The Man Who Closed the Asylums Franco Basaglia and the Revolution in Mental Health Care

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When Basaglia's academic career reached an impasse, 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 provision, 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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