The Politics of Mental Health in Italy

The politics of mental health in Italy In 1978 the Italian Parliament passed a law effectively closing public mental ho...

Author: Michae Donnelly

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The politics of mental health in Italy In 1978 the Italian Parliament passed a law effectively closing public mental hospitals throughout the country. This has been the most radical attempt undertaken anywhere to ‘deinstitutionalize’ the mentally ill. What brought Italy to take this dramatic step is the first question which The Politics of Mental Health in Italy addresses. In fact, the Italian psychiatric system was hardly well prepared for such a radical initiative. The psychiatric profession was oriented towards inpatient care in what were largely still rather traditional or backward custodial institutions; social psychiatry and varieties of community care had only recently been introduced, and had only developed on a small scale and in a few places. What distinguished the Italian situation, however, was a strongly politicized mass social movement on behalf of mental patients. Far broader than comparable ‘anti-psychiatry’ currents elsewhere, this movement not only engaged a sizeable proportion of mental health professionals, but was also successful in constructing wide-ranging alliances which linked the struggle for mental patients with other demands and reforms in health care and social assistance. The results of the Italian initiative have been mixed. Where there had been a strong movement in place before 1978, the phasing out of mental hospitals helped to encourage further alternative varieties of care. In other places the law created a vacuum of sorts, winding down older treatment methods before new ones were developed or diffused. The second aim of the book is to comment on the result of the law, more than a decade after its passage, and to assess prospects for the future. The book is based on first-hand acquaintance with a variety of psychiatric institutions in Italy, on interviews with mental health professionals and administrators, and on wide reading inrepresentative printed sources. Given the topicality of the theme,it may well be of interest not only to mental health workers but toothers professionally engaged in social policy or in the study ofdeviance and social control. Since the 1978 law was one of theprinciple off-shoots of the late-1960s protests, the book also offersan interesting case study which reveals a good deal about modernItalian society and politics, and about the cycle of mobilization incollective movements. Michael Donnelly lectures in sociology at the University of New Hampshire, USA. He has taught at Harvard and has been Visiting Professor at the Universities of Milan, Trento and Modena, and at the European University Institute in Florence.

The politics of mental health in Italy Michael Donnelly

TAVISTOCK/ROUTLEDGE London and New York

First published in 1992 by Routledge 11 New Fetter Lane, London EC4P 4EE This edition published in the Taylor & Francis e-Library, 2005. “To purchase your own copy of this or any of Taylor & Francis or Routledge’s collection of thousands of eBooks please go to www.eBookstore.tandf.co.uk.” Simultaneously published in the USA and Canada by Routledge a division of Routledge, Chapman and Hall, Inc. 29 West 35th Street, New York, NY 10001 © 1992 Michael Donnelly All rights reserved. No part of this book may be reprinted or reproduced or utilized in any form, or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library. Library of Congress Cataloging in Publication Data Donnelly, Michael, 1949– The politics of mental health in Italy/Michael Donnelly p. cm. Includes bibliographical references and index. 1. Mental health policy—Italy. I. Title. RA790.7.I8D66 1992 362.20945–dc20 91–42685 CIP ISBN 0-203-35935-6 Master e-book ISBN

ISBN 0-203-37191-7 (Adobe eReader Format) ISBN 0-415-06176-8 (Print Edition)

Contents

List of tables

v

Preface

vi

1

Trends in mental health care

1

2

The historical background of Italian psychiatry

25

3

Pilot experiments with ‘alternative’ psychiatry in the 1960s

37

4

Towards an ideology for Democratic Psychiatry

51

5

The Trieste model

61

6

The enactment of law 180

71

7

The implementation of the law

81

8

Current prospects and future dilemmas

95

Appendix: Documents from the movement

101

G. Jervis, ‘Psychiatrists and politics’ (1967) F. Basaglia et al., from ‘Considerations on a communitarian experience’ (1967–8) The programme of Psichiatria Democratica (1973) Notes

123

Bibliography

133

Name index

151

Subject index

153

Tables

1.1 Resident population of public mental hospitals, USA, 1950– 85 1.2 Patient care episodes per 100,000 population, USA, 1955– 71 2.1 Patients in mental institutions, Italy, 1875–1954 5.1 Changes in mental hospital population, Trieste, 1967–77 7.1 Classification of Italian mental hospitals by province, on scale of ‘territoriality’, 1975–6 7.2 Residents of psychiatric hospitals on census day, Italy, 1955–84

20 20 26 67 86 88

Preface

Until fairly recently it would hardly have been possible to speak of a ‘politics’ of mental health. There have of course long been policies, and legal norms, for dealing with mental illness. The law has for centuries recognized mentally disordered persons, particularly those deemed dangerous to themselves or to others, and provided for or their commitment and safe custody. Similarly the support of mental institutions has, at least since the nineteenth century, been widely accepted as a public responsibility. In most of Europe and North America there has been a rough consensus about these matters, which is not to say that insanity, psychiatry and mental institutions did not occasion conflicts and controversies. But in so far as there was a politics of mental health, it was largely a politics of advocacy, asking more or better of the same— more resources and more caring treatment; or better facilities and better legal safeguards.1 What grounded the consensus about how to deal with the mentally disordered were essentially two elements. It involved, first, recognizing that insanity was in some measure a public concern, what would nowadays be called a social problem, and something more than a misfortune which struck a private individual or household. Insanity could make its victims irresponsible and unpredictable, and therefore socially unreliable and suspect; some of its victims became actively threatening and dangerous. Insanity was also likely to be a chronic or at least recurrent condition which might destroy livelihoods, disrupt family life, throw individuals on the poor rolls. As a police or welfare matter, insanity was in sum considered to be at least potentially a worrisome threat and risk, against which some provision had to be made. Connected to this perception of threat was, however, a second element which tended to soften the social response. Insanity was understood to be disease; therefore its victims ought not to be held responsible for their actions, and it did not seem proper that they should be punished or, if

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they were disabled, simply abandoned to their fate. The more humane and generous response would be to distinguish the insane as a special group, to be treated in a manner fitting to their condition; it was thus appropriate to separate them from other social threats and social burdens like criminals and the indigent poor, and provide for them apart, ideally under medical attentions.2 It was the combination of these two elements which provided the historic rationale for the asylum, and later the mental hospital. The two elements did not fit together without tension or difficulty; just as the insane might inspire both pity and terror, so the institutions built for them had a mixed character. Asylums might be likened to and eventually called hospitals, but they were typically organized quite separately from general hospitals, and in many ways more resembled poorhouses and prisons. Similarly the mental inmate was something of an intermediate category between the hospital patient and the prisoner or workhouse pauper: formally like the patient in some respects, but in practice sharing much of the social fate of the inmate. It was on the basis of such (partly contradictory) principles that social provision for the insane was conventionally organized; and it was in that context that psychiatry evolved as the authoritative specialist discipline to treat and manage the insane. By the 1960s and 1970s a good deal of this century-old consensus had apparently broken down or been transformed beyond recognition. The principal gatekeeper of mental hospitals, the psychiatric profession, had become a storm centre of controversy. Not only were the abuses and overweening ambitions of psychiatric power challenged and criticized; even its traditional prerogatives were questioned as never before. The mental hospital was portrayed by sociologists as a ‘total institution’, the very emblem ‘of organizational tyranny, and a closed universe symbolizing the thwarting of human possibilities’ (Perry 1974: 353). The psychiatrist, in or out of the mental hospital, was labelled an agent of social control. Civil libertarians sought to erect barriers against the intrusions of the ‘therapeutic state’, and to establish and regulate by law minimum standards for care and treatment. The very existence of mental illness, and hence psychiatry’s whole basis of legitimacy, was put into question. It seemed, in sum, that psychiatry itself had become a politically contestable, and contested, operation. Why the apparently stable consensus around psychiatry and the traditional mental hospital broke down as it did, is a complicated question to which there is no single or simple answer. There were developments both within and external to psychiatry which undermined a number of

viii

long-standing and conventional attitudes and assumptions. It was in that new climate that it became possible, and even commonplace, to speak of a ‘politics of mental health’. In retrospect, it is not difficult to indicate two developments in progress, which occurred independently but at a critical point were joined together into an explosive challenge to institutional psychiatry. First, the traditional mental hospital came under unprecedented critical fire, at a time when health planners were beginning to discuss a general reorganization of mental health services. Secondly, the professional authority of psychiatry was in some ways being undermined by its own success; the growing reach of psychiatric expertise, and the rising expectations about what psychiatry could deliver, ironically engendered a sharp challenge to its traditional authority. The mental hospital had often been criticized, but in the 1950s and 1960s it was in many ways completely discredited. That raised openly the question of how mental health services ought to be organized in the future, and how resources for mental health should be allocated and committed. With the prospect that the system would be reorganized, the professional essional categories involved (psychiatrists, but importantly also newer categories of mental health workers) began to mobilize, as did their counterparts in the mental health and hospital bureaucracies and in private pressure groups. A fairly predictable series of conflicts ensued between different groups of mental health professionals, and between those professionals and various government and other funding authorities, over the direction of future services for mental health. Beyond a scramble for resources, there were two questions of principle involved, in what was effectively a newly emerging philosophy of care: first, there was the question of standards and levels of care: given the rapidly rising expectations about the quality of life that mental patients should enjoy, and given a new concern and optimism about the prognosis and the prospects for rehabilitation of the mentally ill, what should appropriate standards look like? Secondly, were the isolation and social exclusion of the mentally disordered, which had been their customary fate, necessary or defensible? If, their confinement had demonstrably deleterious effects, was it nonetheless justified for reasons of security, or tolerable for reasons of economy? In the circumstances, to defend the traditional mental hospital seemed a retrograde choice, particularly when it was confronted with optimistic predictions that the mentally disordered could be treated instead in their own communities, without loss of their liberties or disruption to their social networks. The optimism evinced in such claims was not necessarily backed up by solid experience but it

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became nonetheless a powerful social ideal. The legal phrase ‘the mental patient’s right to treatment’, and the corresponding ‘right to refuse treatment’, were in many ways emblematic of these developments. Though in practice the struggle for such rights often had unintended, and undesirable, consequences, they symbolized the elimination of the old status of wardship and the conquest of a new status and new entitlements due to the mental patient. The second development involved less the treatment of the mentally disordered than the claims of psychiatry to direct that treatment. Here too there was a shift in cultural perceptions, which affected the very definition and recognition of mental illness and mental health, and raised a challenge to the cultural authority conventionally accorded to psychiatry. One of the traditional grounds of psychiatry’s authority has been the technical skill to diagnose mental disorders. There have often been challenges to the powers of psychiatry, but by and large expert judgements about who is sane, and who insane, were traditionally not too dissimilar from popular judgements. The distinction had never of course been an absolute one, without grey areas or ambiguities, but it had been reasonably sharp and clear—a matter of gross distinctions. By contrast to the past, however, in the period after the Second World War there was a gradual but decided blurring of boundaries, which eventually called into question the sharpness of the distinction. There were a number of sources for this shift in perceptions, which was only slowly diffused but with a whole string of consequences. In some ways the blurring was a natural counterpart of the shifts taking place in the actual practice of mental health professionals, as they came to serve a greatly expanding clientele including many people (the ‘worried well’ for instance) suffering only minor complaints. What psychiatrists were dealing with was obviously no longer insanity alone, but an array of conditions and complaints. This put a strain in some ways on the old categorical distinctions which both lay people and to some extent also professionals had shared.3 The increasing use of psychoanalytic or psychodynamic vocabulary among professionals and among segments of the lay public similarly tended to undermine the seemingly hard-and-fast medical distinction between pathology and normality. On the continuum from ordinary unhappiness, to neurotic impairment, to psychotic loss of contact with reality, there appeared to be a gradation of psychological disturbances; if there were a role. for psychotherapists even among the normally unhappy, that placed most members of society somehow on the same psychological continuum.

x

What most fundamentally brought the authority of psychiatry under attack was, however, the emergence of an apparently rival ‘social’ or nonmedical interpretation of mental disorders, deriving in part from psychoanalysis but more directly from sociology and anthropology. Such social interpretations shifted the focus of attention from processes ‘inside’ the individual to interpersonal or more broadly social interactions. It was not inevitable that this rivalry would break out into open conflict, but in the event a somewhat simplistic polarization of views developed, pitting the ‘medical model’ of mental illness against various social accounts. What sharpened the polemics of this dispute was the open identification of many professionals with one position or the other, with the divide working all too neatly along disciplinary lines. Since the various social interpretations of mental illness did offer new ways of thinking about the aetiology, the outbreak, the course, and the treatment of mental disorders, their challenge was a substantive one. But since the conflict also had all the trappings of a power struggle, it involved much more than an academic controversy, and this helped in its own way to sharpen the sense of a political battle taking place over the very definition of mental health. This book describes how a politics of mental health, in several of these various senses, emerged in Italy. What happened there was in some ways parallel to developments in Britain and the USA, although how it happened makes a distinctively Italian story. There are, however, two additional reasons why the Italian experience merits particular attention, as something far more significant than a national variation on an international theme. Italy produced, first, a radical mental health movement of unprecedented strength and breadth; and secondly, this movement succeeded in legislating the abolition of the mental hospital, thus initiating the most radical experiment to date anywhere to ‘deinstitutionalize’ the mentally ill. In 1978 the Italian Parliament passed a law to phase out entirely the country’s system of public mental hospitals. As a first step the law ‘locked the front doors’ of existing hospitals, barring new admissions, but allowing those patients then in hospital to be released gradually. New cases were henceforth to be treated in the community, as much as possible in or near their normal environments. The expectation of the law’s framers was that mental hospitals could be quite quickly run down and closed, and that no new patients would have to be institutionalized. Communitybased services, supplemented by a very limited number of short-stay psychiatric beds in general hospitals, would thus supplant entirely the traditional system of mental hospitals.

xi

This ‘revolutionary’ law was a striking victory of principle. The complete abolition of the mental hospital had hardly ever been mooted in other countries; in Italy the practical dismantling of hospitals seemed by contrast actually to be underway. And yet Italy was in many ways poorly prepared for such a radical experiment. Unlike Britain or the USA it had virtually no tradition of social psychiatry. The psychiatry practised in Italy well into the 1960s was almost entirely institutional psychiatry, centred in large and rather traditional custodial asylums. The orientation of Italian psychiatry was heavily organicist, with training programmes closely tied to university departments of neuropsychiatry. Psychoanalysis and psychodynamic treatments were effectively absent; psychology and social psychology were poorly developed, and completely missing from the neuropsychiatry curriculum; the more advanced techniques of social treatment and rehabilitation in use abroad were little known and not at all widely practised. Psychiatry in Italy seemed in fact isolated from many of the theoretical and practical currents in psychiatry elsewhere; not only did it lag, behind, but the gulf separating it from more advanced countries like France, Britain, and the USA appeared to be growing. It was against this background that a number of younger psychiatrists began to experiment with reforms to humanize the regimes of several traditional mental hospitals. Their experiments were quite localized, and dispersed over several regions of Italy. But by the mid-1960s there was a growing awareness in the profession of a new ‘alternative psychiatry’ in formation. What guided the experiments were two common, and apparently straightforward, aspirations: somehow to make contact directly with mental hospital inmates, even those chronically withdrawn; and to shake up or revitalize the custodial routines of hospital wards, These aspirations were typically expressed in the idiom of phenomenology or existential psychiatry (probably the only oppositional current available in Italy to the prevailing bio-determinist psychiatry), and often with direct allusion to the ‘therapeutic community’. But it was important that virtually from the outset these aspirations took on a markedly political tone and urgency. While the aim was to practise psychiatry in a new way, what the reformers made of and wrote about their experiences spoke much more directly to politics than to science. This is striking in the first major publication of the new psychiatry, L’istituzione negata, The Institution Denied (Basaglia 1968), which became an immediate success, and was soon one of the important books for the post-1968 protest movements which swept Italy.

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The merging of the alternative psychiatry into the ambit of the students’ and workers’ mobilizations of the late 1960s is one of the keys to its later development. There was a good deal of resonance between the two: the alternative psychiatry fitted easily with the anti-authoritarian temper of the movements, and was held up as a practical demonstration of anti-institutional politics in action, presaging a new ‘social logic’ and a transformation of social relations. In turn the alternative psychiatry adapted to certain selective pressures in the movement environment. The class dimension of traditional institutional psychiatry was more sharply accentuated and criticized, and perhaps more significantly, the mentally disordered were represented as emarginati (excluded or marginalized people—a highly resonant term in the movement) whose social needs had been harshly refused or ignored by the system. The mentally disordered came to figure emblematically in the notion of a ‘deviant majority’ which expressed, if inchoately, the experience and aspirations of unrepresented but newly emerging ‘social subjects’ (youth, southern migrants in northern factories, women). These ideological themes help to explain why the mental health movement in Italy was so much broader than comparable ‘anti-psychiatric’ currents in other parts of Europe or in the USA. In a general climate of social reform the movement captured the loyalty of a sizeable proportion of psychiatrists working in the public sector; moreover, it was not exclusively a professional affair, but an outward-looking group which linked up with other broad-gauged campaigns to reform the health system, to monitor health conditions in the workplace, and in general to raise demands for ‘democratic’ health and social services which would better serve the immediate needs of ordinary people. Explaining how and why this new politics of mental health developed as it did is the main burden of this book. It is a task which has to be approached in two spirits: generously and sympathetically, in the interests of recapturing the appeals which channelled so many energies into a remarkable and enduring social movement; but also realistically and soberly, in the interests of assessing the situation the movement leaves behind when its cycle of mobilization is ebbing. It is important to understand the dedication which pushed the Italians on, particularly when many of the advocates of community care in other countries had already confessed their disillusionment or disappointment. But it is equally important to understand that social movements can be awkward instruments of policy-making. The great strength of the Italian movement was to mobilize, here and there, local energies, which in turn produced experiments, innovations, and sometimes brilliant improvisations. But

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in a country like Italy, with its enormous regional disparities in wealth and political culture, this strength was also a weakness; considering Italy as a whole, the mobilizations left behind an ambiguous legacy. The problem confronting present-day Italians is how to create a decent national system of mental health care; how, in other terms, to build pragmatically, in the existing conditions, on what is in some ways a utopian foundation. The form, that mental health policies will ultimately take is still an open question. This book is an attempt to put that question in context: to analyse the remarkable and unparalleled politicizing of mental health issues, and to describe the policy dilemmas and organizational difficulties which the reformers, following utopian goals, left in their wake. The structure of the book is as follows: Chapter 1 presents an overview of general trends in mental health care since the Second World War, in particular as these appeared in Britain and the USA. The overview helps to set out an international context against which the distinctively Italian developments can be situated. Although Italy has followed what was in many ways a singular course, the earlier British and American (as well as French) experiences in social psychiatry, deinstitutionalization, and community mental health did nonetheless provide important points of reference. Moreover, a look at the goals which British and American mental health policies pursued, and the difficulties which they have encountered, suggests the magnitude of the challenges and problems involved in mental health reform, which Italy in its own way has had to confront. Chapter 2 provides an historical excursus about the formative period of Italian psychiatry in the late nineteenth century, which continued to shape its development through the fascist years and even into the 1950s. By contrast with developments elsewhere, Italian psychiatry in many respects lagged behind, and appeared both ill-prepared and disinclined to emulate leads from abroad. In a number of respects the historical legacy of Italian psychiatry presented obstacles to innovation and renewal. The first real stirrings of change began in the 1960s. Chapter 3 examines two ‘pilot’ experiments in ‘doing psychiatry differently’ which were to be seedbeds for the later radical movement. Chapter 4 reconstructs the ideas which drove these early experiments, and retraces the stages through which the ideas crystallized into an ideology. In the protest years of 1968–9 and after, the anti-institutional struggles of ‘alternative psychiatry’ struck a deep resonance with the social movements of workers and students. The ‘psychiatric question’ thus suddenly gained a far broader audience, and henceforth became a regular

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item on the radical agenda for reform. ‘Alternative’ psychiatrists began to consolidate their loose network of ties, and to set their sights on the national political arena; a nationwide organization, under the name Psichiatria Democratica, was set up to rival the mainstream professional association. Chapter 5 describes the transformation of mental health services in Trieste and its environs in the 1970s. This was a ‘showcase’ demonstration of what new techniques could accomplish, and it was increasingly cited in Psichiatria Democratica’s national campaign as a herald of the direction which concerted reform might take. In 1978 the parliamentary log-jam was broken, and a sweeping new law enacted. Chapter 6 examines the provisions of the law, their rationales and implications. Chapters 7 and 8 review two stages in the implementation of the law, looking at the situation in the first several years after its enactment, and then ten years later. The book closes with an assessment of the current (1990) situation, and a discussion of what the next period likely holds in store. The study is based on interviews and mainly Italian printed sources. Serious evaluations of the consequences of the reform have only recently been Undertaken in Italy; their findings are still fragmentary. Given the general lack of hard data, it will be some time still before it is possible to produce a real assessment or full-blown policy study of the Italian experiment. The intent here is rather to introduce an important but as yet relatively unfamiliar experience to interested English-speaking readers. There are a number of articles in English which discuss the Italian reforms, but they tend to be polemical or partisan, and often not entirely reliable in the information they report. A good sampling of the Englishlanguage sources can be found in the bibliography. Two collections of articles in English are worth noting: Mollica (1985) and Perris and Kemali (1985) The research for the project was carried out in Italy during 1988 and 1989, while I had teaching appointments at the Universities of Trento and Milano. Given the character of the work, and the paucity of official sources, I incurred a good many personal debts. It is one of the compensations for the sometimes frustrating nature of doing research in Italy to have the opportunity to meet Italians. I would like to thank, among others, Diana Mauri, Giovanni Jervis, Bianca Beccalli, Angelo Barbato, Alessandro Pizzorno, Piero Del Giudice, and the staff of the Centro di salute mentale di Via Gambini, Trieste. I am also grateful for the hospitality of the Institute for Advanced Study, Princeton, New Jersey, where I was fortunate to be a Member in 1990–1. M.D. June 1991

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Chapter 1 Trends in mental health care

