community – notably opportunities for paid
employment and independent accommodation – which simply rendered the asylum increasingly irrelevant. In some ways, Parma became the
opposite example to Gorizia. Most of the change that took place in Parma was
outside of the asylum. Inside, patients were still tied up and there was a grim
atmosphere of violence and oppression. [p317] In a third
region, Perugia, services were transformed in a collaborative effort, with new
community based services displacing the discredited asylum model. After
1965 Perugia was the setting for one of the most successful movements for the
reform of mental health care in Italy, and perhaps in the world. An alliance of
politicians, nurses, patients and psychiatrists managed not only to transform
Perugia’s huge asylum system, but also to set up alternatives to that system
across the Umbrian region. In addition, this process of rapid and radical
change was accomplished with the active participation of the citizens of the
city and the region. [p285]
We need to ask ourselves
this question: when a psychiatric hospital closes, what is it that opens up?
For while there is a celebration about closure, and the knocking down of walls,
and the throwing open of doors and gates, there is silence on what is opened
up.’ Brutti and Scotti [p298]
These changes did indeed impose challenges on communities and families,
to receive back and help care for liberated patients, and a number of tragedies
did occur, with great public alarm, but it was always evident to the people
responsible for closing asylums that alternative, community based services were
an indispensible part of the solution. The end of the asylum was only the
beginning of a revolution. For Manuali, the death of the asylum did not mean
‘the disappearance of madness, but [rather] a facing up to it’. [p305]
Indeed, Basaglia and his associates worried that excessive interest in
the way asylums were transformed ran the risk of implying that reformed asylums
could become the model for future provisions, a solution that would misrepresent
everything he stood for. He did not even
see Gorizia as a model for managing change, since it was generally so experimental,
tentative and gradual. He did not even
accept that Gorizia was a particular success. It was an interesting experience,
a learning process, not a model. ...everyone wants to know what to do,
what can be done … and this is another way of destroying an experience. I think
that today, I have become an institution … and I think that the people here
today want to know things from me, and discuss specific issues, but they are
asking me for something that I cannot deliver. [p456]
Basaglia and his associates moved out
of Gorizia and helped to manage much more radical and rapid transformations in
other (more progressive) parts of Italy.
Basaglia himself went first to Parma, where he was not really needed,
and then to Trieste. Much more than Gorizia, Trieste became a
concrete utopia, a place where transformation could be touched, experienced,
seen with your own eyes. Basaglia presided over all this with the experience of
Gorizia and Parma behind him. He wasn’t interested in creating another ‘golden
cage’, or a Maxwell Jones–like therapeutic community. All of that was
superfluous, a waste of time. The key work would be outside of the asylum, in
the city of Trieste and across the province. It was time not just to break down
the walls, but to construct something entirely new, an alternative to the
psychiatric hospital itself. [p414] Trieste’s
hospital was not just closed down, with speed; its whole raison d’être was
undermined, built as it was on separation, exclusion and silence. The period of
closure was noisy and joyful, and impossible to ignore. From a total institution,
built on its own rigid set of rules, violence and the idea of a closed world,
the Trieste asylum was transformed into an open, creative place, where freedom
and debate were more common than in the outside world, a model for change. It
had become an anti-asylum. It is now something else, an ex-asylum. [p430]
If asylums served political,
economic and social functions, they were also part of a wider network of
established institutions serving similar requirements and evoking similar
pressures both for and against change. ‘I used to think that various kinds of health institutions were necessary. The
mad in the madhouse, the abandoned kids in the orphanage, the old people in the
old people’s home. Basaglia taught me everything. I learned how to reject these
kinds of solutions, and look for others. I began to understand the real aim of
these institutions: to avoid dealing with more serious social problems. Health
assistance of this kind was an alibi.’ Mario Tommasini [p316] The asylum itself was just the tip
of the iceberg. Parma’s local authorities presided over a whole galaxy of
institutes, ranging from orphanages to places where handicapped, deaf, dumb and
blind children and others were sent, as well as decentralized asylums and a
juvenile prison. Historically, Parma’s problems had been expelled to the north
of its province, where they could be safely hidden away. [p310] Among other public institutions
with comparable webs of influence and powerful forces both for and against
social change, none were more exposed to scrutiny and conflict than the
education system, from schools to universities.
For Manuali, ‘Behind every
situation linked to madness, there lies a hidden plan of failed normality.’ ‘Mental illness’, he continued, ‘can be seen
in the institutions who legitimate marginality’. [p299] The fact is that Basaglia was working to
undermine one particular institution at a time when a whole array of factors were waking Italy up to a period
of transformational change, or at any rate demands for change, which peaked in
1968 and did not subside until the Eighties.