There have been two overall trends in the development of mental health care since the Second World War: (1) a striking expansion in the scope of care, with more providers treating a greater variety of complaints in an increasingly diversified clientele; and (2) a shift away from the mental hospital as the principal setting for care, towards a mixed system including psychiatric units in general hospitals, outpatient clinics, day hospitals, and a variety of community-based settings.1 The expansion of care has been in many ways an unplanned development, although apart from depending on economic conditions, it has been shaped by insurance provisions and by new social welfare benefits. The trend is clearly visible in the growing number, and in the diversified employment patterns, of mental health professionals.2 Even more remarkable has been the growing number among those professionals who are not physicians, and who provide a considerable proportion of the total care, often in nonmedical settings.3 As the providers have diversified, so of course have the consumers; in particular, demand for treatment of the less serious varieties of psychological disorder or distress has grown enormously. The aims of care in general have likewise changed. At the beginning of the century psychiatry was hospital-based and focused almost exclusively on insanity; across the century, and especially since the Second World War, it has become focused far more broadly on ‘mental health’.4 Psychiatry is now only part of a complex of mental health professions and other allied disciplines concerned broadly with ‘psychological well-being’. The nature of psychiatric and mental health expertise, and the claims made on behalf of its treatments, have tended to change accordingly. The emergence of new categories and whole new professions of therapists has meant moreover an unprecedented variety of theoretical orientations in the mental health field jostling next to each other. Although medicine has not lost its place atop the hierarchy of prestige and power, it has lost its exclusive primacy; there are now many

2 THE POLITICS OF MENTAL HEALTH IN ITALY

settings for mental health care where psychiatry is hardly represented, or where the psychiatrist’s only real role is to prescribe drugs. The theoretical reflection of this situation is a competing set of perspectives which are in some respects fundamentally different and even incompatible. If, the old question ‘what is insanity?’ hardly ever received a univocal answer from psychiatry, the question ‘what is mental illness?’ or ‘what is mental health?’ is now answered from a number of disciplines with notably different (if somewhat overlapping) vocabularies and strikingly different theoretical frames.5 The shift away from a treatment system centred on the mental hospital is a specific aspect of the larger trend towards diversification of services, and one which has been fairly clearly driven by policy choices. It was a goal clearly formulated, for instance, in 1953 by the World Health Organization’s expert committee on mental health, which urged that ‘priority should be given to the development of psychiatric activities within the community which the hospital serves at least equal to that given to the addition of further psychiatric beds’ (WHO 1953:6). Rather soon such community services were seen not so much as supplements to inpatient beds, but as substitutes for them. In 1957 a British Royal Commission investigating the mental health laws argued that: in relation to almost all forms of mental disorder, there is increasing medical emphasis on forms of treatment and training and social services which can be given without bringing patients into hospitals as inpatients, or which make it possible to discharge them from hospital sooner than in the past (Royal Commission 1957: 207) Several years later an expert American commission advising on mental health policy wrote in very similar terms: the objective of modern treatment of persons with major mental illness is to enable the patient to maintain himself in the community in a normal manner. To do so, it is necessary (1) to save the patient from the debilitating effects of institutionalization as much as possible, (2) if the patient requires hospitalization to return him to home and community life as soon as possible, and (3) thereafter to maintain him in the community as long as possible. (Joint Commission 1961: 270)

TRENDS IN MENTAL HEALTH CARE 3

Considered against the long-term development of psychiatry, such statements represented a remarkable and dramatic turnaround. For most of its history, from its beginnings in the late eighteenth century onwards, psychiatry had been virtually identified with institutional psychiatry, that is, with psychiatry as practised in the asylum or mental hospital. In the nineteenth century, as Kathleen lones has remarked, institutional care for the insane was the solution, not the problem.6 The building of mental institutions was one of the historic achievements of Victorian philanthropy, which provided assistance to indigent, suffering, and otherwise incapable people, and helped to relieve families and local communities of the burdens of caring for them directly. As a matter of policy these institutions represented society’s practical acceptance of responsibility for the fate of the mentally disordered; in harsh times they offered, in sum, ‘asylum’, in the positive senses of the term.7 Since the Second World War there has developed, by contrast, a decided bias against institutional care. What began as criticisms of unacceptable levels of care in traditional, custodial mental hospitals grew into a wide consensus that institutional care is itself undesirable. This has been the ideological counterpart to, and one of the conditions for, the shift away from remote, bed-care institutions to a comprehensive range of services available locally in the community. ‘Deinstitutionalization is the term generally used to describe the postwar trend (see Bachrach 1989). In fact there has never been a single, coherent policy of deinstitutionalization, and the term is, somewhat confusingly, used in several senses: it describes (1) the actual trend, a gradual emptying out of mental hospital beds, or a sometimes more dramatic and rapid runningdown and phasing out of traditional mental hospitals; but the term is also used normatively, to express (2) the goal of treating mental patients in the least restrictive conditions possible, using community alternatives in preference to prolonged hospitalization; and most confusingly of all, ‘deinstitutionalization’ is also used, as (3) a synonym for community mental health care, on the misleading (or often simply false) assumption that institutional care and community care are inversely related (when institutional care goes down, community care goes up) and that the one supplants and replaces the other. Whatever the ambiguities attached to the term, it is nonetheless fitting that ‘deinstitutionalization’ has stuck, since it is the negative disavowal of the institution which has marked the conception of policy far more than the positive construction of community alternatives. The growing disenchantment with the public mental hospital passed through several stages in the postwar period, more or less in tandem with


the actual emptying of mental hospital beds. The process occurred somewhat differently in different places, but the overall patterns are similar, and in general three partly overlapping phases can be distinguished: (1) an initial phase of reform, with efforts to liberalize, revitalize, and humanize the traditional mental hospital; (2) an intermediate period, characterized by a new philosophy of early release, during which the decline in hospital populations became apparent; and (3) the efforts, finally, to develop alternatives to the hospital and to coordinate the different parts of a new mixed system. The Second World War and its immediate aftermath were in many ways the catalyst of these developments, very clearly so in Britain and the USA, where the experiences of wartime psychiatry had an important effect on public thinking about mental health.8 The war, presented an unparalleled opportunity to apply psychiatry as a technique of public health medicine. Generally the results were interpreted quite favourably, which gave an unexpected boost in the postwar period to social psychiatry in particular. Despite the special conditions of wartime psychiatry, a number of prominent psychiatrists were quick to draw lessons from their experience for civilian psychiatric practice. The war, provided dramatic illustration of the role social and environmental factors could play in affecting mental breakdown, recovery, and rehabilitation; this was taken somewhat uncritically as evidence to strengthen the environmentalist stream in psychiatry and to recommend the value of early detection, quick referral, and expeditious treatment of mental problems. Moreover the treatments improvised in battle aid-stations near the front lines, and the brief therapies designed to return a soldier quickly to his unit, seemed to be reasonably effective, which further encouraged enthusiasm about the possibilities of an active social psychiatry. These were positive, confidence-building factors which in some ways recast the image of psychiatric effectiveness. After such experiences psychiatrists demobilized at the war’s end were understandably impatient with the depressing conditions which they encountered in traditional mental hospitals. Their entry into hospitals injected a new element of vigour, and helped to diffuse more widely both wartime experiments and experiences, and a new optimism about the possibilities of caring for and rehabilitating the mentally disordered. In the atmosphere of social uplift after the war, there was moreover a wider public revulsion against prevailing mental hospital conditions, which seemed to be both backward and needlessly authoritarian. A prominent historian of mental health care in America was moved to compare the back wards, of mental institutions to the conditions of


concentration camps; after visiting more than two dozen mental hospitals in 1946–7, he complained of: scenes that rivaled the horrors of the Nazi concentration camps— hundreds of naked mental patients herded into huge, barn-like, filthinfested wards, in all degrees of deterioration, untended and untreated, stripped of every vestige of human decency, many in stages of semi-starvation. (Deutsch 1948:28) This ‘shame of the states’ evoked strong feelings which did a good deal to motivate a re-examination of the traditional mental hospital.9 The postwar period was not of course not the first time that asylum regimes have been denounced. In fact through much of the history of the asylum there has been a periodically repeated cycle of sorts, in which the discoveiy of scandalous conditions has been followed by a period of reforms, which in turn have gradually lapsed into a familiar backsliding decline, at which point the cycle can be initiated anew. What was different in the postwar period was that the scandals gave rise to a sustained period of reforms, which were based in many ways on new organizational studies of the mental hospital. In the late 1940s and 1950s there was a remarkable rapprochement and co-operation between committed psychiatrists and consulting social scientists, who experimented as never before with the possibilities of liberalizing or humanizing asylum conditions. The neglected and often run-down state hospitals became in fact the setting for a number of important studies in organization theory. Books like Human Problems of the State Mental Hospital (Belknap 1956), The Culture of the State Mental Hospital (Dunham and Weinberg 1960), and From Custodial to Therapeutic Patient Care, in Mental Hospitals Greenblatt, York: and Brown, 1955) offered both a closely observed analysis of how mental institutions actually worked, and a host of criticisms and suggestions for organizational reform. Other works such as Maxwell Jones’s The Therapeutic Community (1953) provided a blueprint of sorts for revitalizing institutional regimes, or studied hospitals like those analysed in The Mental Hospital (Stanton and Schwartz 1954) and The Psychiatric Hospital as a Small Society (Caudill 1958) where the therapeutic community was already an active ideal. The new collaborative studies identified and targeted with virtual unanimity two main problems in traditional mental hospitals: ‘custodialism’, which describes an attitude and orientation of the hospital staff at odds with any genuine therapeutic goals; and ‘institutionalism’,


which refers to the perverse, debilitating consequences for patients of long-term residence in closed institutions. The two problems were at first closely linked. The predicament of the long-stay mental patient is to suffer prolonged confinement in the monotonous, deprived atmosphere of a closed institution. A custodial regime further aggravates the problem, since it ‘tends to exercise a comprehensive control over the inmates’ daily lives, leaving little or no scope for individual initiatives. Moreover the authoritarian, rigid, and impersonal manner in which custodial regimes are administered ‘tends to induce apathy and compliant behaviour; the predictable result is a general loss of spontaneity, of social skills, and of interest in the world. Neither custodialism nor institutionalism was a new discovery; indeed such phenomena had often been vividly portrayed in works of fiction (see Wing and Brown, 1970: 1–3). The purpose of social scientists in describing such problems was of course different, although it is arguable that their apparently clear purpose was actually ambiguous: was the aim merely to remove features of the institution which had obviously deleterious effects?; or were such changes expected in the process to make institutional regimes genuinely therapeutic? From the outset there was a more or less open assumption that humanizing reforms would be themselves therapeutic, or that removing the pernicious features would by itself release the ‘therapeutic potential’ of institutions. The studies of the mental hospital were based on a fairly standard notion of how the traditional hospital was structured and how it functioned.10 Although the hospital is avowedly dedicated to treatment, it also requires an administrative structure to manage its resources and personnel, to represent it to the outside world, and to maintain the security and good order of the place. In more formal terms the mental hospital is structured by two hierarchies, one ostensibly concerned with treatment, the other with administration. The critical point is that these parallel hierarchies are in some ways incompatible or at least potentially in conflict The treatment side tends to be perennially short-staffed, starved of resources, afflicted with low morale, and weighed down with a constant round of administrative tasks and routine physical care; as a result medical energies are diverted, and the therapeutic goals of the institution tend to lose out The administrative hierarchy tends on the other hand, by default and partly by design, to prevail. The most closely observed of the staff members in these studies are the attendants or psychiatric aides, the lowest ranking, least well-paid, and usually least well-educated members of staff, but those who have the most contact with patients. Although often closest in social background


to the majority of patients, the aides also tend to have the harshest and most moralistic, negative, and pessimistic attitudes towards patients, considering them by and large disruptive and incurable. Since aides are, however, most directly responsible for maintaining order and ensuring the custody of the inmates, they are a critical group in the administrative hierarchy, and a tacit alliance of sorts tends to develop between the higher administrators and the veteran attendants, which effectively runs the hospital and orients its priorities. In the treatment hierarchy, the personnel in their medical staff roles, seem far less present in ward life; as a consequence, both because of the relative aloofness of the medical staff and the importance of order and custody in the larger institutional economy, the attendants effectively run the hospital wards, those with supervisory positions tend to be the most stable element among the staff, and hence to act effectively as the carriers of the dominant institutional culture, a predominantly ‘custodial’ culture adapted to the attendants’ pessimistic view of patients (see Belknap 1956, and Bateman and Dunham 1948). The rather obvious conclusion drawn from such observations is that the hospital’s avowed therapeutic goals tend to be displaced by custodial ones; the explicit professional ‘goal’ of treatment may be more symbolic than real. Given what the hospital actually does, the real power of the attendants in the day-to-day running of the hospital looks quite functional for sound administration; indeed it is appropriate, as an organizational theorist remarks, that ‘power goes to those who perform the most urgent and difficult tasks in organizations’ (Perrow 1965: 927). On the basis of such an analysis the first problem of reforming mental hospitals appeared to be counterbalancing the custodial drift of the hospital with an effective therapeutic orientation or ideology. A flurry of new administrative proposals ensued, which talked variously of making the hospital into a ‘total treatment organization’ or an intensive ‘school of living’ to resocialize patients; the hospital administrator would direct the whole ‘psychosocial treatment apparatus’ in the role of a ‘social system clinician’ (see for instance Greenblatt, et al. 1957:317–23). These were at the least strikingly new images of the mental hospital administrator, and a new rhetoric for speaking about the hospital as a sociotherapeutic environment. The revitalized hospital was not simply the setting for care; it would also be its means.11 There were two predominant themes which recur again and again as targets for this administrative transformation: open communication and flexible, non-hierarchical teamwork. Blocked communication, particularly between the attendants and the medical staff, was understood


to be one of the pitfalls of custodialism; similarly, rigid hierarchy stood in the way of involving staff at all levels in the ‘total treatment’ plan. Both of these themes touched in particular the attendants. The proposed remedies varied, but many were focused on changing the character and roles, of the attendants, either by training (to imbue them with a more ‘therapeutic’ ideology) or by upgrading their status. The activities of conscientious objectors assigned to work in the back wards, of hospitals have often been cited hopefully, in this regard, as an example of how enthusiastic attendants, even if untrained and inexperienced, can have an invigorating effect on ward life. The notion of ‘milieu therapy’ in some ways built on and generalized such hopes; it was explicitly conceived as a way of counteracting custodialism and the lethargy of patients, creating new and positive images for the hospital ward, and involving everyone in the hospital ‘community’ (regardless of rank or status) in a cooperative enterprise. The ‘therapeutic community’, in both its narrow technical sense and in its looser applications, was the most fully articulated plan to harness the processes of institutional life to therapeutic ends. It involved a radical critique of prior mental hospital practices in the effort not simply to make the hospital benign but to turn its collective social life to positive effect The basic approach is to conceive of the hospital or hospital ward in holistic terms, as a bounded community with a more or less closed corporate character. The focus is on the here and now, on what happens day-to-day in the community; by contrast with the traditional hospital focus on the individual patient (with his or her history, presenting symptoms, diagnosis), the therapeutic community is set up to examine its own ongoing collective life, and to interpret the behaviour that happens in that setting. Daily life is structured around community meetings in which all are invited, or obliged, to participate. In what ‘tends to become a tightly knit, intensively interacting community, there can be a good deal of social pressure directed at particular individuals. The formal principles which guide community life are permissiveness (‘acting out’ is tolerated, up to a point); democracy (all participate in discussing matters of community policy); egalitarianism and communalism (staff differentials are reduced, flattening the authority pyramid, and patient-staff distinctions de-emphasized). The aim is a social rehabilitation of patients, as the therapeutic community replaces a pathogenic environment with a ‘good’ learning environment. The whole model of the therapeutic community could not easily be applied in many mental hospital settings (even if administrators had been interested to do so); but much that was characteristic of its style, and


many of its particular elements, were quite widely admired, and at least formally emulated. Indeed what was perhaps most significant about the therapeutic community was the stamp it left on so much of administrative psychiatry. Compared with the worst features of the custodial regime, there was obviously much to recommend in the new vogue for redesigning the institution. There is also no doubt that such proposals had real tonic effects in practice where they were genuinely applied.12 The difficulty is how to assess or interpret the real promise of such administrative reforms. In what ways was it realistically possible or plausible to transform the large, traditional mental hospital into a ‘total treatment’ organization? Was it right to speak of administrative reforms releasing the ‘therapeutic potential’ of such places? Posing the question in such a way reveals a number of ambiguities and limitations in the new administrative psychiatry There was first of all the problem of scale: what is the unit which is to become a therapeutic milieu or therapeutic community? In fact there was considerable wavering in the literature between a narrow, strict interpretation of the therapeutic community and a much broader one; the relevant unit in one case is a particular ward, in the other a whole hospital (see Zeitlyn 1967). The same sort of issue had arisen with the old ideal of ‘moral treatment’, which was usually linked with a small-scale, even quasi-domestic institution; applied on a much grander scale, the techniques seemed much less effective, or were likely to be quickly displaced by sheer administrative exigencies.13 In the more evocative descriptions of the therapeutic milieu there is in fact often an implicit, or even explicit, contrast drawn between small, intimate settings and large, impersonal ones. The milieu is usually characterized as an arena of face-to-face aceto-f ace encounters in which a specialist staff works intensively with a relatively stable and clearly bounded community of patients. But it is not clear how such a model could be projected on to a whole hospital ‘community’; nor is it clear that such a work of transformation could be accomplished with the same (or similar) personnel at the same level of resources. Doubtless small, resource-rich, elite institutions have something to teach large, resource-poor public ones, but the lessons would likely have to be considerably adapted. In large, traditional hospitals the possibilities of upgrading staff are unfortunately probably rather limited; as Perrow commented, ‘the literature on the desirable quality of [psychiatric] aides is most unrealistic, calling for truly remarkable people who would be hard to find even if they were given the pay and prestige of psychiatrists’ (1965:926). The general difficulties


for such an upgrading strategy are fairly clear: it is difficult to recruit high-quality staff, and to motivate them over the long term, with what are generally scarce institutional resources; and even where new treatment programmes do have an immediate tonic effect, it is hard to preserve that beneficial effect over time. At the extreme, conditions can be so bad that ‘any change helps’, at least for a time, but such benefits are likely to fade quickly. Hence, far from being a general panacea, such changes may have only a limited applicability (since they require special resources); and even where they are instituted there are recurrent problems sustaining the good effects. There is also the broader issue of whether administrative reforms, desirable as they may be on their own terms, really accomplish the therapeutic gains claimed for them; or did social scientists raise unrealistic expectations about the possibilities of transforming large, traditional custodial institutions into dynamic, curative therapeutic regimes? In the traditional custodial mental hospital there was a more or less effective ‘technology’ for the control, routine care, and custody of inmates; the question is whether there can be a technology for cure or rehabilitation in similar conditions. Humanizing reforms may be well worth undertaking in old custodial hospitals, but these may not amount to a new technology, and may not be able to satisfy the new and higher demands placed on the institution. On a sceptical view it may seem that the large public mental hospital is caught in a fatal dilemma: the asylum was acceptable when expectations were lower; the problem is that ‘cultural definitions [about the goals of an institution] may change even though there is no appropriate technology to implement the new goals’(Perrow 1965: 915). Expectations in other words may outrun possibilities; cultural demands may exceed what existing human technologies are capable of delivering. In that case, the result is likely to be that the old ways of doing things look unacceptable, but that there is nothing effective to put in their place. Such sceptical points, as well as a host of practical difficulties, fairly rapidly dimmed the more optimistic hopes for administrative psychiatry. There was moreover a shift of sorts in the social science literature about mental hospitals, or in the ways of interpreting it, which came to focus increasingly on a different, more fundamental, order of problems, and which led if anything to even gloomier conclusions about the reformability of the mental hospital. What characterized this second stream of investigations, or the new way of reinterpreting older studies, was a more searching and intensive focus on the quality of social interactions in the mental hospital. This produced in some ways a more


profound institutional analysis, and one which illuminated problems evident even in the enlightened, humanized regimes of elite or model institutions. It was not difficult to show how staff in a resource-poor public hospital could allow chronic patients to vegetate on back wards, it was a more powerful and challenging finding that even in resourcerich, enlightened therapeutic regimes untroubled by the problems of custodialism, some of the same perverse mechanisms continued to operate. Part of what was novel was a shift in the observers’ point of view. In their eagerness to make policy recommendations, many of the authors of the early hospital studies had tended to assume more or less naturally the vantage point of an energetic social psychiatrist surveying the hospital from above; the research question was implicitly what administrative reorganizations would aid psychiatrists in their therapeutic work. By contrast some later studies were more detached and independent in their point of view. They emulated in some ways the stance of a third party, identified neither with the professionals nor with the patients (although in practice often closer to the patients’ point of view). The effect was to bring out more vividly than before what institutional life looked like from the inside, and often from the bottom up. This shift in point of view also began to open a breach in the collaboration between psychiatry and social science. The original rationale for social science studies of the ‘mental hospital as a small society’ had been to discover what actually happened in the hospital, and to understand how social processes which hindered treatment might be altered, while those which promoted treatment were enhanced. In the joint efforts of psychiatrists and social scientists, the social scientists had originally been junior partners, who took on board many of the assumptions of the psychiatrists. The ‘psychosocial’ or ‘sociotherapeutic’ notions developed in administrative psychiatry clearly borrowed from social science, but in order to modify existing psychiatric practices. In the end, however, social scientists were developing a new social and interpersonal point of view, which proved to be difficult to combine or to synthesize with the psychiatric treatment model. From speaking about social factors affecting the aetiology, onset, course, and treatment of mental disorders, social scientists moved increasingly to thinking of social explanations for the aetiology, onset, and so on of mental disorders, although in fact much of the medical framework was laid aside in the process. From offering advice on how to improve social psychiatry (a synthesis based on psychiatry which ‘took account’ of social factors), social scientists were moving towards an independent set


of conceptions. The distinctively sociological view that was called the ‘sociogenetic’ hypothesis was in the event no longer an add-on or even a corrective to the psychiatric view; it was a rival. Or rather, as a distinctive social science viewpoint emerged, the older collaboration began to appear more fragile; in time a polarization of sorts developed between the ‘medical model’ and a cluster of social interpretations. A clear sign of the breach was the effort of some social scientists to ignore (or ‘bracket’) in a thoroughgoing way the reasons psychiatrists themselves gave for what they did. This could produce sometimes strange or surprising results. By deliberately ignoring or downplaying, for instance, the patients’ illnesses—their conditions, diagnoses, and presenting symptoms—hospital observers describing ward life sometimes gave the impression that the patients were the sane group, whose needs and concerns were being irrationally frustrated by the staff. The point is familiar to any reader of Erving Goffman’s Asylums. The intent of such an apparent inversion of positions was not to question the sincerity of psychiatric staff, much less to ridicule them. It served to point up an occupational hazard or bias of psychiatry which leads, according to such outside observers, to occasional or even systematic misinterpretation of patients and their behaviours. Psychiatric staffs tend to perceive patients in and through the frame of the diagnostic labels pinned on them. Whatever the patient does is liable to be interpreted not in terms of the social situation or the surrounding context, but in terms of the patient’s disorder. In this way diagnoses could serve unintentionally or unwittingly as invalidating labels. The result of the psychiatric staffs singular focus is (probably) to overestimate pathology or to attribute it to the patient all too frequently. It may be that at least some of the patient’s behaviours are not symptomatic but possibly rational, sane, or reasonable reactions to the hospital situation or to hospital interactions. This is a point about the power of ‘labelling’ which became a fundamental part of the social science challenge to medical conceptions of mental illness. Terms referring to the ‘insane’ and mentally disordered (and even the more refined diagnostic labels) are peculiarly powerful ways of describing, which tend to prejudice others’ perceptions of the individual so labelled, and to colour or distort subsequent information which becomes available. The effect is to skew the impressions which other people form, and to create at least some of the conditions for a selffulfilling prophecy. Hence behaviours among the patients which are actually stimulated by the environment may be misattributed to the patient’s disorder, and thereby invalidated.


The general point is one of which psychiatrists were well aware. Gross stereotypes of the insane have long been powerful obstacles to their rational treatment. One of the characteristics of attendants which was most criticized by psychiatrists was their prejudice against the mentally disordered, which predisposed them towards pessimistic or moralistic reactions. What was novel, and unsettling, however, was to have similar points directed at professional psychiatric staff, with the suggestion that such misperceptions of, or failures in communication with, inmates may be widespread, even endemic in the mental hospital setting. If, the best therapeutic communities are at risk of invalidating or infantilizing their patient-members, this would seem a hard challenge to their claims to rehabilitate. The thrust of the analysis was, however, to provide just such an explanation of how even good institutions unwittingly induce or confirm pathological behaviours. There is a more subtle mechanism, in other words, which helps to explain institutionalism; it is not only that chronic patients vegetate and deteriorate because they are depersonalized, and because their passivity is easily tolerated by and appreciated in a custodial regime. The problem runs deeper; and hence the target to criticize is not only custodialism but those perverse mechanisms which even in sophisticated, actively therapeutic institutions tend to deprive mental patients of their identity’, and agency. The logical conclusion of this line of thinking led away from the mental hospital entirely; or perhaps better, the new way of interpreting the social science studies of the mental hospital lent itself to, or was exaggerated to support, damning conclusions about the hospital. Even if the conclusions were in some ways unwarranted, they seemed at the time almost irresistible. The net effect of this stream of the social science contribution was, first, to induce a generalized fatalism about institutional care, which even in its enlightened forms can apparently be pathogenic; and secondly, to lend support to the general sociogenetic theory of mental illness, and to confirm a powerful assumption contained in the sociogenetic view, that if the causes of mental disorder were social, then so should its treatment and prevention be social. From the idea that institutional care could harm patients, or exacerbate their conditions, emerged the view that patients would be straightforwardly better off without the mental hospital. On the principle that a hospital should do the ill no harm, it would be better not to hospitalize mental patients. Such a global conclusion did not by any means follow from the premises of the research on mental hospitals; but it became a more and more diffused attitude in the climate of opinion to


which radical sociologists directly or indirectly contributed. Goffman’s Asylums, for instance, whatever the more cautious statements of the author, became a metaphor for the ‘totalizing’ institutional forces which denied the individual’s dignity.14 The danger moreover was not only characteristic of the worst, most degraded institutional conditions, but of the institution itself.15 Even if this argument were correct, it does not follow that care outside, or simply life outside, the mental hospital would be better. If institutional treatment is ‘bad’, that does not mean that it is also worse than feasible alternatives. The second, comparative proposition would have to be established independently. It was here, however, that the sociogenetic argument was used, somewhat mischievously, to provide a positive endorsement of ‘social’ therapy. From the psychiatrist’s point of view, the contribution of the social scientist in the mental hospital had been to counteract the negative effects of institutionalism, and possibly to provide new positive sociotherapeutic techniques. For the social scientist, however, it was but a step to extend this limited contribution into a full-fledged alternative approach. If, pathological behaviour could be traced back to, indeed understood and interpreted as a response to, certain social conditions and patterns of interaction, then it seemed the problem was not ‘in’ individuals but in interpersonal (social) contexts and situations. In principle the vogue for sociotherapeutic approaches was a way of understanding and exploiting such interactive dynamics; in reality, according to social science critics, psychiatrists were still disposed to think in terms of pathological processes within the individual.16 For reasons of their professional socialization, in other words, psychiatrists were unlikely fully to appreciate sociotherapeutic approaches. This was one argument against pursuing the collaboration with psychiatrists. Even more powerfully, the sociogenetic argument seemed to suggest a new independent, non-medical rationale for social treatment—not merely as a way of humanizing a hospital, preventing the deterioration of patients, or reclaiming the chronically ill, but as therapy in its own right From a technique for reforming the mental hospital, the sociogenetic view became a rationale for encouraging a new type of therapy beyond the bounds of the hospital, in the community, where such social dynamics could be explicitly addressed. The idea that certain root causes of mental disorder are in some sense social does imply that prevention of mental disorders, on a public health model, should look closely at social factors. It does not follow, however, that if the cause is social, so should the cure be social. There is a certain intuitive appeal to the idea that if mental disorders spring (somehow)


from society, then that is where they should be treated; and that a ‘social’ treatment is more appropriate than one constructed in artificial institutional settings informed by an individualistic idea of disease ‘inside’ patients. There is a slipperiness, however, in the use of the term ‘social’ which vitiates the argument. Removing a ‘social’ cause, or undoing its work, does not amount to cure, unless one also assumes that the causal relation involved is completely reversible. In the case of mental disorders that is highly unrealistic, since the disruption that mental disorder causes has itself lingering effects and emotional consequences. Isolation and loss of social skills, for instance, may well be secondary effects of mental disorder which will by no means disappear once the presumed cause is removed. What will work best to rehabilitate the mentally disordered is a question logically independent from the question of what causes mental disorders. In the event the research problems raised by social psychiatry were somewhat rudely upstaged by a number of new trends and developments which more immediately affected the use of and demand for hospital beds: (1) the advent of psychotropic drugs considerably eased the managing of many forms of acute and chronic disorder, and seemed to hold out possibilities of releasing patients and enlarging outpatient treatments; (2) new administrative policies were more and more commonly applied to break down the walls. between the mental hospital and the community, by instituting ‘open door’ wards, encouraging shorter stays in hospital, and releasing patients quickly—even in the likelihood of their having to be readmitted; (3) fiscal pressures fostered a more thoroughgoing interest in rationalizing mental health services, in order to reduce the number of mental hospital beds or to merge inpatient mental health services into general hospitals. These trends arose independently (and in different countries with different rhythms) but their cumulative and joint effect ultimately was to feed into and reinforce the logic of deinstitutionalization.17 Psychotropic drugs were widely diffused in the mid-1950s, and were greeted in many quarters as ‘wonder drugs’. There can be no doubt about their dramatic effects on many chronic patients who rather suddenly seemed humanly reachable; nor of the relief the drugs brought to those patients whose overpowering symptoms became less intrusive and compelling. But arguably the most important immediate effects of the drugs were not on the patients but on the image of psychiatric care itself. To psychiatrists and other mental health workers the drugs brought a new sense of optimism, and encouraged their efforts at actively intervening against patients’ disorders. ‘The use of drugs gave staff greater


confidence in its own efficacy and helped dispel the feeling of helplessness and apathy that had captured the mental hospital’; in turn ‘the feeling of hope and efficacy felt by the hospital staff was communicated to patients and the community generally and gave both renewed confidence in the ability of patients to cope with difficulties outside the hospital’ (Mechanic 1980: 87). The effect on the conditions and even appearance of ward life was equally striking. Drugs damped down the more florid signs of psychosis, and thus eliminated some of the more threatening, violent, and bizarre aspects of the ward. This made certain prison-like characteristics of mental hospitals seem even less necessary, and in general positively encouraged the effort to humanize wards, As one psychiatrist recalls: ‘Much of the physical, frankly combative aspects of patient care was simply no longer necessary, and calm reigned in wards, which previously had strong resemblances to the worst sort of snake-pit’ (Minto 1983: 173). At the same time the increasing use of drugs tended in some ways to draw attention away from the traditional mental hospital as the primary context of care for mental illness. Patients maintained on drugs could more easily be managed through outpatient clinics; moreover the apparent efficacy of drugs, and the fact that only MDs could prescribe them, tended to enhance the specifically medical status and identify of psychiatrists. Becoming an expert in psychopharmacology might make a psychiatrist more medically respectable, and lead to closer ties, with general medicine. But if or as psychiatry drew closer to general medicine, there would be less likelihood of collaborations between psychiatry and sociology, and perhaps less direct concern on the part of psychiatrists with social psychiatry. As drug treatment made care look in some ways more ‘medical’, moreover, the newly released patients needed social supports outside the hospital which came to look increasingly and unambiguously ‘social’. Even if patients were well managed on drugs, they often still required help overcoming the isolation and loss of social skills which their illness had occasioned. The role. of such support services was increasingly recognized, and in some ways looked to be the heir to certain varieties of social treatment practised in the mental hospital. But here too there was a pull away from the mental hospital; if or as social supports were located outside the mental hospital, that also tended to reduce the centrality of the hospital, and thus to weaken what had been the undoubted base and focus for expert mental health care. From two sides, as psychiatrists were drawn towards general medicine and as psychiatric social workers became involved outside the hospital in the wider


concerns of social assistance in the community, there were pulls which threatened to dilute the distinctive identity of professional specialists in mental health care. Where the mental hospital had been conceived as the setting for joint medico-social efforts, the trend away from the hospital presented the risk of a new separation of medical from social treatments. In Britain such a split was to some degree sanctioned by policy, with the result that, where the mental hospital had once been the single central context of care, care was now divided between medically oriented psychiatrists and community-oriented social workers, two groups who shared responsibility for the mentally ill: but who in many ways no longer shared a common institution between them. The trend was to develop two bureaucracies, with two ways of viewing patients. This has been a recurrent problem quite generally, despite efforts to integrate or coordinate the discrete services which are both geographically and institutionally dispersed. The ‘open door’ policy and the efforts towards early release developed independently from the use of psychotropic drugs, but the two fit well together and in some ways tended to become mutually reinforcing. The idea behind the open door was two-fold: if the patient had more possibility of ‘exit’, that would also increase his or her ‘voice’ (the psychiatrist would have to take into account the patient’s own point of view, which would increase the patient’s bargaining power, and make it more likely that he or she would get a hearing from the hospital staff); and it would tend to break down the walls separating the hospital from the community. Similarly the notion of early release (what was later, in somewhat different circumstances, to be called pejoratively the ‘revolving door’) was meant to encourage the rapid discharge of patients from hospital, in the hope of avoiding their prolonged dependence on the hospital regime and too great a disturbance or interruption of their social lives outside the hospital. Even multiple admissions of short duration would be preferable to long-term hospitalization, since the patient would be less likely to develop ‘secondary handicaps’ from the debilitating experience of being in hospital. The desired effect was to create ‘a new dynamic relationship between the hospital and the community, and between the patient and society’ (Hunter 1967: 70). The slogan was: people don’t go to hospitals to get well, but to ‘get well enough to go home where treatment continues’ (Cameron 1950: 64). What the term ‘revolving’ hinted at was the likelihood that early release would lead to readmission, even to cycles of release and readmission. The policy depended on a greater confidence in managing patients outside the ‘totalizing’ atmosphere of the hospital, and a correspondingly greater


tolerance for having disturbed people in the community. Drugs were often instrumental to these policies, both in aiding discharges and in helping to maintain people outside the hospital through outpatient care; there were, however, frequent complaints that drugs were being too widely and heavily prescribed, and that treatment patterns in general were coming to depend too much on their use. Exactly when and how fiscal pressures and cost-cutting contributed directly to deinsititutionalization is still a debated subject. What is nonetheless clear, in any event, is the effect on hospital planners of the growing disillusionment with mental hospitals, which became a strong disincentive to invest in mental hospital beds. The reasoning took more or less this form, in the total budget of mental hospital costs, some expenses are directly related to treatment, but others are incurred in the maintenance of the physical plant and for the round-the-clock supervision and provisioning (food and clothing) of the inmates. By far the greater part of the costs come in fact from the nature of residential facilities rather than from treatment itself. On the assumption that treatment could somehow be provided without incurring all the additional costs of residential care, it would obviously be fiscally sound to prefer, for instance, community-based treatment programmes. The point is not necessarily that planners were in a position to make such actual calculations, but rather that the practical possibilities of cutting back on beds led them to entertain the idea of cutting back generally on the costs of residential care. This situation was quite apparent in (Britain) in the early 1960s when health planners faced the predicament of ordering extensive and expensive renovations of the decades-old mental hospital buildings. Such renovations would have been in tune with the energetic efforts underway to renew, upgrade, and revitalize traditional mental hospitals; yet committing resources in this way would also have seemed an endorsement of hospitalization in preference to other forms of care. In the event, the government opted for a progressive phasing out of separate mental hospitals, and the integration of mental hospital wards, into general hospitals. One of the short-term effects was ironically to deny resources to what would probably have been worthy efforts at humanizing the existing mental hospitals. But the signal being sent was quite clear: funds that might have gone into mental hospitals would go towards psychiatry in general hospitals and to social services for mental patients in their communities. In the USA there were similar doubts and hesitations about planning for the future development of mental hospitals.18 And through a different mechanism there was a similar shift in resources away from the mental


hospital sector. In the USA mental hospitals have largely been the responsibility of the states and of some local authorities. Two trends began to affect the patterns of use of mental hospital beds. New federal programmes, like Aid to the Permanently and Totally Disabled, and later Medicaid and SSI, created new categories of beneficiaries; this in turn created incentives for the states to transfer patients who were eligible for the new programmes out of state hospitals and to house them elsewhere (for instance in nursing homes) on federal funds. State legislatures took similar steps, passing welfare legislation whose effect was to shunt people away from, or to move them out of, mental hospitals; in many states such legislation dramatically reduced the numbers of geriatric patients in mental hospitals. This was an important component in the general decline of resident patients in American mental hospitals. To make the point in such terms is already to raise certain dilemmas. What happened to the released geriatric patients? Many were simply transferred to other institutions, where there was no guarantee that conditions would be better; on the contrary, where the institutions were poorly regulated, conditions might well be worse. The effect of such developments was, in Britain as well as in the USA, to transfer fiscal responsibility for some mentally ill patients from mental health facilities to the public welfare rolls. This was to be an important and growing trend throughout the deinstitutionalization movement. Indeed the pace of deinstitutionalization has depended fairly directly on the availability of welfare funds newly directed to (former) mental patients. The data on the actual use of mental hospital beds illustrate quite clearly the effects of these policy trends. In the USA the number of patients resident in mental hospital peaked, after a long, slow secular rise, in 1955, when there were 560,000 resident patients on census day. By 1974 the patient census had declined to 215,000, a decline of about 60 per cent in the number of hospital residents (see Table 1.1). The peak in Britain occurred at about the same time, with a less precipitate decline afterwards. The figures also reveal dramatically that mental hospitals were now only one site of mental health care. In fact while the patient census declined sharply, the number of ‘patient care episodes’ dramatically rose. In the period 1955–71, for instance, just after the peak in inpatient residents, the extent of outpatient care dramatically expanded (see Table 1.2). What that growth represents is largely an expansion of services to include a new group of patients—a phenomenon which indicates a good


Table 1.1 Resident population of public mental hospitals (thousands), USA, 1950–85 As percentage of 1955 1950 1955 1960 1965 1970 1975 1980 1985

512.5 558.9 535.5 475.2 339.6 193.4 132.2 109.9

91.7 100.0 95.8 85.0 60.8 34.6 23.7 19.7

Source: National Institute of Mental Health, Division of Biometry and Applied Sciences Table 1.2 Patient care episodes per 100,000 population, USA, 1955–71

1955 1961 1971

Inpatient

Outpatient

Total

795 811 846

237 563 1,122

1,032 1,374 1,968

Source: National Institute of Mental Health, Biometry Branch

deal about the character of the new alternative, community-based mental health facilities which had been developed in the meanwhile (see Greenblatt and Glazier 1975). The idea of community care emerged first as a rather general principle; indeed it was largely an ideal projected as the opposite of institutional care. ‘Community’ evoked a series of positive associations: to ‘home’ and domestic life, rather than impersonal institutional regimes; to normal social intercourse, rather than stigma and withdrawal; to integration of the insane locally rather than their segregation afar; to small-scale local care in preference to large-scale and remote care. There was an implicit belief, apparently not often critically examined, that the insane would be better off in the community; spared the neglect and deterioration associated with institutionalism, they could escape their passive and dependent hospital roles, exercise some measure of independence and initiative, and reach at least some minimal level of normal functioning outside. Instead of suffering the isolation of hospitalization, they could maintain their living arrangements with the minimum of disturbance.


What legitimated the idea of community care was the (negative) sense that long-term hospital care had become simply unacceptable, bolstered by the (positive, but largely unexamined) hope that the community would be receptive and supportive. What had yet to be demonstrated, however, was that to take the mentally ill out of the hospital would be to put them into the community. It took some time to give form, to such a principle; and still longer before the idea was tried and eventually judged in many ways wanting. By the mid-1970s, however, there was a good deal of disillusionment with a slogan that seemed increasingly hollow; moreover the economic climate by then hardly encouraged thoughts of launching or relaunching ambitious new initiatives.19 In the USA the idea of community care had originally been introduced with a great flourish. In a personal Message to the Congress in 1963 President Kennedy called for a ‘bold new approach’ to mental health problems. This was the first time a President had taken cognizance of mental health issues and stated a national policy (Levine 1981). The core of the new approach was to be a network of community mental health centres, acting as ‘a main line of defense in reducing the need of many persons with major illness for prolonged or repeated hospitalization’ (Joint Commission 1961:7). The Community Mental Health Centers (CMHC) Act was passed soon afterwards. It was to set up new mental health centres in catchment areas (geographical areas containing from 75,000 to 200,000 people) across the country. The centres were to serve all the mental health needs of those areas, whose residents would be entitled to care without restriction according to their diagnosis, prognosis, age, sex, race, or ability to pay. The principle was that the centres should provide for all, including children and geriatric patients, and not restrict their services to certain kinds of disorder. Federal funds were committed to establish the centres, but over time the states were to become more responsible. The bold initiative was in the event somewhat slow to take off; by 1967 there were only 186 CMHCs nationwide; by 1975, there were 603, but these were still mostly concentrated in the North-east and on the West coast Even the more successful centres showed signs of strain. The activist and idealist professional staffs seemed to ‘burn out’ fairly quickly. The flexible style of work, and the of ten deliberate attempts to blur distinctions between psychiatrists and other professionals, and between professional and ancillary workers, took a heavy toll. There was a very substantial investment of professional energies in innovative work, including storefront clinics and various other efforts at ‘outreach’ to local


communities. In many places the centres nonetheless had problems in establishing good relations with their communities. Despite a strong emphasis on building grass-roots community support for the centres and recruiting ‘indigenous paraprofessionals’ to join therapeutic teams, the ‘communities’ which the centres actually served were in general amorphous geographical areas, defined in administrative terms rather than by any sense of corporate identity. The wide, ill-defined, even unbounded responsibilities (to cover ‘all mental health needs’) and the difficult job of tapping community resources in what were often socially diverse populations, amounted to a serious overload on the centres’ professional energies. The predictable result was that centres began to specialize in certain services, and more and more plainly to abandon their vague and unbounded charter. Although officially proposed as an alternative to the mental hospital, what the centres probably did least well was to care for former long-term hospital residents or for those long-stay or chronic patients who had recently been released. In large measure this was a result of a scarcity of resources in the community, as well as of CMHCs’ orientation; simply housing ex-patients proved a difficult burden, and they were of ten passed on to welfare authorities as a matter of course. What ‘after-care’ consisted in for many such patients was to be housed by the welfare department in conditions often no better, and sometimes rather worse, than in mental hospitals. As more than one observer noted, this was effectively to transfer ‘custodialism’ to the community, and to turn a blind eye. In Britain community services were put together in a more piecemeal fashion, without the fanfare of a special new programme. At the outset it was assumed that no new provision would be necessary, since the National Health Service (NHS) already provided a comprehensive system of hospitals, outpatient care, general practitioners, and some limited community services. A good deal of confidence was placed on psychoactive drugs as a means of managing patients outside hospital, with the hope or expectation that patients could draw on existing family and community networks. From the 1950s onwards social treatment of the mentally ill both in and out of hospital had been more advanced and more widely diffused in Britain than in the USA; and in Britain the decline in numbers of mental patients hospitalized was less sharp and rapid. Nonetheless relying on the existing health and welfare systems quite soon looked inadequate. There were psychiatrists with a socialpsychiatry orientation who argued for special provisions for communitybased mental health services, but psychiatrists on the whole were probably more identified with general hospital medicine. Psychiatric


social workers, on the other hand, had been more or less integrated into the larger group of social workers. The consequence was effectively a split in the responsibility for the mentally ill between hospital-based psychiatrists and social workers employed by local authorities. Not only did this divide what had been a shared speciality into two separate ones, it created an administrative split which raised problems of co-ordination between the NHS and local authorities (Jones 1988: 32–5). In Britain as in the USA, the rundown of mental hospitals created real problems of accountability: patients were released into the communities, but there were often no effective means of tracking them and ensuring that they were receiving care. The mental hospital had at least sheltered, fed, and clothed its inmates in secure conditions which were in principle open to public scrutiny. A basic test of any community-care alternative was not to fail at the task of at least duplicating such material care. As the balance sheet on deinstitutionalization has typically been drawn, however, there have been many minuses to set against whatever pluses are acknowledged. Italy was by and large a distant spectator of most of these developments, with the exception of psychotropic drugs which were quickly and widely diffused. Many individual psychiatrists were aware of, or directly in touch with, other developments abroad, but until relatively late in the 1960s there was little consistent echo of the more important international trends in the national-level discussions within Italy. What is striking is that once the Italian movement was finally underway, given this lag, it was considerably out of phase with developments elsewhere. In fact the moment when the Italian movement culminated—with the new law of 1978—was an especially low. period in the fortunes and reputation of community care elsewhere. The Italian psychiatric movement did not, however, see itself as following any foreign model. If, anything its participants had the sense of reaping the benefits of being a latecomer—leaping over whole phases of development. As for the acknowledged failures abroad, for some at least of the Italian radicals the lesson of those failures was to be more, not less, ambitious; instead of being bogged down by political compromises, they would push through to a new system (see Pirella 1987: 126).