Basaglia’s initial focus and that of this book was to change psychiatry
and the treatment of mental health, and in Gorizia between 1961 and 1968 he
worked to this end without the backing of the politicians or the general
population of that dull town. In other
parts of Italy, similar transformations had different trajectories which the
book describes, some with political support and an alliance of professionals
with politicians, some with politicians fighting for change against reactionary
psychiatrists, but ultimately the point was starkly apparent – that just as
traditional institutions served the needs of their societies and their
political masters, so it would ultimately be impossible to secure the desired
transformations in the treatment of mental health without corresponding changes in society itself.
As Basaglia himself said
in 1977: ‘The plan assumes that there is already a democratic health reform in
place, a democratic culture. But in reality the people are what they are, the
doctors are what they are, as are the hospitals.’ [p455]
We were looking for an alternative to psychiatry, we wanted to explore the
possibilities and limits of a new way of doing things. In our society, however,
a real alternative to psychiatry can only be partly realized – in a specific
context and for a certain time period. Afterwards, especially if our work was
effective, it became ‘dangerous’ – and then the forces of repression intervened
to stop everything in its tracks, or to reintegrate and neutralize things
within the system. All of this was inevitable and we knew that this was the
case, but we have all learnt a great deal during this long march. [p466]
One theme
throughout this book is the “dangerous” nature of Basaglia’s work and
thought. During the Sixties and beyond, radical
themes in psychiatry were picked up, amplified and elaborated as a central
component of the immense social upheavals which peaked in 1968, not only in Italy
but globally. It suggests, in fact, that
the movement taught Italians how to be a ‘68er’.
However exhilarating
and even inflammatory the work within the asylum of Gorizia became, the radical
nature of these events seems better illustrated by the experience of Perugia. The Perugian model was clearly very
different to that of Gorizia or Parma. In the former case, the asylum itself
was the main focus, and the territory around the asylum was unaffected by
Basaglia and his équipe. Political hostility increased this entrenchment. In
Parma, the territory was used against the asylum, which resisted change.
Meanwhile, in Perugia, the asylum was quickly transformed and things shifted
into the cities and towns of Umbria. Gorizia introduced democracy into the
asylum, but only there. Perugia could never be associated with one
person or one set of ideas. The movement lived through its sense of conflict
and debate – a state of permanent (if friendly) discussion. The end of the
asylum was only the beginning of a revolution. [p305]
The real lesson from Perugia (but also from Reggio Emilia and later from many
other areas) lay in the work carried out in pioneering decentralized mental
health centres. These were known as Centres for Mental Hygiene (CIM), the
rather antiquated term used in the 1968 Mariotti law. The peak of the Perugian
movement in terms of the general public was marked by a series of meetings held
in the 1973–74 period across the province, which ended up with the approval of
a set of radical rules governing the mental health centres. These meetings were
packed and addressed by politicians, psychiatrists, students (Perugia is a
student town), members of the public and journalists. The rooms were always
thick with the smoke of hundreds of cigarettes. Debate was fierce but carried
out in a civilized and calm fashion. Nobody shouted. At the heart of all this
was Manuali, whose interventions were short and went straight to the point.
Accounts of the meetings were published in full, and they were recorded on tape
and later studied by anthropologists. [p297]
There
could be no greater contrast than this.
On the one hand the surviving fascistic institutions and authoritarian
political styles, intellectually oppressive and physically violent, the
forcible marginalising and exclusion from society of those who are
different. On the other hand, the
Marxist, at times avowedly Maoist, political style, raucously inclusive,
riotously anti-authoritarian, tearing
down walls and barriers, and yet immensely creative, throwing out a plethora of
exhilarating new opportunities for human and humane development and growth. So
many readers will run from such language – to be Marxist, to be Maoist, these
are not serious positions; these ideas are not within the permitted range of
discourse. Would it not be dreadful and
subversive to discover that Mao’s Cultural Revolution contained useful lessons
for Trump’s America or Tory Britain!!
A chapter
of this book puzzles over the failure to translate Basaglia’s writings into
English, which a glance at Amazon’s site confirms to be the case, and it
protests at length over the poverty of serious historical examination of the
movement that did, in time, close all of Italy’s asylums. Indeed, sources in English assert that the
movement in Italy led to chaos, which was simply not true. To be honest, the
book would be more readable if it gave less prominence to its complaints. Instead of this, why not just write a decent
account of this astonishing and exhilarating transformation and make sure that
this time it is accurate and complete? I
am sure it would be a best seller. Yet the explanation may be more obvious than
it seems. Basaglia’s ideas were too
dangerous then and they still are. After all, he was not trying to cure
madness. He wanted to cure society and that really is revolutionary.
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