24

Chapter 2 The historical background of Italian psychiatry

The historic roots of Italian psychiatry go back to the second half of the nineteenth century.1 In many respects the basic and enduring patterns of the discipline and its practice were laid down or codified in those decades: the main professional association of Italian psychiatry was founded in 1873, on the basis of a strongly organicist programme; asylums were built or planned in different regions of the country at an unprecedented rate; and in 1904, after several decades of pressure, the Parliament enacted an asylum law, which codified the public mandate of psychiatry to defend society against the ‘dangerousness’ of the insane, and laid down the legal framework for mental health policy in force right down to the present. In earlier periods there had of course been a medicine of insanity, and there were physicians who specialized in treating mental disorders, some of whom, like the Tuscan Chiarugi (1759–1820), achieved wide renown. Insanity remained nonetheless a special topic of general medicine. In so far as a separate field was distinguished it was based less on specific theoretical discussion or research than on the practical achievements of the asylum-keeper. Even here, the opportunities for developing a specialized practice were relatively few. By the early nineteenth century most Italian states had developed some sort of explicit policy for the mentally disordered, differentiating them at least in principle from the poor and from prisoners, and generally entrusting their care to medicine. 2 The Grand Duchy of Tuscany had been an early leader, having enacted already in 1774 one of the earliest laws in Europe to regulate the condition of the mad. A different sort of example was provided by Aversa, in the Kingdom of Naples, where a ‘model’ lunatic asylum was established in 1813 under the Napoleonic regime. Despite these ‘enlightened’ cases, and notwithstanding the long traditions in various parts of Italy of organizing charity for the insane and feebleminded, the scale of provision was relatively small.3

26 THE HISTORICAL BACKGROUND OF ITALIAN PSYCHIATRY

It was not until after 1860, with the political and then gradual administrative unification of the country, that systematic provision for the insane was really extended. In so far as there was a ‘great confinement’ in Italy, it was a phenomenon of the late nineteenth century. In 1866 a census of the newly unified Kingdom’s asylums counted only some 8,000 inmates in a population of about 26 million.4 A somewhat fuller survey in 1874 found close to 13,000 inmates. From 1875 to 1914, however, the number of institutions for the insane increased from 43 to 152. Over the same period, the number of inmates grew four-fold, from 13,000 to 54,000; and the rate of confinement for mental disorders tripled, from roughly 50 per 100,000 of the population to about 150 per 100,000 (Canosa 1979: 91).5 Asylum populations continued to grow, more slowly, until reaching a peak in the early 1960s (see Table 2.1). The spread of the asylum system was an important practical spur to the professionalization of psychiatry. Asylums had been customarily entrusted to medical superintendents, and often to specialist mad-doctors. But psychiatric culture, such as it was, tended to be provincial; and superintendents were likely to be selected more for their practical skills as asylum-keepers (and in Church-controlled institutions perhaps as Table 2.1 Patients in mental institutions (thousands), Italy, 1875–1954 Rate per 100,000 inhabitants 1875 1885 1889 1898 1908 1926 1935 1941 1949 1954

12.9 20.0 22.4 33.6 45.0 60.1 83.5 96.4 70.5 86.7

47.3 68.9 74.9 105.6 133.8 150.1 196.0 218.0 153.0 179.5

Sources: Verga, A. (1897) Studi anatomici sul cranio e sull’encefalo, psicologici e freniatrici, Milano: Manini-Wiget (for 1875–81) Direzione Generale della Statistica (1885–1908) Porta, V., Ermentini, A., and Cossoncelli, C. (1976) ‘Le malattie mentali e l’assistenza psichiatrica in Italia’, Rivista sperimentale di freniatria 100:361ff (for 1926–54).

THE POLITICS OF MENTAL HEALTH IN ITALY 27

much for their religious sensibility) than for medical expertise proper. It was, again, only after the 1850s that a professional discipline of alienists, with a self-conscious sense of their specialist medical identity and a clear career pattern, began to emerge. In this sense, professional psychiatry really developed, or was decisively refounded, with the unification of Italy. In the mid-century a group of alienists gradually coalesced around the programme of forging a national discipline, and working towards the construction of a national system of asylums. The task was really twofold: to link existing asylums, raise their standards, and extend the network of asylums into new areas; and to foster a new identity for Italian psychiatrists which would reach beyond the welter of different regional schools and traditions. In some ways the goals were hard to carry on together. Extending the asylum system engaged the psychiatrists’ practical skills as asylum-keepers; and yet the new identity of psychiatry should be based on something more than practical skills. In the event, two small clusters of psychiatrists, first at Milano and then at Reggio Emilia, took the lead, and developed a remarkably explicit strategy not only to secure the scientific status and prestige of their discipline, but also to enhance and widen the sphere of its influence.6 What had been predominantly a practically oriented specialism, tied to various local and regional traditions, thus projected into the future an enlarged and enhanced role. for itself in the new Italy. Significantly, these practitioners typically saw themselves not merely as men of science but as patriots contributing materially to the moral and cultural Risorgimento of the country. The unification presented both an opportunity for a newly organizing profession and an obligation that they do their part. The political and cultural context in which the newly professionalizing psychiatry emerged marked its character in a number of ways. In a word, psychiatry was to be ‘positivist’ in a thoroughgoing sense.7 This implied in fact rather different things about how psychiatrists saw their work with patients, and how they saw their broader social role. It led to a narrow, materialistic, and ‘anti-spiritual’ foundation in medicine, but also to a wideranging involvement of psychiatrists in sanitary and moral education, and in the active containment of social pathology. Within medicine, the risk and error against which the discipline explicitly defined itself was ‘spiritualism’, evident at once in Church teaching, in Romantic psychiatry and vitalist medicine, and in many ‘metaphysical’ aspects of psychological medicine. There were some psychiatrists who openly contested the use of terms such as ‘mental’ disorder, which were judged to be inexact and misleading. The general


tone of positivist culture was congenial to such anti-spiritualist emphases, but within the traditions of psychiatry this represented in many ways also the updating of an earlier, established approach. The organicist emphasis was by no means new; indeed the medicine of insanity in Italy had long followed the general medical currents. It was still common to cite the illustrious and ‘robust’ tradition of the great eighteenth-century pathological anatomists Valsalva and Morgagni. There was, however, a sharpened emphasis on the organic, which in the new circumstances carried two important advantages for psychiatry: it both re-emphasized psychiatry’s direct connections to general medicine, and pointedly advanced psychiatry’s own scientific claims to study mental disorder to the exclusion of any competing approach. By stressing the anatomical and physiological bases of their speciality, psychiatrists tried in effect to overcome the legacy of their practical orientation, and their consequent isolation from the rest of medicine. What was at issue, however, was not merely a question of scientific orientation, but also practical institutional interests. The Church was still fundamentally involved in charities for the insane, and had its own traditions of care and assistance. There were, moreover, other professional groups which had some interest or stake in the practical management of, or scientific reflection about, the insane. Interestingly, the statutes of the psychiatrists’ professional association explicitly limited the possible role in the association of lawyers, philosophers, and even other natural scientists interested in mental disorders. By pointed contrast to the model of the French association, the Italians expressly barred psychologists (Giacanelli 1975: xxiv). In sum, there was a strong consensus that psychiatry had to be strictly ‘tied to a somatic and organicist conception of mental illness’, since that was ‘the only conception through which it seemed possible to transfer madness unambiguously from the moral to the medical sphere, and thus shift its treatment away from expiation or re-education towards properly medical care’ (Agnetti and Barbato, 1982:356). Positivism provided, at the least, a convenient cover for this dual operation. The orientation of the discipline was laid out very plainly in the founding acts of the first major professional essional society. The statutes of the new Società Italiana di Freniatria, founded in 1873, referred to mental illness as an organic phenomenon, and committed the society to study it through the experimental method in pathological anatomy and physiology. The programme published in the first number of the society’s journal, the Rivista sperimentale di freniatria e di medicina legale, left no doubts about what methods were appropriate. The very complexity and the mysteries of the mind, wrote Carlo Livi, require psychiatrists ‘all


the more to grope around in the hidden organic recesses of the brain for the mechanism of human thought’: Our preferred methods will always be histological studies and physiological experiments…. The microscope and the experiment, along with clinical observations, will always be the three guides and instructors which will carry us forward in the exploration of that material seat of the human self known as the brain. (Livi 1875: 4) Only through such observation and experiment could science discover ‘why and how man, by means of the brain, thinks and becomes mad’ (4). The very choice of a name for the association reveals tellingly the same emphases. One obvious possibility would have been to follow the French example, and model the Italian organization on the Société MédicoPsychologique. (Given the influence and prestige of French psychiatry in many parts of Italy this might have seemed an attractive choice.) But significantly, the term psychological was explicitly rejected; indeed the new term chosen, ‘freniatria’, was a way of avoiding entirely the root ‘psych-’, on the grounds that ‘psyche’ connoted the spirit (with lingering echoes of the Platonic conception) whereas ‘fren’ indicated ‘the complex of dynamic forces of the organism’ thus ‘expressing better the idea of an organic material seat’ of the individual (De Peri 1984: 1081). Despite its rather narrow materialist basis in medicine, psychiatry had in practice a quite wide range of applications. For all the emphasis on the dissecting table and the microscope, it was clinical observations of a much grosser sort which provided psychiatry with the concrete means of reaching out and making links with other sciences, in particular anthropology and evolutionary biology. In fact the early researches in neuropathology proved to be relatively fruitless (although they laid the groundwork for a later and more successful tradition).8 What the links between psychiatry and anthropology provided, however, was a way for psychiatry to enter the field of the human and social sciences; the general positivist climate doubtless facilitated such a passage, which amounted to psychiatry’s ascending progressively from anatomy, to nosology, to the social realm beyond. For psychiatrists themselves, the fact that ‘freniatria sperimentale’ had, ‘so to speak, the organ of thought in its hands’ (Livi 1875: 5) put psychiatry in a fundamental position among the sciences, poised to ‘reveal man to himself’, and to provide society with access to a newly discovered realm of moral facts about its members.


This was the second, more public aspect of the ‘positivism’ of Italian psychiatrists. Like other scientists in Risorgimento Italy they were good representatives of that ‘well-established tradition [linking] scientific and above all medical practice with progressive political thinking and activism’ (Tagliavini 1985: 180).9 The particular role of psychiatrists, spanning laboratory research and practical experience with the administrative and political problems involved in running asylums, gave them an important strategic position. Psychiatrists were in a way the ideal interlocutors between general medicine and the wider scientific community involved in developing the applied human and social sciences. In turn the public activities of psychiatrists created a broader interest in their field, ‘involving the whole medical community in a discussion on a discipline which was leaving behind the restricted confines ines of the asylum to include within its proper scientific ambit anthropology, forensic medicine, the law and social science’ (De Peri 1984: 1084). In the climate of the Risorgimento, this public activity of psychiatrists took on something of a reforming zeal. Lombroso was the most famous example of the socially committed psychiatrist, although the influence of his variety of evolutionism on other psychiatrists was limited; even when his influence had faded completely, however, he remained in many ways a characteristic figure for the profession’s wider aspirations.10 There was more to this commitment than good will towards the secular state and a simple desire to raise the public health standards of the nation. The problems of unifying Italy seemed to engage in a particular way the skills of psychiatrists and criminal anthropologists. If, the Risorgimento had ‘made Italy’, as a famous phrase put it, it had not yet ‘made Italians’. 11 There was a pervasive sense that the great social diversity of the inhabitants of the peninsula raised large, and intractable if not insuperable, obstacles to welding them into a modern nation. In the prevailing state of social science in Italy, it was all too easy and likely to interpret the diversity of Italians in gross evolutionary terms, as if some regions or groups had become more highly evolved (not merely in their economic activities, but in their level of civilization and morals) than their backward neighbours. There was also a good admixture of quasi-racial thinking about the presumed origins of the different ‘peoples’ coexisting in Italy. Not surprisingly, many of the problems occasioned by deviants (criminals, madmen, and also some political activists) were likely to be read in biological rather than social terms. The effect of all this on psychiatrists was to make them more than usually sensitive to the social correlates of insanity—and more than usually prone


to provide psychiatric explanations for disturbed (or disturbing) social behaviour. Psychiatrists had to become, in sum, experts on social pathology; and this fixed a social role for them which was over the decades to grow in significance (see Canosa, 1979: 84–5). The first national legislation on asylums was enacted in 1904, four decades after the unification, following a long campaign by the psychiatric community. For years psychiatrists had been struggling to upgrade the conditions of asylums, and trying to introduce a genuine reform which would make asylums more like hospitals. Against the background of those struggles, the 1904 law was in many respeets a hard defeat, although in other ways it offered a full public recognition to the profession. What the law failed to do was to establish a medical or therapeutic charter for the asylum; on the contrary, the mission of the asylum was defined in strictly juridical rather than medical terms. It was as if the framers of the law considered only the custodial, repressive function of the asylum, and hence recognized only that part of psychiatry which was directly involved in public safety.12 The law, and its accompanying regulations passed in 1909, in principle addressed two different ends: the public safety problem of defending society from the dangerously mad; and the need to set general standards for the appropriate care and treatment of the insane, in order both to reform outmoded practices and to unify or supersede the variety of local and regional rules and customary practices which the kingdom had inherited. Of these two ‘opposite purposes’, ‘a custodial-repressive one and a humanitarian-sanitary one’, ‘the former one seems ultimately to have prevailed’ (Maj 1985: 16). In the 1904 law, as contemporaries put it, ‘custodia’ took preference over ‘cura’. The main purpose of the law was to ‘incapacitate’ dangerous madmen, and hence it was drafted explicitly in order to complement other laws on public security and to mesh with the norms of the penal law. In fact, given this intention, the law does not really deal with the ‘mentally disordered’ as that group would at the time have been medically defined. The law disregards completely the variety of conditions presented by mental disorders; it takes into consideration only those which represent social dangers. In other words the law is not concerned with illness, but with dangerous social behaviours which happen to be caused by an illness. This is explicit in the criterion for commitment, and hence admission, to the public asylums, which is reserved for those judged dangerous to others or to themselves, or causing public scandal. There was no provision for voluntary admission (the law was not changed in this regard until 1968).


Commitment required a medical certificate, and had to be ordered by a court or in emergencies by the police; after an observation period of one month, the commitment had in principle to be confirmed. The whole procedure was moreover recorded in the court register, analogously to the treatment of convicted criminal offenders; similarly commitment imposed the loss of various civil liberties. The 1909 regulations were more concerned with the humanitarian and general welfare ends of asylums. They laid down various sanitary rules, cautioned against the overcrowding of asylums, and established the prerogatives and responsibilities of the Director, who was charged to recruit ‘personnel for surveillance from among people having special aptitudes and adequate culture’, and to organize theoretical and practical training for them. The regulations also set down fairly enlightened principles for the management of inmates: mechanical restraints were to be abolished or used only in exceptional cases; work therapy (ergoterapia) should be generally available, preferably in the setting of agricultural colonies; and quiet, chronic madmen, harmless epileptics, and incurables who were not dangerous to themselves or to others, should be housed separately, in places appropriate for the chronically and incurably ill. Many of the protective regulations remained in the event a dead letter, since they were in practice largely ignored. Despite the specific concern of the 1909 regulations with the fate of the mentally disturbed, they in effect sanctioned ‘a rigid institutional structure closely modelled on that of the prison’ (De Plato and Minguzzi 1981: 72). Overcrowding remained a general problem. Asylums had already become silted up with chronic cases, some judged incurable, others in advanced stages of deterioration. But there was no workable way of housing them elsewhere. Instead there was considerable ‘mixing’ of inmates, acute patients put with chronics, the quiet with the furiously mad. the old with the young. In practice, the strict criterion of dangerousness was not the only standard applied to admissions. Some asylums had long had, and others took on, a more general character as welfare institutions. By custom, asylums typically took in young retarded people, the senile, and others with more minor complaints, all generally from the lower social strata. There were alternatives to institutionalization for those who could afford them; as a result the stigma of the asylum was very much associated with poverty. If, admission to the asylum was in practice somewhat more casual than the letter of the law prescribed, the legal strictures nonetheless affected everyone; and since psychiatrists were legally responsible for their wards, they were likely to move very cautiously in allowing people to exit.


The general standards of the institutions were probably similar to those elsewhere in southern Europe at the time. There were some ‘model’ institutions, but in general the whole sector tended to be treated as a necessary evil; hence maintaining good conditions was likely a recurrent struggle, with the constant risk of lapsing into a barren, routinized custodial regime. In Italy, as elsewhere, the high standards of a ‘model’ asylum dedicated to giving medical attentions to those with a prospect of recovery proved very difficult to sustain. The public role of psychiatry was in many ways reshaped by the 1904 law. Although the law frustrated many psychiatrists’ aspirations, the discipline as a whole undoubtedly benefited from the public recognition which the law extended. The law gave it ‘a new prominence, both in the scientific community and in the sphere of social control, where psychiatry could claim to represent more “modern” and less crude techniques than those traditionally used in penal institutions’ (Canosa 1979: 97). For better or worse psychiatry became tied up still more closely with the manicomio (asylum); even if it represented a compromise on certain therapeutic ideals, running the asylum would allow psychiatry to link up its humanitarian and philanthropic bent with its scientific and medical pursuits, and to pursue both while fulfilling the mandate to protect society from the dangerously mad. The asylum seemed to offer psychiatry, in sum, a ‘space to organize secure confinement, along with the most ample opportunities for its scientific work, for experiments with rehabilitation, and for practical charity and relief’ (Giacanelli and Campoli 1973: 3). The 1904 law was probably the single most important factor in shaping the development of public psychiatry in Italy. Although frequently criticized, it remained in force, unmodified, until 1968. Even though certain of its provisions were in practice ignored, it was nonetheless a legal fact, and perhaps more significantly a legal fact which made a strong symbolic statement about the social problem of insanity, the public role of the psychiatrist, and the necessary distance between society and the psychiatric institution. The law helped to fix certain images which it proved quite difficult, even in very different circumstances, to overcome. The ‘dangerousness’ of the madman, the juridical definition of the psychiatrist’s wardship over his charges, the whole purpose of the asylum to ‘incapacitate’ a social peril: these were elements of the law which not only conditioned public attitudes, but threatened to override any more benign, therapeutic image of the mental patient, the psychiatrist, and the mental hospital. This was one important historical legacy which continued to weigh down on Italian psychiatry right up to the present.


The longstanding organicist orientation of Italian psychiatry was a second sort of conditioning influence, although one whose effects are harder to gauge. Some historians have been tempted to regard this organicism as an ideology of sorts, and one particularly appropriate for purposes of social control. On such an argument, the prevailing biological determinism of Italian psychiatry essentially precluded any interpretation which would make deviant behaviour socially intelligible; hence the repression of deviance appeared to involve, not political or social agents, but rather the technical roles, of physician and mentally afflicted patient This is doubtless a useful framework for understanding certain political abuses of psychiatry. But there is no need, and probably no good justification, to flatten out the history of Italian psychiatry in this fashion. It is perhaps better to see organicism as a general medical orientation which operated as a filter of sorts, letting in some things, while blocking out others. In the nineteenth century, for instance, Italian psychiatry was receptive to certain (limited) ideas of ‘moral treatment’, but quite hostile or indifferent to others that were judged too ‘metaphysical’ (see for instance Agnetti and Barbato, 1982:358–68). Likewise, in the early twentieth century, the prevailing organicism hardly presented a congenial atmosphere for psychoanalysis, which in fact was acknowledged only relatively late, and never warmly received. When later the leading Italian analysts were forced into exile, psychoanalysis was effectively banished from the scene until the 1960s.13 The most important effect of this filtering was probably the relative weakness of psychology, social psychology, and their offshoots, which never really gained a foothold in the neuropsychiatric training programmes and contributed little to hospital practice. The consequence was that areas in which Italian psychiatry had traditionally concentrated were likely to thrive, while other varieties of psychiatry were blocked, underdeveloped, or simply unrepresented and absent Compared with other national traditions, Italian psychiatry was notably less diversified, and more monochrome. In the fascist period these general characteristics were probably accentuated with the sharp emphasis on national traditions, and the isolation of Italian culture from many foreign currents. When Italy emerged from the fascist period at the end of the war, its psychiatry for whatever cluster of reasons looked in many respects backward and provincial.14 There was nonetheless a certain logic (a perverse logic) evident in the way that the parts of the psychiatric system were combined and functioned together. This is perhaps a clue to the longevity and resistance to change of the system, and a way to explain the lingering effects of Italian psychiatry’s historical legacy. More than in other countries there


was a ‘fit’ of sorts between the psychiatric profession, the mental health law, and the asylum system. The prevailing bio-determinism of Italian psychiatry (with its not uncommon assumption of a hereditary ‘taint’ in insanity) tended to induce a certain therapeutic pessimism, even fatalism, about the prognosis of mental disorders; the expectation was not quick treatment and release, but having to deal with chronic, enduring, and probably degenerative conditions. Hence psychiatrists were disposed to think of the asylum as a place to provide care for long-stay patients. The public mental institutions, for a different set of reasons, were explicitly organized for long-term care. Conceived as they were for social defence, to incapacitate the dangerously insane, mental hospitals shared many characteristics with penitentiaries; their custodial regimes, for reasons of security or economy, were similarly well adapted to the exigencies of long-term custody. Finally the law, in highlighting the dangerousness of the insane, tended to rationalize long-term commitment as in the interests of the community; it moreover justified the notion of excluding the insane from society and erecting high barriers against their reintegration into society. The perverse fact is that these various elements—therapeutic pessimism, concern with dangerousness and social defence, custodial regimes designed for long-stay chronic patients—tended to fit together all too well, and to reinforce each other. There was an evident risk in the psychiatric system as it had developed of collapsing into a selfreinforcing, vicious circle from which it would be difficult to exit. Custodial institutional regimes encouraged or tolerated cronicità (chronicity); the organicist orientation of psychiatry explained without difficulty why insanity produced chronic disorders, or it tended to induce resignation about them; and anxiety about pericolosità (dangerousness) provided, among other things, a rationale for and justification of the custodial asylum, and the pessimistic state of affairs.

36

Chapter 3 Pilot experiments with ‘alternative’ psychiatry in the 1960s

By the early 1960s there were widespread signs of discontent with the state of Italian psychiatry and its mental hospitals. Within the psychiatric profession there was a growing sense that Italy lagged behind other European countries and the USA, and that it needed to catch up with international standards. The backwardness of Italian psychiatric services seemed in fact more and more glaring; it was taken up polemically as a symptomatic and characteristic example of a general cultural backwardness, at odds with an increasingly dynamic economy and society. The 1959 Mental Health Act in Britain and the ‘bold new initiative’ in 1963 proposing community mental health centres in the USA, were contrasted pointedly with the repressive 1904 law which was still ‘scandalously’, in the view of its critics, in force in Italy. There was also an accumulation of frustrations from earlier, failed efforts to get the system moving. In 1951 and again in 1953 a proposal had been presented in Parliament to modify the 1904 law, which in essence would have shifted the problem of mental disorders from the public security to the public health realm. The point of the proposal was to make psychiatric services available as a matter of medical need, independent of the criterion of dangerousness. While the proposal gathered some support, a number of psychiatrists expressed reservations, and the idea languished (see Centro nazionale di prevenzione e difesa sociale 1956). In 1964 a national psychiatric conference was convened under the provocative title ‘Processo al manicomio’ (The asylum on trial’). This was an occasion to air wide-ranging criticisms, and to urge the modernizing of the traditional mental hospital, and of mental health services generally. The conference participants voted a number of resolutions, including one strongly endorsing the principle of ‘territorial services’ for mental health, on the French model, to be provided by medico-social teams working in geographically defined catchment areas

38 PILOT EXPERIMENTS WITH 'ALTERNATIVE' PSYCHIATRY IN THE 1960S

(Processo al manicomio (1965). Despite the active discussion of new initiatives in social psychiatry, the practical outcomes were, in this case as in others, few and disappointing. The prospects for any widescale reform or modernization of services seemed in fact rather dim. There did not seem to be the political will, or the resources available, to attend seriously to the problem of institutional psychiatry. Psychiatrists as a group were moreover internally divided and largely indecisive in recommending clear directions for change; the majority tended to be corporatist and rather conservative in their orientation. What emerged against this background, and effectively began the process of innovation, were a series of local initiatives which captured and channelled the energies of a number of discontented younger psychiatrists. Working ‘experimentally’ in what often looked to be decidedly marginal conditions, such psychiatrists tried ‘to do psychiatry in a new way’, and to break out of the limiting and discouraging circle of pericolosità, eredità, and cronicità, (dangerousness, hereditary taint, chronicity) in which asylum inmates seemed to be caught. What began as isolated initiatives would in the end prove to be ‘pilot’ experiences, which formed a whole generation of leaders in the eventual movement for an 'alternative' psychiatry. It is important that these initiatives were focused from the beginning on the public system. The discontents in other countries which were gathered under the rubric ‘anti-psychiatry’ were often diverted into creating private alternatives (like the Philadelphia Association and Kingsley Hall organized by Ronald Laing and his associates in London). This was probably not an option in the Italy of the early 1960s; in any event there was a clear commitment to work in and through, and to try to transform, the public institutions. It is also significant that these initiatives did not arise in, or draw support (until much later) from, the universities. The training of psychiatrists in that period was organized largely through departments of neuropsychiatry, allied with university clinics. The structure of training and employment was very hierarchical, with appointments and promotions openly controlled through patronage networks. Since the university clinics were dominated by the senior professors, they would likely have been relatively impermeable to discontents percolating up from below.1 The public mental hospitals, on the other hand, were basically a separate and independent network, and were seen in comparison to the elite university clinics as the poor relations of the mental health system. In university clinics the case loads were predominantly voluntary


patients, often neurotics or others suffering from the less serious disorders. The university clinics were in a position to admit their patients quite selectively. The public mental hospitals by contrast practised ‘heavy’ psychiatry, with an involuntarily committed patient load, drawn overwhelmingly from the lower classes, and filled with chronic patients and those suffering the more serious disorders. Positions in the public hospitals were obviously in general less prestigious; they were often seen as dead-end jobs, or way stations where psychiatrists waited for the chance to reenter the university hierarchy. In some ways, however, the public hospitals, despite their general scarcity of resources, offered an opportunity for innovation which would likely have been blocked elsewhere. Their lower status made them relatively more open to those who might choose to pursue unconventional careers; and more importantly their degree of independence from the centres of power in university departments, and the unusually wide powers and scope of the hospital director’s office (as those powers had been established by the 1904 law), made the public hospitals at least potentially a rival powerbase for innovators.2 The single best known, and most influential, of the local initiatives began at Gorizia, a town in the remote north-east corner of Italy on the Yugoslav border, where in 1961 a young psychiatrist from the Veneto region, Franco Basaglia was appointed medical director of the large (800bed) local mental hospital. Basaglia gradually formed around him a small équipe of psychiatrists interested in non-traditional work; for most of the group, going to Gorizia was something of a break from typical career patterns and involved some considerable sacrifices. The members of the group were not all like-minded, but were unusually determined to innovate and to try to resolve their dissatisfactions with the practice of psychiatry. For most this was to be an intense collective experience enduring over several years or more. Basaglia himself was in many ways not well prepared for work in a public institution. Although he had more than ten years’ experience working at the neuropsychiatric clinic attached to the University of Padova, he had little or no experience with the conditions of working in public mental hospitals.3 He brought to the job, however, as a coworker later testified, ‘a passion and courage of which no one else would have been capable in those years’, and was determined ‘in unpropitious cultural and political conditions to make [Gorizia] into a model, “pilot” experiment’ (Jervis 1977: 20). The group working at Gorizia had in general few theoretical resources to draw on, and virtually no domestic examples or models to follow.


What they knew. of social psychiatry came in large measure from reading and to a lesser extent from visits to psychiatric facilities in other countries. Their image of what ‘progressive’ psychiatry might be was drawn almost entirely from abroad. But what Gorizia became was something more and different than a copy or local adaptation of foreign models. Even though later the image of Gorizia was idealized and mythologized, there was undoubtedly much that was original and imaginative in the actual experience. The first steps that Basaglia and his team took were simple practical changes designed to humanize the hospital environment, and to begin to introduce the look and feel of an ‘open’ hospital. They abolished physical restraints, substituting a closer and more attentive vigilance of patients. They did away with various demeaning institutional rituals, and tried to introduce a measure of patient self-government. Cupboards were brought on to the wards, so that patients could keep personal things. They were allowed to wear their normal clothes instead of the standard hospital issue. A café and a beauty parlour were opened for the patients’ use, which would eventually be handed over for them to run themselves. Among therapeutic measures, the use of electroshock was suspended, and medications were reduced or monitored more closely.4 Creating the atmosphere of an ‘open’ hospital marked an abrupt change in established practices. At the outset this apparently created a gulf of sorts between the psychiatrists and the nurses and psychiatric aides, many of whom were disturbed and challenged by the changes and the sometimes authoritarian, top-down way in which they were apparently introduced. Although there was still a formal hierarchy of roles, the new policies had effectively undermined for a time the traditional solidarity of the staff. As a consequence the psychiatrists were obliged themselves to spend more time on the wards, and to delegate less, than they might have done in other circumstances. This dynamic alone encouraged what one staff member recalled as the apparently ‘continual and “ubiquitous” presence’ of the psychiatrists on the wards (Slavich 1968: 187). From the outset the changes were the occasion for discussion and reflection among the team. A strong collective orientation soon developed, with a sharp self-consciousness about the process of changing the hospital. The team viewed what they were doing as in many ways a laboratory for innovation in public psychiatry. Basaglia’s theoretical orientation had a strong effect on the early work of the group. After a conventional medical training, he had been drawn to phenomenology and existential psychiatry, which were then very much a minority current in Italy but effectively the only alternative available


to the predominant bio-determinism of the field. (Psychoanalysis was to have a flourishing in Italy, but beginning really only in the 1970s.) Phenomenology and existential psychiatry were in many respects the opposite extreme to what was still characterized as the ‘positivism’ of Italian psychiatry; in some ways they were its logical antidote. As a theoretical resource they set up from the beginning a critical opposition to prevailing theory and practice, and seemed to present a new and alternative stance from which to approach patients. In the way that it placed value on the subjectivity of mental patients, even the most regressed, phenomenology offered a theoretical rationale for the ‘ubiquity’ of the staff; its immediate practical effect was to throw the staff into the midst of the patients, mingling with them in a way then quite uncommon for Italian psychiatrists in the public hospitals. The first aim of the experiment at Gorizia was to come to know and to communicate with the patients, not first and foremost as patients, but simply as individuals whose world was the hospital wards. In the idiom of the moment, psychiatrists wanted to understand how these individuals perceived their world as ‘subjects’, rather than how they were ‘objectified’ by diagnostic categories. To approach a patient without prejudice or pre-suppositions, Basaglia argued, it was necessary to ‘place in brackets’ the patient’s diagnosis, ‘since that diagnostic label hung fixedly on the patient like a preformed value judgement’ (Basaglia 1968: 32). This ‘bracketing’ was not, as later critics were to charge, a denial of mental illness; it was part of an interpretative strategy to approach a patient, enter into a relationship with him or her, and then on the basis of an understanding of the patient’s actual ‘being-in-the-world’, to start to treat him or her. ‘It is not that we leave out of consideration the illness’, Basaglia wrote, but that in order to enter into a relationship with an individual, ‘it is necessary to establish [that relationship] independently of the label by which the individual is defined’. ‘What is important is to become aware of who is this individual [the patient] for me, in what social reality he is living, and what his relation is to that reality’ (Basaglia 1968: 31–2).5 In the conditions of a crowded asylum, it was of course difficult to create encounters one-on-one; the limitations, even preciousness, of phenomenology and existential psychiatry as treatment modalities quickly became evident. (In the mid-1960s (Basaglia 1968: 25) there were about 500 patients at Gorizia, 9 psychiatrists, 150 nurses, and a few other staff members.) The theoretical significance of phenomenology as a counterweight to traditional psychiatry nonetheless remained fundamental, not only at Gorizia but at least implicitly throughout much


of the later movement for an alternative psychiatry. The significance was two-fold: phenomenology (and later psychoanalysis) served, first, as a rationale for trying to make direct contact with the patient, for valuing the patient’s subjectivity, and for regarding the patient as a socially intelligible individual; and secondly, these more interpretative psychiatries offered an alternative standpoint from which to launch an all-out attack on traditional ‘positivist’ asylum psychiatry, whose real function was assumed to be to rationalize, or provide an alibi for, the degraded conditions of asylum life. Not only was ‘positivist’ psychiatry judged to be unhelpful, it was attacked as positively misleading and mystifying. The phenomenological notion that positivist psychiatry had ‘objectified’ the patient led on to a second critical step in the reformers’ reasoning: in trying to ‘make contact’ with patients they discovered that what constituted the social reality of these patients was their ‘objectification’ as certified, mentally ill inmates in a closed institution. This was the object that the psychiatrist could actually observe in the mental hospital. Hence, what ‘positivist’ psychiatry actually confronted, and provided the means of describing, was not a suffering individual but the depersonalized shell of an individual. Here the reformers, moving well beyond phenomenology, began to draw in a strong, even tendentious, fashion on the notion of ‘institutionalism’ or ‘institutional neurosis’. It was the hospital itself which was making the patients as they were. The deteriorated state of the inmate in the asylum (the ‘shell’) was not a datum to be explained as the progressive outcome or end-result of a disease process; it was rather the social product or artefact of institutional conditions themselves. Thus psychiatry treated a ‘disease’ which it was complicit in creating. Positivist psychiatry had traditionally served to obscure this social process, which Basaglia and his associates took rather uncritically to be an unambiguous fact, by then conclusively established by British psychiatrists and American sociologists. On such an argument psychiatry was doubly guilty: it both mistook the results of the degrading social effects of institutional conditions for the results of incurable chronic mental diseases; and it served to cover over and obscure that process, while justifying its outcome (Onnis and Lo Russo 1979: 55; Basaglia 1968: 128–9, 141). Given the ‘corrosive’ processes of institutionalism, any real approach to the patient necessarily ran into the barrier of the institutional regime itself, with its frozen hierarchy and mortifying rituals. Having looked for and tried to make contact with the


patient, Basaglia had discovered instead that the institution was a barrier standing in the way. In order to confront more directly the conditions of institutional life, t he (Basaglia) team turned to group techniques more adapted to institutional conditions. They began the practice of daily assemblies, bringing together both staff and patients; this was a familiar technique derived from British and American social psychology, but in Gorizia the assembly soon took on a quite different form, and significance. In fact in some ways these asylum assemblies prefigured the spontaneous mass assembly which was to be such a characteristic feature of the late-1960s workers’ and students’ mobilizations in Italy. The assemblies presented a number of opportunities. They created activity on a ward, which sometimes had a stimulating effect. They could be used as a forum for inviting discussion about problems, conflicts, or tensions within the group. They were a practical means for working out collective decisions, or for focusing group pressure on particular individuals. Basaglia seems to have regarded the assemblies also as a way of drawing patients out, and putting them ‘back in touch with their own biographies’; the focus was not merely on the here and now, but on understanding the transformations which people had suffered over time in the institution. Retracing a life history was thus (among other things) a way of drawing attention to the malign effects of the institution, identifying it as the problem, and thus bringing to light the patients’ collective predicament as inmates. As a colleague of Basaglia later wrote, the assembly offers everyone involved in the hospital and even the public the opportunity to meet with each other, [and it] has given a voice to those previously excluded and has utilized a new epistemology founded on the collective decodification of suffering, of its history and of the possible answers which have been given, denied, or will be given. (Tranchina et al. 1981:185) The spirit in which assemblies were conceived was evident also in the way that the ‘therapeutic community’ was gradually introduced as a technique for the collective management, and ultimately for the collective destruction, of the hospital. Basaglia and several other of the psychiatrists were familiar firsthand with some of the British experiences of therapeutic communities; but from the outset it was clear that they had quite different purposes in mind. In Britain the therapeutic community


was used to focus attention on the social dynamics of ward life, as a way of harnessing those dynamics for therapeutic or rehabilitative ends. Or, more generally, the therapeutic community was seen as an innovative style and technique of administration, a way of modifying how an institution was run; in place of an authoritarian, custodial, and antitherapeutic regime, it offered a new direction at once humanitarian, permissive, and presumably (as the term suggests) communal and therapeutic. At Gorizia the therapeutic community did not represent so much a new technical model for running the asylum, as a powerful means of unleashing new and dynamic interpersonal relations. To what end, it took some time to spell out. The very way Basaglia describes the therapeutic community indicates a new conception: it is ‘a place where all the elements (the mentally ill, nurses and physicians) are united in a total effort’; but in this union, it is conflicts which provide the therapeutic motor: ‘the contradictions in [the community’s] reality are the soil from which spring a reciprocal therapeutic activity’ (1968:108). The flattening of hierarchy, communal norms, and permissiveness served as means, in other words, of revealing and throwing into relief the ‘contradictions’ inherent in the institution. Such language hints at a dynamic process (of what was styled dialectical or ‘negative’ thinking) which is simply absent in the British experiences. Given the different ends to which Basaglia turned the therapeutic community, he naturally enough tended to criticize what he saw as the limits of the British conception; and not surprisingly criticism of the limits in theory led to criticism of its limits in practice. Basaglia came in the end to speak of a second phase in the creation of the therapeutic community, which would involve contesting and even attacking head-on the community itself. It was in this second phase that the wider ‘political’ aspirations of the Gorizia experiment began to appear. Basaglia himself traced the passage to this second phase in roughly these terms: ‘opening’ the hospital could materially improve the conditions of inmates. The activism of the staff could communicate to the patients a new optimism, counteracting the prevailing therapeutic nihilism or fatalism, and conveying to the patients that the community was now a place of caring. On the other side, patients with more chances to take initiatives could better develop and express their own points of view, and demand a hearing. In so far as patients became newly conscious of their rights, they would ‘no longer accept to be “objectified” by the distancing gaze of the physicians’ (Basaglia and Tranchina 1979: 13). These were undoubtedly ways of humanizing the hospital, but by the same token there was a risk of creating a ‘comfortable haven’ or a


‘communitarian island’ in which the inmates would still be effectively imprisoned, but against which they might be less inclined ever to rebel (see Scheper-Hughes, and Lovell 1987: 19). For them to recover their ‘subjecthood’ and capacity to act as agents would require calling into question the humanized hospital itself, which was still a segregated place denying full dignity to its inmates. To make this step, Basaglia spoke of trying to mobilize sentiments among the patients into an ‘institutional rage’, which would focus their aggressivity on the institution as both the symbol of, and the practical means for, their exclusion from the broader society. The logical sequel to this institutional rage would be actually to destroy the comfortable haven or communitarian island—actually to destroy the physical barriers which separated mental inmates from society at large. That would mean in turn raising explicitly the question of the place of the insane in society. Why were they excluded? Destroying the institution would call into question the dynamic of exclusion itself; it would raise, in other words, the ‘contradictions’ in the larger society itself which had been silenced or shunted aside by the practice of excluding and segregating the mad. As Basaglia reconstructed the stages through which the Gorizia experiment passed, this conclusion seems to arise in his account as the culmination of a natural course of development: the custodial hospital was intolerable; it had to be humanized. But in the humanized hospital, the institution, as symbol and reality of the insane’s exclusion from society, persists; it too must be destroyed, so that the root contradiction could be confronted. The rather schematic and ideological notion that the asylum had to be destroyed as the prerequisite for any further advance, became more and more insistently the conclusion of the experience. The real struggle in other words had to move beyond the asylum, beyond attempts at making the asylum therapeutic, to questioning why it need ever exist. To put the matter in a formula, if phenomenology could alter the psychiatrists’ perception of the inmates, it would take a different praxis to allow those inmates to realize their subjectivity; in a therapeutic community inmates could begin to act again, but only in the very process of destroying the asylum which had depersonalized them and stripped them of their liberty and dignity, could they fully restore themselves. But destroying the asylum would mean in turn forcing society at large to confront the mad. or forcing society to confront the contradictions which had originally called into existence, and which continued to justify, the asylum’s function in sequestering and hiding deviance. The object was


to deprive society of the place ‘which it had expressly created to inter its contradictions’ (see Castel 1971). What the destruction of the asylum really implied or required was finding a way for or the insane to be in society, or a new way for them to be with society, even as they were being treated and ‘cured’. Basaglia presented this as the conclusion to which the experiences at Gorizia, proceeding through their various stages, logically led. In a sense that theoretical conclusion is also a way of understanding the actual outcome and legacy of the Gorizia experiment. Having reached the point of moving out of the asylum into the larger society, Basaglia himself felt that the Gorizia experiment was effectively over and ought to be terminated. What could be accomplished within had been accomplished. He had apparently wanted to move on, in any event, for some time; the explicit motive for his leaving in 1969 was that local political resistance and interference threatened the Gorizia experiment, and made it impossible to move out from the asylum into the community. In fact there was probably a more explicitly political motive involved on Basaglia’s part; as he later wrote: ‘the Gorizia experience had to be liquidated’, because its purpose had never been to create and perfect a new ‘technical’ model of the asylum which would remain there as a demonstration case for anyone to come and see, and perhaps imitate elsewhere. Gorizia raised instead the larger political and social problem ‘which could never have been limited to the humanitarian transformation of the hospital’; what was at stake was ‘to put in question the whole purpose of the existence of the asylum and its functions in our social structure’ (Basaglia and Ongaro Basaglia 1975:37–8). Once this had been accomplished, at least part of the psychiatrist’s task would lie not in working with patients, but in a broader political and cultural campaign to change society’s relation to the mentally disordered. In the wider sense the real outcome of the experience was the publication of the collective volume L’istituzione negata (The Institution Denied), edited by Basaglia (1968) and with contributions from many of the Gorizia équipe, which marked the symbolic culmination of the experience. It was as if the experiment had gone as far as it could, and the future struggle lay elsewhere. This was effectively what the book announced. Its great success, coming at a crucial juncture in the great social mobilizations of the late 1960s, quite suddenly made the Gorizia experience famous, and opened the way to a new phase in the advance of ‘alternative’ psychiatry.6 A second ‘pilot’ experience which was to have wide echoes was organized in Reggio Emilia from 1969 through the mid-1970s. This was


in many ways complementary to the experience in Gorizia, since it was an effort to organize from scratch new psychiatric services ‘sul territorio’. (outside the hospital, in the social environments of the community itself) which would not depend in any way on the existing psychiatric hospital facilities. There were two rationales for working outside the hospital: to try to prevent hospitalization by timely interventions in personal crises as and where they occurred; and to try to bring psychiatry into the community by increasing popular awareness of and familiarity with psychiatric difficulties and psychiatric interventions. It was, perhaps even more to the point, a way of taking up the challenge of a thoroughgoing social psychiatry: if the psychological distress of individuals is somehow ‘social’ in origin, then why should the intervention to respond to psychic distress not be comparably ‘social’, going to the very roots of disorder? The plan to create such new services came from the communist-led local administration of Reggio Emilia and its environs. Reggio Emilia is a town of about 140,000 people in the Red belt of central Italy known for its sound civic administration. The invitation to organize the services went to Giovanni Jervis, a member of the Gorizia group who was also known to be one of the more politicized of the group.7 Jervis recruited a staff made up of other politicized psychiatrists, psychologists, and social workers, who came from all over Italy and even from abroad; the team also recruited local people who were trained as paramedical personnel. The locals were by and large Communist Party militants, who were for their own part well disposed to trying to link psychiatry and politics, and provided one sort of immediate link with the community of Reggio. In the beginning, ‘in the spirit of 1968’, there was a tendency to interpret all psychiatric or psychological problems in social and political terms; the idea was that a consistent sociological orientation, and a dose of common sense, would suffice. But fairly quickly the limits and naiveté of this attitude became evident. The group was trying to break new ground, and was accordingly uncertain about, and willing to experiment with, its public image, style of work, and relation with public institutions. But if it became clear that merely attending to the material needs of clients was not enough, it was still not clear what followed. The group wanted at all costs to ‘de-psychiatrize’ their work, and to refuse to enter situations which seemed to thrust them into any role. of psychiatric ‘policing’. In order not to fall into the risks of playing explicit roles, in social control, the group kept its work quite fluid, refusing to establish enduring structures or to build structures in which their roles, could be institutionalized. This posture even led to their rejecting the idea of


creating a day-hospital and a supportive hostel for ex-inmates, on the grounds that these could easily degenerate into segregating structures (mini-asylums) serving the old social control functions. The stress throughout was on working in ‘normal’ settings—in the situations, from families to factories, in which psychic distress actually emerged. Several years into the experiment, the staff were organized into six teams assigned to different neighbourhoods of the area, along with a seventh team specialized in child psychiatry which worked exclusively with local schools. Within each team, cases were assigned to a pair of workers, usually including one more experienced person with another less experienced. The style of work of the teams was quite informal. Decision-making was collective, and even the paramedicals who had no previous training were expected to contribute to discussions and shoulder responsibility for decisions; with growing experience many of the paramedical staff became, on Jervis’s judgement, competent therapists. The therapeutic orientation of the work remained quite eclectic, partly as a conscious strategy of resisting the allure of one or another competing school, and partly as a means of insisting that in the great array of situations which presented themselves, the appropriate response would have to be figured out ad hoc, drawing on the full variety of therapeutic resources. Many of the clients treated were psychotics; in fact the group tried to seek out the more difficult acute cases, since its charge was to try to prevent hospital admissions. Much of the work was done through home visits, drawing in parents, relatives, neighbours, workmates. In fact there was a tendency to speak not of ‘cases’ but of ‘situations’, on the idea that whole social networks had to be addressed. The model of intervention was more like a collective politics than individual therapy. It was typical for the team to try to collect together a whole set of people who were part of a ‘situation’, including, for instance, a whole family but also neighbours and relatives, or teachers and local government officials. The style of intervention with such assembled groups was rather low-key, a matter of trying to link the given problems at hand with the characteristic problems of everyday life in similar social milieux. There was a parallel focus on preventive work, again in collective settings. One of the innovations the team developed was organizing meetings directly on the shopfloor in factories to discuss such problems as stress, anxiety, and nervous exhaustion in the workplace. The team was actually conducting research on that topic, which provided a pretext for being around, and for sharing its analysis; in group discussions and presentations the team would try to link the individual and collective


psychological problems of workers with ‘the contradictions and oppression inherent in the workers’ situation in factory x’ (Onnis and Lo Russo 1979: 251–2). After several years the experiment began to run into a series of troubles, which signalled how precarious were the circumstances in which it had been encouraged or tolerated. A number of changes in the local and national political climate cooled politicians’ and administrators’ attitudes towards the experiment; a local government reorganization stripped the psychiatric teams of some of their autonomy, making them subject to relatively unsympathetic local neighbourhood councils. From 1973 onwards the activities of the teams were subjected to an increasingly heavy-handed scrutiny and political pressure from local and provincial (Communist Party) administrators. Moreover the criticisms from the quarter of the physicians’ professional organization became more acerbic and more publicly assertive. It became clear that despite the teams’ having reached out successfully to certain groups in society, their general acceptance in public opinion was still rather low. For these reasons the experiment at Reggio had a fairly limited life-cycle; but this was in a way to be expected, given the efforts of Jervis and his associates to pursue a radical experiment which seemed at times less oriented towards providing systematic services, than to exploring in an open-ended way the possible forms of an alternative psychiatry. The experience did, however, seem to carry a broader message. The work of the teams demonstrated that it was possible to ‘socialize’ psychiatry, in the sense of bringing psychiatric services to the community at large. Rather than sending people to a remote, bed-care institution, it was possible to identify needs in the community first, and bring services into the locale, to serve those needs. But the other part of the lesson was that such ambitious attempts to socialize psychiatry were likely to be tolerated only up to a certain point. If, and when they became too ‘dangerous’, the experiments could be quickly undermined or wound up by local authorities.8 The conclusion from the experience at Reggio, in other words, was that in addition to creating innovations and experiments, it was necessary to secure the political conditions in which the new kinds of psychiatry would be allowed to develop.

50

Chapter 4 Towards an ideology for Democratic Psychiatry

One virtue of Basaglia and his associates’ writings on Gorizia is the sense they offer of ongoing work—of a dedicated struggle to push through and beyond the dilemmas they encountered in their psychiatric practice. Gorizia was lived as an experiment, although towards what end no one at the outset really knew. But even as the work remained ‘provisional’, it was carried on in the midst of its contradictoriness. The institution was denied, but of course not abandoned; the patient’s illness was bracketed, but also cared for; therapy was rejected, but still, in less formal or obvious ways, practised (see Basaglia 1968: 373). When Basaglia began to think beyond the Gorizia experience and to present its lessons in more general terms, his writings took on different tones, more schematic and sloganizing—in sum, more ideological. It was one thing to try to find a new way of doing psychiatry, conceived as the project of a group of psychiatrists working in a given setting with a given set of patients. It was quite another thing to draw a general lesson, and to try to communicate in wider terms what the experience had been about, and what it implied about reforming the mental health services. For this second task Basaglia and his associates really had no recognized professional discourse in Italy to draw upon. They did not choose, even if they had been able, to present their work simply as an experiment in social or administrative psychiatry, as comparable experiences abroad might have been conceived and reported in places where those fields were already familiar. Instead they hoped to communicate directly with other practitioners in Italy, who were similarly without obvious frames of reference, to suggest what it might be possible to do differently in Italian psychiatry, even in the then current situation. For this reason alone it is not surprising that the writings of Basaglia and his associates were quickly cast in a wider, improvised, and decidedly non-technical framework. Although the more ‘ideological’ writings lose the immediacy

52 TOWARDS AN IDEOLOGY FOR DEMOCRATIC PSYCHIATRY

of accounts of practical work with patients, they proved to be in other ways a vivid means of communicating a point. As Basaglia’s political horizons expanded, his writings took the form, of a virtually symbolic analysis of Society and the Madman, focused on the general mechanisms of exclusion and segregation. The path from one to the other—from the specific institutional setting to the general problem of madness in society—was worked out in Basaglia’s writings through the idiom of a Sartrean social psychology.1 The encounter between psychiatrist and patient in the asylum had to be understood as the endpoint of a series of developments. The critical interpretative question was what prior (and now hidden) social processes had created the very roles, ‘psychiatrist’ and ‘mental patient’, and locked them together away from society in the closed world of the asylum. The clue to understanding the pre-programmed interpersonal dynamics of the asylum lay, in other words, in society, in the mechanisms of social exclusion which had created the asylum and thus determined the relations between society and the outgroups it has ejected. The Sartrean emphases were one of Basaglia’s distinctive contributions (although not one shared equally by his associates);2 and they left an important mark in what was probably the central organizing concept for alternative psychiatry—the notion that the mentally ill were excluded and ‘marginalized’, and that the important task was to reintegrate them into the fabric of society. ‘In a Manichean world’, Basaglia wrote, ‘the figure’ of the mental patient cannot be confronted since it evokes a problem that calls the world into question’ (1973:9). Behind this formulation lies a cluster of notions. The ‘mental patient’ represents a category of danger, a symbolic Other, which cannot be known in itself. Hence the ‘mental patient’ plays a symbolic social role: it is the mental patient’s exclusion from society which marks the boundary in the Manichean world. Whatever may be the individual’s own identity’, disappears beneath the symbolic role which the mental patient must bear. Moreover this role is also a social destiny: ‘at the most [the mental patient] can change roles, within the system itself, for it is the tranquillity of that system that must be safeguarded above all else’ Basaglia (1973:9). This is a conception governed, in other words, by a general mechanism of Self and Other, of identity and exclusion. ‘Society continues to try to envelop him [the mentally disturbed individual] in the role of patient so that it is not obliged to confront him in everyday life’ (1973:12). More fundamental than the fate of any one individual is the logic which predetermines the roles, available; it is this logic which provides the key to the madman’s social fate. Since the tranquillity of


the system depends on the expulsion of the Other, the mental patient’s social fate is effectively sealed; once branded as a mental patient, the individual is unlikely ever to escape entirely that stigmatizing symbolic role. What the experience at Gorizia had demonstrated, recast within these terms, was that society’s ‘tranquillity’ had to be disturbed. Put in blunter words, ‘society had to be brought into collision with the problems it had tried to lock away in the asylum’ (Mollica 1985: 31). Thus ‘only when the problem [of the mental patient] has become part of the experience of each and every one of us, will society feel obliged to come up with real solutions through the establishment of truly therapeutic measures’ (Basaglia 1973:12–13). There is something chilling in the abstract consistency of this formulation. For what it requires is not sympathy for the mentally disordered or acknowledgement that they have been badly treated, degraded, abandoned. The point is that the category ‘mental patient’ itself should not exist; the indignation arises not against the fate of actual suffering people, but against the general mechanism of ‘splitting’, which is the Manichean fault of existence. It is true that talk of a Manichean world may also be effective rhetoric for mobilizing support and sympathy for the mentally disordered, in the same way as the slogan ‘out of sight, out of mind’ works to focus guilty attention on the neglected and needy. But there is an abstract radicalism in Basaglia’s formulation which betrays a more serious ideological point. It is as if psychic suffering could only properly be relieved through the long, indirect route of discovering and resolving the social, and ultimately existential, contradictions which are at its root. This is the idea which ultimately drives Basaglia’s abolitionism: wherever the asylum continues to exist, society will inevitably continue to use it to silence and sequester the evidence of its contradictions; by contrast the radical act of abolishing the asylum would undermine ‘the ideology of a society that, by denying its own contradictions, would like to be seen as a sane society’ (Basaglia 1973:13). The idea is nothing less than destroying the asylum in order to force a revolutionary change in social relations, and in the quality of the human experience of suffering and finitude. It was in such terms that Basaglia initially formulated the ‘political’ task of the psychiatrist. As abstract and uncompromising as this notion of abolishing the asylum was, the anti-institutional analysis arising from Gorizia immediately struck a deeply resonant chord in the Italy of the late 1960s. In fact L’istituzione negata was one of the key texts of the ‘biennio rosso’ (red years), 1968–9. There was a seemingly natural fit between the


experience of Gorizia and certain themes of the workers’ and students’ movements in the post-1968 years. In the event this resonance, which helped to merge the nascent alternative psychiatry with other streams of the movement, offered a new and broader framework for conceiving of how psychiatrists could become engaged in politics, and for seeing why it made sense to take the campaign against the asylum as broadly significant politically. Two themes prominent in movement ideology were immediately serviceable to the alternative psychiatry: (1) the category of ‘technicians’, as this was articulated in certain theories of the new class, which provided a way of locating psychiatrists and their functions, and giving them a political mission; and (2) the idea of the excluded or marginalized as a potentially radical or mobilizable social subject, which apparently gave a clearer social class referent to the existential category of the excluded, as Basaglia had elaborated it from Sartrean social psychology. What was appealing about the new-class notion of the technician was its stress on discovering politics in the workplace, which was not so much a matter of mobilizing people for wider, external political goals as revealing the hidden power dynamics structuring the workplace itself. This notion fit very well with the Gorizian psychiatrists’ spontaneous stress on transforming the institution from within. But perhaps more significantly, the psychiatrists, by conceiving themselves as technicians, would gain a sense of their connection to a larger social process. The new-class theories attributed to such ‘technicians of practical knowledge’ a key role. in organizing consensus, enforcing discipline, stifling dissent, and maintaining social peace. They were ‘functionaries of consent’. The call to mobilize the technicians accordingly was a call for or them to contest their very roles, in the workplace: this was their privileged political task. What it amounted to was unmasking the apparently scientific, or technocratic, theories which rationalized their tasks, and choosing to side explicitly with those they had been delegated to oppress. Rejecting their official role. technicians could ‘facilitate an understanding of how ideology manages to make the subordinate class accept measures that seem to meet its needs’ (Scheper-Hughes and Lovell 1987:149), although in reality they are frustrated. Through the critique of science, new positive objectives could be defined; technicians could enable the subordinate class to take possession of the technicians’ knowledge, and hence emerge themselves as subjects. These were themes which could be grafted seamlessly on to the emerging programme of ‘alternative’ psychiatry.


The stress on subjectivity was yet a further link. It seemed possible to create a practical bond between technicians and those they had previously dominated and managed; in the very process of freeing themselves from the thrall of an apparently neutral, technical-practical orientation, technicians would transform their own relation to clients or subordinates, which would create in turn new opportunities for the subordinates to express their subjectivity, and to develop their demands. The general category of the ‘excluded’ were also conceived in such terms. From being victims of neglect or rejection, cast aside as of no value to the system, they were now to press their own demands on society, gaining both recognition and the practical experience of expressing themselves. The excluded or marginal were an important category for the Italian movements for long after 1968; the category moreover had a strong symbolic and evocative resonance in the social imagination of many Italians, for all the reasons that Italians think themselves to be generous and well-disposed towards immigrants and displaced people. What is remarkable is not that mental hospital inmates might be listed among the excluded, but that they were prominent in the list. They seemed to represent an important example of certain dynamics of exclusion, and therefore came to represent symbolically a poignant instance of social oppression. This was a striking, and perhaps unique, use of the mentally disordered in a rhetoric of social oppression: not only were these suffering people, worthy of support and sympathy; they somehow expressed, at an extreme, the very emblem of social rejection —a picture of need to which society responded not with help but with civil exile. The mentally disordered figured, in other words, in some respects as the most vulnerable and unprotected of the subordinate classes. It was on the strength of such associations that a phrase like Basaglia’s the ‘deviant majority’ (the title of a 1971 book) took on the peculiar resonances that it did. The original sense of the term, borrowed from an American discussion of the ‘problem of misfits in society’, was quite different.3 What is significant is the Basaglias’ appropriation and reformulation of the notion, as a way of linking the mentally disordered with others who fell outside or were thrust outside the productivist logic of capitalist society.4 In this company, to stress again the symbolic echoes of the terms, the mentally disordered were somehow the original and extreme expression of alienation from productivist norms: as social waste assumed to be forever unrecuperable for productive life, they represented symbolically the maximum degree of rejection of society; and their fate —locked up and stripped of their civil personality—was somehow the


appropriate penalty. The powerful resonance of ‘exclusion’ was also to feed into the sentiment of abolitionism. Carried by the resonance of such themes, the reputation of Gorizia as a fundamental anti-institutional experience was widely popularized. The groundswell of interest and support it created offered a new and widened context for the growing alternative psychiatry, which made it far more than a loose network of professionals exchanging information about their respective experiments. (By the early 1970s the centres involved included Perugia, Arezzo, Reggio Emilia, Parma, Trieste, and Naples.) The ideology which crystallized, and which provided more and more plainly the language for communicating in this network, showed clear signs of its lineage in the Gorizia experience, and also of its refraction through the protest movements of the late 1960s. Put schematically, the ideology that came to be called ‘democratic psychiatry’ expressed three interlinking propositions, around which the progressive programme cohered. First, the insane should be regarded as suffering individuals, whose real needs must be attended to, and who are at least potentially capable of regaining control of their lives and of becoming again actors and agents. The roots of this notion in the phenomenological critique of psychiatric positivism are evident, but so are the emphases of the protest movements on releasing and expressing new subjective points of view, on fostering new categories of agency. (It was common for these themes of subjectivity and ‘needs’ to include a concern with matters of health; the women’s movement has been a prime example.) Secondly, the asylum or mental hospital is neither a vehicle for, nor even a possible site of, therapeutic interventions. The general critique of the asylum had identified it as the ‘repressive end station of a whole series of conditions that, behind the label “mental disease”, concealed serious distortions and inadequacies in the way social life and public health were organized’ (Pirella 1986:127). By its very nature the mental hospital is a hierarchical and authoritarian structure which distorts human responses and crushes human initiative. It follows, thirdly, that genuine attempts to reach the insane or those suffering psychological distress can only occur outside the framework of the asylum. What this third proposition heralds is actually a quite new relation between the insane and society at large, no longer based on exclusion and segregation, but on acceptance, sympathy, and proximity. There is still, however, a fundamental role for the ‘technician’ even in this final stage: it is the technician who can supportively help the psychologically distressed individual in the community to confront his or her situation and, with others, begin to formulate and express that ‘need’ which is going unsatisfied. In other


words, although professional psychiatry is debunked, the programme still foresees ‘therapeutic’ teams actively working, intervening in the community, to facilitate the expression of needs. It was this activism, perhaps more than anything else, which distinguished the Italian democratic psychiatry from the antipsychiatry currents elsewhere. The Italians showed few if any of the hesitations or self-doubts about how to act, which in so many ways afflicted or even paralysed the anti-psychiatrists elsewhere. In the Italian movement, probably even more than in the antipsychiatry of the USA or Britain there was a thoroughgoing de-emphasis on professional qualifications, and a refusal even to speak in terms of therapy. The old authoritarian role of the psychiatrist was thoroughly debunked and delegitimated. Psychiatrists tended to work in teams with non-psychiatrists, and even with colleagues who were not university graduates, with a minimum of status distinctions. And yet the psychiatrists continued to act, indeed were activists—as psychiatrists. Doubtless the explicit political goals of democratic psychiatry accounted for much of this activism and the apparent confidence with which it was carried on. But there were probably two other factors which came into play, and which in the end made ‘democratic psychiatry’ far better adapted to be a successful movement ideology than ‘anti-psychiatry’ ever had the prospect of becoming. First, the debate about the ‘myth of mental illness’ never found a deep echo in Italy, as it had in other countries, and hence there never developed to nearly the same degree the debilitating and largely fruitless controversy about whether, or in what sense, mental disorders were illness or disease. In Britain and the USA this debate tended to have two effects: it redescribed mental disorders as a variety of social deviance, which implied (from the stance of solidarity with deviant ‘underdogs’) that any professional interventions to ‘treat’ deviance were likely to be suspect, likely to be more or less sophisticated efforts at ‘social control’. Hence the self-questioning and virtual paralysis among many radicals in the ‘helping professions’. The debate, secondly, exacerbated the tension between medically based approaches to treating mental disorders, and social treatments which paid little attention to organic factors. The tension eventually produced a split between ‘the medical model’ and social approaches, which in fact tended to simplify both positions into an overly schematic polarity. To complicate matters, the ‘medical’ and ‘social’ positions were picked up and reflected all too neatly in the divisions among mental health professions, with physicians lining up on one side, and non-medical professionals on the other.


In Italy the situation was quite different The second crucial factor which played into the strength of the democratic psychiatry ideology was the make-up of forces supporting the movement. The audience was much wider, but perhaps more importantly, there was no comparable medicalsocial split in Italy, perhaps simply for the reason that non-medical professions working in mental health hardly existed. Psychiatric social work, clinical psychology, and psychotherapy were relatively weak and underdeveloped; the categories which in other circumstances might have challenged psychiatric leadership and medical monopolies were effectively absent5 The conflict which arose in Italy was essentially within psychiatry, with one part of the profession opting for and emphasizing social treatments and politically motivated interventions, while the other defended traditional medical practice.6 It was psychiatrists who spoke on both sides, even though on the ‘democratic’ side they might appear to be self-effacing about their professional identity. As the ideology of the movement gradually coalesced, a more enduring network evolved to exchange information, and to co-ordinate strategies for the wider diffusion of the movement. By 1973 the movement was prepared to establish a more formal organization representing the alternative psychiatry (Psichiatria Democratica), which more or less coincided with the beginnings of a concerted strategy to transform the whole of mental health services, not by piecemeal local initiatives, but by national legislation. The orientation and aims of Democratic Psychiatry are clearly set out in the programmatic manifesto of the movement (see Appendix). Although in some ways set up as a parallel to the official professional association of psychiatrists, Democratic Psychiatry explicitly played down professional prerogatives and a professional identity. In the jargon of the movement, its activities were ‘de-psychiatrized’ and ‘detechnicized’. In fact, rather than working in the closed spaces which it was psychiatry’s historic mandate to supervise and manage, Psichiatria Democratica contested on principle the segregation and isolation which experts impose on ‘special’ categories of people (the mentally disordered, handicapped or exceptional children). The call instead was for ‘interventions’ in the normal environments in which people live and work, including preventive interventions designed to address noxious or adverse conditions which are health-threatening. The stress in the Psichiatria Democratica document falls throughout on the needs of users, and on the primacy of those needs over organizational or bureaucratic concerns. The idea is to treat persons, not illness. Social assistance must


be reoriented to serve the needs of ordinary people, and it is part of health workers’ responsibility to fight against the stigma or degrading consequences of seeking assistance. Needy citizens have a right to help which respects their dignity and does not disrupt their daily lives. The spirit of the document, in other words, is to place mental disorder among other illnesses or problems of living which citizens can properly claim assistance in trying to confront. Moreover, as consumers, the users of social services have the right to dignified treatment which respects or enhances their normal functioning and competence, and does not stigmatize their pathology or deficits. The whole tone of the document is up-beat, radically democratic, and concerned to defend the needs and interests of the users (consumers). It is striking that there is little, if any, comment in the document on the nature of mental disorders. The stress is on the needs of consumers, which might conceivably require social assistance and/or health care of some description. The ‘mixed’ nature of interventions was apparently not at all problematic. But that raises implicitly the question of what psychiatry as a distinctive speciality would amount to during and after the reforms. Was there need for a special discipline? Was there a specificity to psychic suffering which would require a particular expertise for its appropriate treatment? There is no sense of expertise operating as a filter, to direct consumers with one sort of need towards care-providers with a special kind of skill. It is significant that such questions of substance, or of the contents of care, are left entirely aside. The ‘needs’ to be served are relatively undifferentiated (although the hints are that many are material), and the stress falls on the style of work more than on its contents. In place of specialized but routine services in the closed, ‘psychiatrized’ space of the institution, the new services would be global in their interventions, would go to where the problems are in the community, and would respond specifically to the concrete situation. The ‘problem’ of mental illness would thus be displaced from the technical domain of the professional to the terrain of ‘the social’. The appropriate response to the problem would be to build up ‘from below’ a new sort of social organization, which would supersede the traditional backwardness and patchiness of the state’s social services, and at the same time substitute a new collective control for the traditional separation of the people from the means of social administration. It is as if undifferentiated need were to be confronted by multipurpose, diffuse care. The principle was: once the path to the asylum is barred, then the contradiction between the closed professional institution and the society could be overcome by the ‘socialization’ of psychiatric services, which


would involve forging a new dynamic of social life. Given that this was a programmatic political document, the lack of specifics is understandable. But it was also because the utopian aim of creating a new kind of social relations was seriously intended.

Chapter 5 The Trieste model

At Trieste we can show that we have destroyed a hospital— Franco Basaglia, December 1976 (quoted in Elkhaim 1977:157) The pilot experiences at Gorizia and Reggio Emilia had eventually been curtailed by conflicts that arose with the local authorities. What developed at Trieste in the 1970s was by contrast a sustained experiment which enjoyed substantial or at least continuing support from local administrators, and which by the end of the 1970s had developed into a showcase demonstration of what alternative psychiatry could accomplish in practice. Trieste had gained attention all across Europe, and was identified as a model to be studied and perhaps emulated elsewhere (WHO 1980). In a grand gesture the mental hospital at Trieste was eventually phased out and closed; the whole experience figured prominently in the public discussions, professional debates, and mass media coverage leading up to the new mental health act of 1978.1 In 1971 Basaglia was invited by the provincial administration of Trieste to reorganize the local mental health services. Public psychiatry at that time was centred almost entirely in the large mental hospital, which dated back to the beginning of the century and in the late 1960s contained over 1,200 inmates, most of them compulsory admissions. Basaglia was able immediately to hire new staff members (the addition of ten new psychiatrists almost doubled the number of physicians, and these were joined by a number of students and volunteers) and set to work following some of the same initial steps that had been taken at Gorizia. Ward doors were opened, isolation rooms and restraint-beds eliminated, and shock therapy abolished. But from the beginning the idea was to pick up from where the experiment at Gorizia had ended. There was now an emphasis on planning for community-based care; the goal was not to improve the

62 THE TRIESTE MODEL

hospital but to move outside and beyond it entirely. Hence the work at Trieste involved both changing the hospital environment and beginning extramural work in the surrounding community—and building links between the two. Trieste was in many ways a propitious site for the experiment Basaglia and his associates had in mind. The city and its surrounding province contained a relatively compact population of about 300,000, most of them living in the city itself. The mental hospital’s catchment area coincided with the administrative boundaries of the province; this was a considerable advantage, which reduced at least some of the organizational problems that have commonly beset community care in large cities and metropolitan areas. There was a single authority responsible for the hospital and for the whole of the province, which made it easier to plan a comprehensive set of services covering the area as a whole. In turn the mental health services would have a one-to-one bargaining relationship with the provincial authorities, the local social services, and so on. The pattern was in fact similar to that of the English county boroughs (Portsmouth, York: Croydon) before 1948, where some of the more successful early experiences of community psychiatry had been carried out (Bennett 1978:210–11). As a first step towards linking more closely the hospital and its surroundings, the hospital’s catchment area was divided into five sectors or districts (of roughly 60,000 inhabitants each); then the hospital was broken up into five corresponding divisions, and hospital staff formed into five teams which were to be responsible for the respective sectors. Finally the hospital patients were transferred to mixed-sex wards, allocated to the different teams, on the basis of their areas of residence. The idea was to begin to create connections between units of the hospital and areas of the city and province. Henceforth admissions to the hospital would become the responsibility of the new sector teams. The central admissions wards, for men and for women were phased out, and smaller reception units in each of the geographically based divisions of the hospital set up. The plan for ‘sectorization’ of mental health services differed fundamentally from the way community services had been established in the USA. The community mental health centres were in general set up from scratch as a new system independent of mental hospitals in the locale, and surrounding area. One of the centres’ problems was in fact how to establish and maintain contact with the hospitals, and to coordinate services. The respective staffs were not only separate and independent, but often had different orientations and priorities. The


design in Trieste on the other hand involved using the same staff members to run the hospital wards, and gradually to establish extramural programmes. There was a good deal of shuttling back and forth, but this was seen not as a waste of energy, so much as a practical means of blurring the boundary between the hospital and the surrounding community. After the internal reorganization of the hospital, the next step was to make a careful survey of the patients to reassess their conditions and the extent of their need for residential care, and determine what it was that kept them in hospital. The survey apparently turned up a number of cases of individuals who were not mentally disabled, but were in the hospital because they had nowhere else to go, or lacked the economic resources to support themselves independently. There was a push to release such patients with financial and other supports, and to encourage others who were capable of living in the community to leave. By all accounts this was a gradual and planned deinstitutionalization, and not at all a precipitate ‘dumping’ of ex-patients into the city. One of the first concrete responsibilities of the sector teams was to prepare the way back into the community for the discharged patients, to help them find accommodations, pensions, subsidies, and so on, and then follow up their progress in resettling. As a result of this new philosophy of release, backed up with material resources and assistance, by 1972 two of the original eleven wards, of the hospital had been closed.2 There were also broad changes underway within the hospital to reverse the prevailing ‘institutional logic’, and to establish patients’ rights, privileges, and bargaining power. The goal was to replace the status of wardship with a more egalitarian, quasi-contractual relationship between staff and patients. Patients who were reclassified as voluntary regained some of their lost civil liberties and status, including the right to social security allowances.3 The old system of ergotherapy (work therapy) was abolished on the grounds that it demeaned the patients’ dignity while paying them only a pittance; self-managing co-operatives (run and staffed by patients and ex-patients) were set up, which in time won contracts from the regional administration for cleaning the hospital.4 A number of group apartments were established on the hospital grounds to accommodate in particular some ‘declassified’ ex-patients, who, although discharged, were unable to find accommodation elsewhere. Declassification was a way of making ex-patients eligible for social welfare allowances, which they were previously denied. They were also now (1973) given a new status as ‘ospiti’ (guests), free to come and go, to take meals and to sleep in hospital facilities. The only formal control


over such ex-patients was their having to be registered as overnight guests, which is in fact the ordinary practice of hotels evetywhere in Italy. The new status created some initial perplexity, since as the guests came and went (some of them had jobs in the city) they blurred what had been the hard-and-fast distinction between mental patient and citizen; they were no longer officially patients, and yet they still used certain services of the hospital. The effects of these policies were clearly evident in the movement of patients out of the hospital, and in the movement within the hospital of patients from more to less restrictive statuses. Once the hospital was ‘opened’, some long-stay patients were released; other committed patients became voluntary; and still other declassified patients became guests. In 1972, of the 980 patients remaining in the hospital, 430 were now voluntary patients, and 50 had been given the new status of ‘guest’ (see Table 5.1 below). In the meanwhile the sector teams had begun extramural work, initially on a volunteer basis and rather informally. There was considerable resistance to this move into the community from both nurses and some physicians, no doubt in part because it meant sacrificing the clear and recognized roles, familiar amiliar in the hospital for what seemed to be rather casual and often ill-defined, nonprofessional tasks in the community. Some of the staff opted for continuing to work full-time in the hospital. Gradually, however, the centre of gravity of the mental health services began to shift away from the hospital, as more and more activities were transferred outside. In 1974 mental health centres were established in three of the sectors of the city and province. Two further centres opened in 1976, and the sixth in 1977 With the full complement of centres in place, hospital admissions, which had in the meanwhile been considerably reduced, could be stopped altogether. To provide for overnight stay of acutely ill patients, a single admissions ward was set up in the hospital grounds, but with no connection to the hospital; admissions were no longer automatically fed into the hospital, but henceforth controlled by the community-based centres. The next year an emergency service was set up in the general hospital, staffed not by the general hospital personnel, but by members of the sector teams serving on a rotating basis; the emergency unit functioned as a first filter, to help prevent inappropriate admissions and to offer liaison with the range of community services. In 1977 about 42 per cent of those referred to the emergency team were sent to the mental hospital’s admissions unit; 30 per cent were sent home; 14 per cent were admitted to the general hospital; and 8 per cent were referred to the mental health centres


(Bennett 1980: 76). This was the array of structures which progressively supplanted the old hospital and its functions. In January 1977 there was a public announcement by Basaglia and the president of the provincia of Trieste that the hospital was to be closed within a year. (Basaglia) took the occasion to draw a balance sheet about the Trieste experience, to reiterate that the hospital had been improved but still had to be dismantled entirely, and to sketch an image of what future mental health services would look like. The major point was that 700 ex-patients had been discharged over the previous five years, and reabsorbed into the social fabric of the city. Basaglia did not describe them as cured, but simply as liberated from the asylum and restored to a full and dignified status as citizens. These ex-patients might still in many cases need support and help from the mental health centres, as well as from family and community networks. But they had demonstrated that they could live in the city, independently, among and with ordinary citizens. The asylum, Basaglia continued, had never been a solution for those 700, nor for the several hundred others still living on the hospital grounds. But neither had the asylum really been a good for the citizens at large. It had removed from their midst ‘inconvenient’ and perhaps disturbing people, but at an unnecessarily high cost, both in moral and in economic terms.5 By way of reassurance that the asylum could really be closed without risk, Basaglia insisted that much in the old stereotypes of madness was actually the product of institutional conditions, and not an objective threat which the walls. of the asylum had been required to contain. That was not to say that mental illness does not exist; psychic suffering is undoubtedly real, but it can only be effectively confronted outside the asylum. The occasion finally to close the asylum, therefore, ‘would mean the creation of a new situation in which it will be possible to approach [psychic] suffering in a new way’; ‘only the destruction of the asylum would allow facing psychic suffering as it really is’, and not as it has become after it has already been distorted and frozen into objectified ‘symptoms’. The destruction of the asylum would mean liberation also for mental health workers, who would no longer have the heavy public burden, and legal liability, for sequestering and monitoring the mentally ill. Instead mental health workers could relate themselves directly to ‘those who may not be able to bear their suffering’; psychiatrists would then be in a position to offer a specific sort of help, but it would be only one sort of help among others. The gradual dismantling of the hospital had been carried on in a very public fashion throughout, with a public relations campaign and a number


of cultural initiatives designed not only to keep the public informed but to change their attitudes and perceptions. The hospital sponsored film festivals, performances by repertory companies and musicians, and art exhibits, all intended as drawing cards to attract the people of Trieste into the hospital grounds. One of the more moving events in these cultural campaigns was the construction of a huge, blue horse, Marco Cavallo, which became a symbol of sorts for the Trieste experience. In 1973 a group of artists had transformed a disused ward into a studio, inviting staff, patients, and visitors to join in their work. There was a story behind the making of Marco, which explains much of its significance; Marco had been the name of an old horse who used to cart away the hospital’s dirty linen— the only one, as some of the older patients quipped, who managed to get out of the hospital. When the statue was being made, its belly was filled with letters and scraps of paper on which patients had written their dreams and wishes. The horse was eventually wheeled out of the hospital gates, bearing its cargo of hopes, followed in a long procession down to the town by many of the hospital’s residents.6 There is no doubt that such initiatives and festive occasions mobilized a wide sympathy and interest among the people of Trieste, and probably displaced at least some of the fears which the breaking down of the asylum walls. would otherwise have occasioned. The goal was a fundamental change in attitudes: ‘Once they mingled among the patients, the townspeople could begin to recognize in the distress and suffering of former inmates some of the same problems in living that had plagued their own lives’ (Scheper-Hughes and Lovell 1987:29). How far such a change actually took place is, however, very difficult to judge. A report prepared for the World Health Organization by the English psychiatrist D.H. Bennett provides a fairly comprehensive picture of the Trieste services as of 1978. The movement of the hospital population had been quite striking (see Table 5.1). As Bennett commented, The provision of mental health centres, group apartments and other parts of a supportive community system was synchronous with the reduction in hospital beds. Staff and patients moved to the community, pari passu with the closure of the hospital wards, There was no interruption of responsibility, and staff and patients were ‘deinstitutionalized’ together. (WHO 1980:12)


Table 5.1 Changes in mental hospltal population, Trieste, 1967–77 (rounded off)

1965 1967 1969 1971 1973 1975 1977 1979 1981

Total

Legally committed

Voluntary

1,230 1,250 1,250 1,060 890 700 450 360 300

1,230 1,250 1,210 830 200 90 40

40 230 420 150 50

‘Guests’

270 460 360 360 300

Sources: hospital census; see also WHO (1980) and Mauri, (1983: 58)

The services in place in 1978 included six district centres, the admissions unit on the hospital grounds, the emergency service in the general hospital, workers’ co-operatives, and a series of group apartments. The community centres had become the centrepiece of the care system. They typically contain sitting rooms, dining areas, and some limited facilities for recreation. There is a staff room, but otherwise the centres are common space; there are generally no private rooms for individual interviews or treatment The teams which staff the centres are principally psychiatrists and nurses (in a ratio of about 1:10), with a very few social workers or psychologists. The centres are open seven days a week, in some cases for twelve hours a day, with a limited nursing coverage at night.7 The operating style of the centres ‘tends to be rather informal and unstructured. There are daily staff meetings, which serve to exchange information about clients; the discussions, as a number of observers have reported, generally eschew diagnostic categories, and indeed hardly seem to distinguish between the ‘mentally ill’ proper and other needy or just elderly individuals. Medications are prescribed but seem to be regarded principally as means of establishing contact and a continuing relationship with clients. There is in general little or no emphasis on formal treatment in the usual psychiatric sense; but a strong assumption that once the ‘impositions’ of the mental hospital regime were removed, improvements in the patients would more or less quickly follow.


There is an insistence that patients must be listened to, that their needs must come first, and that relationships between patients and staff should be devoid of either condescension or deference. The overall impression is of a psychosocial supportive system rather than of medical treatment provision in the narrow sense. (WHO 1980: 13) In the varieties of care offered by the staff, there seemed to be a rough division between time spent in the centres and time spent outside. At the centre staff participated in the general social life, although there were apparently few planned activities deliberately designed for rehabilitation; they also administered small subsidies or allowances, as a form, of direct welfare, which also encouraged regular contact on the part of the clients. A good deal of time went for home visits, and likewise for contacting local bureaucracies to arrange benefits or services for their clients. Bennett was left with the general suspicion ‘that the center programs were geared to provide only generalized support to the poorer adult population, [and that they] were more responsible to the urgent demands of the acutely psychotic patient, and might well overlook the needs of quietly deteriorating patients’ (Bennett 1985: 81). The overall additional costs of the mental health services through these transformations were quite small: corrected for inflation they increased by only 13.5 per cent between 1972 and 1977. Staffing levels had not increased significantly; the costs of medication had declined significantly; there was not great capital expenditure. The greatest change was in the level of social benefits paid to patients. What is perhaps most striking about the financing of the new services is the successful transfer of funds from hospital to community, which Bennett remarks is a ‘probably unique achievement’ (Bennett 1985: 90). The achievement likely depended on the relative weakness of the nurses’ and social workers’ unions, and on the considerable power vested in the provincial government’s psychiatric director, Basaglia ‘who had responsibility not only for the mental hospital but also for the public psychiatric services in the province’ (Bennett 1985: 90). Despite his many favourable impressions, Bennett concluded that ‘it is not possible, without further detailed information [which was lacking], to make a full evaluation of the adequacy, effectiveness and efficiency of the new services’ (1980: 11). Nor was it ‘possible from the available evidence to say whether or not the services decrease or contain psychiatric morbidity’ (1980:13). The Trieste mental health workers seemed to be more concerned to counteract the effects of


institutionalization, and to show concern for the individual client’s personal needs, than to institute any planned programme of psychiatric treatment or rehabilitation. Bennett concluded his report with several specific queries: (1) what was to be the fate of those former long-stay patients who were formally guests, but were incapable of fending ending on their own? In 1978 there were about 350 former patients living in the old hospital buildings. Most were between 65 and 75 years of age, and had been in hospital on average more than 20 years. These were the hard-core of the former long-stay patients, a kind of ‘residuum’ which the staff recognized would need continuing care for years, but whom they regarded as the victims of past custodial neglect, and hence a population which would be extinguished. (2) But were the problems of chronic patients really only a ‘residuum’ carrying over from the asylum era, or would there be new chronic patients in the future? On Bennett’s view, ‘the Trieste service has not confirmed its belief that in the absence of mental hospital admission, there will be no future recruits to the ranks of long-term disabled mental patients in the community or of long-stay disabled in the hospital’ (1985: 91). (3) Finally, how would mental health services so focused on providing social support networks be able to relate with medical services and the medical profession?8 These were worries expressed specifically about the experience in Trieste. But as Trieste was promoted in the media and by the proponents of Psichiatria Democratica as a model system, the broader question was perhaps whether, and how, the successful aspects of the Trieste experience might be replicated elsewhere.

70

Chapter 6 The enactment of law 180

Since the early 1970s the leaders of the alternative psychiatry movement had been looking increasingly to promote change at the national level. The original strategy had been to work ‘from within’, to transform individual institutions by mobilizing their own staffs and by ‘sensitizing’ the surrounding communities. This approach had proven, at least in some places, remarkably effective; but since it characteristically focused attention intensively on a given locale, it was inevitably a rather limiting strategy. The risk was to produce only isolated pockets of reform, which would be hard to extend or generalize into the larger, unreformed system. There was in fact a strong network linking the locales where alternative approaches were becoming established, from Trieste to Arezzo, Ferrara, Perugia, Parma, and so on. But that list reveals another apparent limitation of the original strategy, that it seemed to work best in smallto medium-size cities, and often where there was already a strong civic tradition. The relative lack, or failure, of initiatives in the big cities (with the partial exception of Napoli), and in the South generally, was striking. In order to extend their influence, the leaders of the movement tried to develop alliances with left-wing parties and trade union groups. Such alliances were in some ways an outgrowth of the 1968–9 mobilizations. At the local level alliances had already proven quite important previously, and they were the most straightforward way of bringing the psychiatric issue into the national political arena. The Communist Party (PCI), in particular, proved receptive. As early as 1969 the Party had lent support to a widely publicized conference on ‘psychology, psychiatry and power relations’ (see Psicologia, psichiatria, e rapporti di potere 1971); by the mid-1970s the PCI was one of the principal national sponsors of psychiatric reform, and had included the issue in its national programme. The alliance with the PCI was not, however, without considerable tensions; in 1976 there was effectively a schism in the ranks of Psichiatria


Democratica precisely on the question of the PCI line and the importance of maintaining ties, with the institutional left.1 It would be misleading in any event to overestimate, as several foreign observers have done, the significance of the PCI role.2 What was perhaps most important was that the PCI sponsorship ensured that the issue of psychiatric reform would remain perennially on the national agenda. There was in fact wide and growing support for reform from various quarters; contemporaries spoke with good reason of a ‘reformist bloc’ building behind the issue. The accumulation of criticisms of the traditional asylum from virtually all sectors of the psychiatric profession, combined with several widely publicized asylum scandals, meant by the mid-1970s that ‘the fate of the traditional asylum was effectively sealed’ (Canosa 1979: 172). The mainstream professional association of Italian psychiatry, the Società Italiana di Psichiatria (SIP), endorsed a strong resolution in 1975 calling for the end of the asylum and the reintegration of psychiatry into general medicine.3 The mass media played a very conspicuous role in swaying public opinion, and in making psychiatric reform into a major civil rights issue. As Pirella, remarks apropos the 1970s, the psychiatric question was not popularly seen as a problem for or specialists, but as one involving the ‘civil right to receive care without being compulsorily hospitalized’ (1987: 128). Such issues were becoming increasingly important to the Italian electorate, which was one ingredient in the electoral successes of left-wing parties, and probably helps to explain as well the increasing attention devoted by centre-left and centre parties to civil rights issues.4 It is important in any case to recall that two of the most significant experiences of alternative psychiatry, in Gorizia and Trieste, took place in areas controlled by the centre-right Christian Democratic Party (DC) at Trieste, the humanitarian attitude of the Christian Democrat president of the provincia of Trieste, Michele Zanetti, played a crucial role. In Parliament, the point of departure for discussing the issue of psychiatry was the proposal to organize a national health service; in the context of a comprehensive health reform, the notion was to integrate psychiatry into general health care, and so to eliminate any discrimination against, or segregation of, mental patients. Psichiatria Democratica raised objections against several of the draft proposal’s provisions regarding mental illness, especially concerning the conditions for compulsory treatment. In any event, despite substantial discussions in Parliament from 1973 through 1977 no action was taken. What broke the parliamentary logjam was a new tactic of the small Radical Party, which was designed to force the government’s hand. The Radicals, who were

THE ENACTMENT OF LAW 180 73

then gaining between 5 per cent and 7 per cent of the vote, were known as the party of human rights, and had been very active in both the abortion and divorce campaigns. In early 1977 they began to gather signatures on behalf of a popular referendum to abrogate the important articles of the 1904 asylum law. Over 700,000 signatures were collected (more than the number required to set in motion the mechanism for a national referendum) and presented to Parliament in June: 1977. It seemed, in the prevailing climate, that the referendum might well succeed, which is in itself a telling judgement about the strength of popular sentiment on psychiatric reform. To avoid the risk of the referendum succeeding, and hence the possibility of an ensuing legal vacuum which would have left the country with no statutory basis for mental health policy, the Government (on the basis of a joint DC-PCI majority) moved quickly to redraft the mental health measures in the comprehensive health reform bill, and present a new proposal for a law superseding the 1904 asylum provisions. The Radical strategy had effectively accelerated parliamentary deliberation and debate. The bill was presented in April, and voted in May 1978, with a minimum of discussion and debate, and support from virtually all the electoral parties.5 The enactment of the bill came just in time to pre-empt the referendum. The title of the law enacted, law no. 180, ‘Voluntary and compulsory medical examinations and treatment’, indicates its overriding principle: medical care should be as a matter of course voluntary, and this should hold for mental as well as for other sorts of patient The most striking feature of the law is that it expressly excludes any reference to ‘dangerousness’, which had been the central criterion of the 1904 law for ordering treatment of the insane. The new law hence abolishes what had been the major distinguishing characteristic of the mental patient. It is framed without consideration of any peculiar or special social salience of mental disorders; they are treated simply as occasions of illness, to be cared for in the same legal framework as any other illness. Psychiatry thus loses its juridical status and special mandate to defend society against the mentally disordered. Considered against the background of the history of Italian psychiatry, the law represented the complete ‘purging’ of psychiatry’s traditional and legal responsibility for social control (Betti 1989: 598). The law does provide, in certain restricted cases, for compulsory hospital treatment of individuals suffering mental illness. But the restricting conditions are quite stringent: (1) ‘there must exist such mental disorder that therapy be urgently required’; (2) such measures are not accepted by the patient; and (3) the treatment cannot be administered in


a timely and suitable fashion in some non-hospital setting. Even in the case of an order for compulsory treatment, the law states that the treatment ‘must be complemented by initiatives aimed at gaining the consent and participation’ of the coerced patient, who must in any case ‘have the right to communicate freely with anyone’, and be accorded ‘the respect consistent with human dignity and [the individual’s] civil and political rights, including as far as possible the right of free choice of the physician and the hospital’. Beyond affirming the properly voluntary nature of medical care, the law further holds that the only grounds for ordering compulsory treatment of the mentally ill are to be exclusively medical grounds (analogously to the case of individuals suffering contagious infectious disease). The procedure for ordering compulsory admission is divided into three phases: (1) a physician must recommend compulsory admission; (2) a physician working in the public health service must evaluate the case and confirm the proposal for compulsory admission; (3) the mayor, acting in the capacity of local health officer, must order the commitment. As a final stage the mayor’s order must be communicated within 48 hours to a ‘tutelary’ judge (responsible to superintend the ‘tutorship’ of legally incapable persons), who must ratify, or not, the commitment within a further 48 hours. It is significant that the judge so charged ‘has no penal competence, and cannot, therefore, make assessments concerning maintenance of order and public safety, nor prescribe restrictions to personal freedom’ (Maj 1985: 22). The judge’s only task is to comment upon the appropriateness of the arrangement, and thus to act in the interest of the patient ‘as a subject needing, just like a minor, special guardianship by the legal system’ (22). Compulsory treatment lasts seven days; if a physician wants to extend it, the proposal must in principle be subject to the same set of procedures which allowed the original commitment. Beyond ensuring legal safeguards, the way the law is drafted reflects a clear intent to discourage prolonged hospitalization, and to prevent psychiatric services being transformed into wards, for chronic patients. Further articles set down norms about the proper or permissible settings for mental health care. In particular the law establishes strict limits to inpatient care, and lays down that preventive care, treatment, and rehabilitation should all take place ‘outside the hospital’, as a rule in community-based mental health service centres. To reduce inpatient numbers, the law bars the admission of new patients to mental hospitals after a certain cut-off date; it furthermore bans the construction of new mental hospitals, and forbids the mere administrative transformation of existing mental hospitals into psychiatric departments affiliated with


general hospitals. In sum, the mental hospital is to be run down, as its current patients are released or die, and then abolished completely. If, compulsory treatment is deemed necessary it should where possible be prescribed in community facilities; if hospitalization is judged to be necessary, it should be in a special psychiatric unit (containing no more than 15 beds) in a general hospital, and should last no more than the seven days which the commitment procedure allows. The small size of the psychiatric units, and the very brief (although extendable) period allowed for compulsory commitment are both measures to prevent the conditions for ‘institutionalization’ reappearing among the new alternative services. There is even a rationale for the 48 hours set out for the tutelary judge’s ruling; apart from allowing the judge the chance to investigate, that is taken to be a sufficient time to mobilize the patient’s social network, to try to work out some non-institutional solution. There are procedures for extending the period of commitment, but the clear intent of the law is to discourage prolonged hospitalizations. The provisions of the law were based on a compromise, which was predictable since the proposal had been drafted by a commission to which both the PCI and (DC) had sent representatives, and which had consulted both with members of Psichiatria Democratica and with the more mainstream Società Italiana di Psichiatria. Despite the elements of compromise, however, the partisans of Psichiatria Democratica were quick to claim the law as their victory, and as both a vindication and an application of the principles which they had demonstrated at Trieste and elsewhere in their alternative practices. Appropriately enough, the law became popularly known as the Basaglia law. What Psichiatria Democratica recognized as its own contributions to the law were the principled abolition of the asylum, and the commitment to ‘socialize’ and transfer services to the community-based mental health centres. The Italian anti-psychiatric movement has demonstrated in theory and practice that there does not exist any possibility of reforming the psychiatric asylum…. The legislators have accepted this radical idea and have decreed the total closing of the asylum’ (Tranchina et al. 1981: 187). The law eliminates the special status of mental patients, so that ‘even those who suffer from deep psychic problems have the right to be cured in the place [the general hospital] where all health problems are treated’; hence ‘the stigma that has always been attached to the psychiatric patient is eliminated’ (187). The law moreover ‘strengthens the necessity to privilege community intervention without the mediation of institutional separation’, which follows the alternative principle of


responding to mental illness on the terrain in which it breaks out and appears: Keeping the psychic suffering in their social context permits the utilization of informal therapeutic resources possessed by the community…. Such work aims at propagating an increased awareness in the community, which according to the mental health reform would favor public participation in health problems. This political aspect is characteristic of the Italian situation and can be considered an expression of the [movement from below] that has already asserted itself, for example, in health care, in the factories, and in the affirmation of women’s rights in family counselling. (187–8) Even the procedure that the mayor of a municipality must sign a commitment order is interpreted as sharing out more democratically ‘the responsibility of acting against [an] individual[’s] will’ (188). The general openness of the process of commitment, including the possibility that anyone may appeal against compulsory treatment, ‘enables the community to verify and control the power of the technicians’ (188). On the other hand, Psichiatria Democratica criticized vocally several other aspects of the law, aspects which they had criticized previously in the earlier draft versions of the reform presented in the mid-1970s. The establishment of psychiatric units in general hospitals was judged preferable to the ‘separate psychiatrization’ of mental disorders in asylums, which segregated the mad. from society. But there was the risk of trading the institutional logic of the asylum for that of the general hospital, which would be equally inhospitable to a social interpretation of mental disorder.6 The risk, in other words, was of ‘medicalizing’ psychic suffering; ‘the legislation thus expresses a value judgment on existential experiences which in themselves are neither sane nor ill.… The right exercised by medicine on [over] psychic suffering risks confirming the variables such as labelling, reification and isolation of organicism’ (Tranchina et al. 1981:189). Similarly Psichiatria Democratica continued to protest even the limited and legally safeguarded use of compulsory treatment; notwithstanding the guarantees ‘the possibility of treating persons against their will shows the continued existence of a precise social control such as has been delegated to psychiatry’ (189). Many ‘moderate’ members of SIP greeted the general principles of the law with a certain equanimity, although there were many worries


expressed about the risks of interrupting treatment or making too rapid and radical, rather than gradual, a shift. Interestingly, there were some biologically oriented psychiatrists who saw in the law a possible, perhaps even an attractive, vehicle for their purposes. Their rationales were the same as the radicals’ fears—that the provision for psychiatric units in general hospitals could be a way of bringing psychiatry into medicine, and of modernizing hospital-based psychiatric care. The fact that opposing groups could both see opportunities within the law for developing their respective practices is one hint of the vagueness and abstractness of certain of the law’s provisions, which could be construed as pointing in quite different directions. Law 180 was soon incorporated into law 833, the comprehensive health reform enacted later in 1978 which created the Italian National Health Service. The relevant administrative reform was to create new local health districts (USLs) for catchment areas of 50,000 to 200,000 inhabitants (about 700 for all of Italy), in which departments of mental health would henceforth be responsible for existing mental hospitals, the special psychiatric units in general hospitals, and the community-based facilities. The idea was to create a single authority responsible for all services within a geographically defined health sector, which was to guarantee continuity of care, co-ordination of services, and effective liaison with other public services. The later law also gave a free hand to the regional-level administrations to deal with the precise timing and the modalities of implementing the new reforms. Although there was in principle an evident advantage in locating the new mental health services in the framework of the simultaneous reorganization of general health care, in practice that decision probably delayed and complicated the implementation of the specific mental health provisions. In any event the new law was set out simply as a guideline, not as a definite prescription. The spirit of the law was to state in unqualified terms a principle; in that sense the enactment of the law was a strong victory for an ideal, in favour of abandoning the asylum and opting for community-based alternative care. In stating this principle so sharply the legislators obviously did not take explicitly into account the actual condition of the mental health services, or the immediate possibilities of transforming them. The law states a principle, but in the meanwhile provides no transitional norms, no detailed rules and regulations, and no funds for putting the reforms into place. In part this could be excused as the result of the hurried circumstances in which the law was drafted, discussed, and enacted. Given the impending general reorganization of health services, there was


also a good practical argument for incorporating one set of reforms into the other, and for treating the implementation of the mental health reforms as a particular aspect of the wider reform. But this meant allowing the regional authorities, who were made responsible for drawing up plans for implementing the new health system, to take care of the psychiatric reforms in due course. There was in the event a considerable cost attached to trying to implement the provisions of law 180 in such circumstances. But beyond such contingent problems, there was perhaps a more profound obstacle to implementation in the very conception of the law. The radicals for their part seem hardly to have thought about the problems involved in implementing the law. This betrays not so much an activist’s impatience with the details of devising rules and regulations, and bureaucratic controls; there was rather an expectation that the law would be a means of continuing and extending the movement—a spur to change from above, but one which would work itself out by mobilizing forces from below. It is not unusual in Italian political culture to think of a law as a catalyst for change, rather than straightforwardly as a means adequate to achieve that change. What law 180 really represents is in fact a victory of principle: it abolishes the manicomio. As a matter of law this victory had of course practical consequences and significance. But the implementation of the law would involve a different series of struggles and conflicts, which enacting the law may in one way or another set in motion or focus, but which it does not by any means decide or resolve. This feature of Italian political culture fits in a striking way with the movement strategy of Psichiatria Democratica and its allies. The movement had tended to calculate within a larger political logic, in which the law was not so much the culmination of the movement, but a means of extending the movement’s own reach and dynamism. The idea is that by staking out the moral high ground of principle, a law can serve as a means, both practical and symbolic, of unleashing further struggles, and focusing their direction. In this case, to put the matter schematically, the asylum had served, in a distorted and repressive way, as a response to real needs; to eliminate the asylum by political means would thus be to open up a space for those needs to be expressed differently—for actors to raise new demands against the system. It is on the basis of such assumptions that one should understand the reformers’ support of the new law, and their view of how it should be implemented. It had been a cardinal principle of the alternative psychiatry from the outset to begin working locally within the asylum, and then


move outwards. A process of local mobilization, ‘de-institutionalizing’ both staff and inmates together, and working simultaneously to change community attitudes and perceptions, had been seen as the key to successful and lasting change. The very focus on the process of change, on the need to mobilize and involve local actors in the critique and then transformation of their own circumstances, had been the virtue of the movement. But how could one legislate such changes from above? That would make political sense only on the assumption that the new law would set in motion something like the mobilizations which had occurred in the famous pilot and model experiences. At the height of a broad social movement, such a favourable and generous assumption has a certain sense. In other circumstances, it may be a politically naive or unrealistically voluntarist approach to the problems of implementing a law or new social directive. To recall that in Trieste it took seven or eight years to close the mental hospital, in what were in many ways highly favourable conditions compared with other places in Italy, is one way to put in perspective the objective task to be accomplished. Trieste is a relatively compact catchment area; the mental hospital had a very high staff/patient ratio, quite apart from the efforts of numerous volunteers; the provincial administration was generally well-disposed, or at least tolerant and forthcoming with some resources. Moreover the Trieste experience had the benefit of being the showpiece for an entire movement, which could draw on the extraordinary dedication and energy of movement workers. How could a comparable experience be fostered elsewhere, and then routinized as a policy for the long term? These were the real questions involved in implementing the new law, and the real problems at issue in the psychiatric reforms. And yet the law was not accompanied by any guidelines to the regions about how to institute change, nor did the law as passed contain sanctions for noncompliance or incentives for compliance. What was to happen if the expected cultural mobilization in the name of living in a new way with the mentally disordered did not materialize? The legal effect of the passage of the law in fact was for most parts of Italy to create ‘a vacuum between the abolishment of the mental hospitals and the implementation of community-based facilities’ (Maj 1985: 25; see Scarcella and Macri 1980). The negative part of the law tended to work, in other words, but the positive part was at best slow to reach the point of substituting alternatives for what was destroyed. If Trieste and a few other towns seemed to exemplify the spirit (and some of the substance) of the reform, they were a tiny minority of the concrete


situations in Italy; the law, in its abstractness, not only ignored this reality, but offered no guide as to how different locales might reasonably start on the path of deinstitutionalization.

Chapter 7 The implementation of the law

[M]erely changing the law is no magic formula for altering the practice of psychiatrists, the attitudes of the population, or the concerned involvement of politicians and administrators, especially if a comprehensive program is lacking. Agostino Pirella (1987: 133) As rapid and apparently consensual as the enactment of law 180 had been, any false impressions about a new consensus emerging on mental health policy were quickly shattered. In fact the passage of the law was succeeded by a period of sharp and increasingly bitter conflict between proponents of the law and a newly organized and vocal bloc of critics. What was at issue were not only the real effects of the law, but what were essentially opposing philosophies of care which suggested quite different standards for or judging mental health policy in general. Those who tended to see psychiatry in ‘political’ terms remained relatively favourable avourable to the purposes of the law. Their principal aim had been to reverse the exclusion of the mentally ill, and hence the social reintegration of ex-patients was in that sense a higher priority than medical care per se. Critics of the law, on the other hand, tended to stress the predictable shortfalls of care, which they attributed directly to limitations in the legislation: the law interrupted hospital care, but the new alternative services envisioned by the law were slow to develop and patchy, and the quality of care they delivered uncertain; moreover the predicament of long-stay and chronic patients seemed to be greatly exacerbated by the anti-institutional provisions of the law. The radicals’ response to such criticisms was to argue that the lack of alternative services was a direct consequence of their opponents’ refusal to implement the law, or worse, the result of a deliberate attempt to sabotage


and discredit its principles. The problem of former long-stay patients was a legacy of the past. Both problems, in other words, could be considered remediable or temporary. In many respects this was a clash of basic ideas about the ends and means of mental health care; the two camps, having different goals, disagreed even about how to evaluate the results of the law, and about what should be counted as success. There were charges from all quarters that the problems of the mentally disordered were being politically exploited in the interests of corporatist or sectarian gains. Supporters of the Psichiatria Democratica programme complained that the law was being deliberately and cynically stymied in its application by politicians, bureaucrats, local administrators, and recalcitrant psychiatrists and nurses. Opponents of the law, including representatives of the families of ex-patients, responded that the law itself staked out ideological positions which provided no realistic basis for policy. What both sides agreed was that there remained much to criticize about the present state of mental health services. In fact it is remarkably difficult to reconstruct what actually happened in the early phases of implementing the law (or perhaps better, in the first several years when it should have been implemented). As had happened before the passage of the law, the media continued to play a large role. in shaping opinions, both by publicizing the scandalous ‘abandonment’ of inmates and now also by playing in a sensationalist vein on the dangers and burdens which ex-patients presented to themselves, their families, and society at large. In the several years after 1978 opinions hardened considerably; both proponents and opponents of the law tended to issue equally sweeping judgements on the value of the reform. That such an ideological debate would ensue was perhaps inevitable; but it became all the sharper in the virtual absence of good, comprehensive information about what the reforms were actually doing or not doing. The evidence brought forth on all sides tended either to be anecdotal or to reflect one or other set of local conditions. Documenting and tracking the effects of deinstitutionalization has been a problem everywhere, in part because efforts to ‘normalize’ the ex-mental patient and to minimize his or her stigmatization make it far more difficult to track what becomes of someone after release from hospital. In Italy the gaps in information were considerably greater than elsewhere; and a bad situation was made worse by the Government’s failure to provide for any systematic nationwide monitoring of (or information-gathering about) the reform process.

THE IMPLEMENTATION OF THE LAW 83

There were three kinds of change which the law was meant to introduce: (1) by forbidding the admission of new patients to mental hospitals, and by establishing a deadline for the closing of the hospitals, it condemned the mental hospital to a ‘death by suffocation’; (2) by drastically reducing the possibilities of hospitalization (limited ideally to brief stays in psychiatric units of general hospitals), it endorsed and promoted the development of community care as an alternative to hospitalization; and (3) by abandoning the criterion of dangerousness and introducing stringent new restrictions on compulsory treatment, it tried to limit the use of treatment orders to exceptional circumstances. In the event it was not easy to see how well these goals were being met; and in other ways the goals themselves came to seem increasingly ambiguous. Data collected by the CNR (National Research Council) after the first year in which the new law was in effect revealed a number of trends, whose significance, however, was not always easy to understand. There was a sharp drop in the number of compulsory admissions, from 32,551 in 1977 (the last year before the law came into force) 13,375 in the year from June 1978 to May 1979 this represented a decline of 58.9 per cent, distributed fairly evenly across the areas of the country. Voluntary admissions over the same period increased from 51,137 in 1977 to 67,498 in 1978–9, a rise of 32.0 per cent. If, the figures for total admissions are summed up, there was only a moderate decrease from 83, 688 in 1977 to 80,873 in the first year after the law, a decline of 3.4 per cent A final measure, the census of resident inmates in mental hospitals, dipped from 54,480 in mid-1978 to 44,450 in mid-1979, which represented a decline of 18.4 per cent. These figures were in general consistent with expectations for what should have happened after implementation of the law. The striking decline in the use of compulsory treatment orders appeared to reflect a positive change directly attributable to the law. Pirella, for instance, takes the number of compulsory commitments as a ‘good indicator of the productivity of the facility, acility, its style of work, and the relationship between the facility and the community’ (1987:133). In fact the lowest rate of compulsory commitment was in those areas where pilot experiences began before the law took effect; rates tended to rise considerably in other areas where there were only inpatient facilities acilities available, or where the style of psychiatry practised was ‘bureaucratic’, repressive, and based on pharmacology and behaviour control. And yet some critics suggested that the decline in compulsory commitments may have had more to do with the difficulty of getting the three signatures required for a commitment order, rather than with any


consistently improved relationship with patients. A more serious charge was that some psychiatric staffs might have refrained from using compulsory orders not because that was medically appropriate, but in order to give the impression that their services were being effective in avoiding hospitalization (see Sarteschi et al. 1985: 37). Such criticisms might be supported only by anecdotal information, if at all; nonetheless they tended to raise at least doubts about whether, as the partisans of Psichiatria Democratica argued, the figures reflected an unqualified good. The fact that there were fewer compulsory admissions did not in itself ensure that patients were actually seeking and receiving the care that they needed. The question of what happened to the 10,000 or so patients who disappeared from the hospital census in the first year or so after the law was also repeatedly raised, particularly with regard to the situation in the South. Paparo and Bacigalupi, asked, for instance, ‘how many people in the South not admitted in the mental hospitals in 1978–1979 (neither compulsorily nor voluntarily) were however in need of qualified psychiatric help they could not receive’ (1982: 439). The question was of course unanswerable, but it was put in even sharper relief by the CNR survey of what other mental health facilities were available in the country, apart from the mental hospitals. The survey counted some 564 local mental health centres, and 348 halfway-house apartments housing 1,927 guests. The distribution of these services provided, however, striking evidence of the acute shortage in some areas of alternatives to the hospital; of the 564 local mental health centres only 80 were in the South, along with only 13 apartments accommodating 181 guests. A similar pattern appeared in the number of staff (psychiatrists, social workers, nurses) employed in the local mental health centres. Of a total of 6,203 staff, only 480 were employed in the South (which reflects a ratio between personnel and inhabitants of 1:34,000). There were proportionally more staff in the Centre and North of the country, about 1:6,500. But if even those more favourable figures were compared with the staffing levels in Trieste, there was a marked difference. Accord ing to the figures Paparo and Bacigalupi, presented, the ratio of personnel to inhabitants in Trieste was about 1:3,000, more than twice as high as the staffing ratios in the North and Centre, eleven times that of the South (1982: 439). The most prudent conclusion from such data is that the national-level information was quite inadequate to reflect what was happening in different areas of the country; and that in any event what the figures represented in terms of quality or adequacy of care was very hard to judge.


If, the scarcity and poor quality of data make an ambitious assessment of the first years of law 180 rather futile, it is more possible to indicate some of the general structural problems involved in implementing the reforms, and to track some of the larger trends in utilization of mental health services. The administrative decentralization of Italy, which was a factor that early on had favoured local initiatives and experiments in reforming psychiatric services, was for the same reason a strong potential obstacle to the implementation of the new law. If, in one set of circumstances a strong local coalition endorsing reform could be put together, in another set of circumstances the way was open to opposition. The administrative structure of Italian government in many areas of social policy tends to politicize policy-making at both the regional and at the provincial level, which made it difficult in this case and others to conceive of creating nationwide standards, principles of evaluation, and the like. In the most favourable of circumstances one would expect entrenched local interests to defend their prerogatives. In fact the Italy of the late 1970s presented far from the most favourable of circumstances. The actual conditions of the country, from small and mid-sized towns to large urban centres, from the North to the Centre and the Centre to the South and islands (Sicilia and Sardegna), presented a wide array of objective starting points (differences in resources, levels of institutional provision, and professional staffing; varying degrees of dependence on charity or private initiatives; different traditions of political culture) which the law in its abstract generality in no way acknowledged. Two simple measures can demonstrate the diversity of pre-reform psychiatric services. Only 52 provinces (just over half of the total of 95 in Italy) were directly responsible in 1979 for managing all the psychiatric services in their areas; the other half depended in varying degrees, often heavily, on contracting-out for services, relying in particular on Church-sponsored private psychiatric hospitals. Most of the provinces depending on the private sector are concentrated in the South and in Lazio, the region around Roma. The obvious implication of this pattern is that from the outset, even assuming that other things were equal, there was less possibility of applying the law in the South since more of the basic services there were outside the direct control of the regional and provincial administrations. A second useful measure of the diversity of the country comes from simply classifying the pre-reform psychiatric hospitals in terms of their orientation, as ‘traditional’ or ‘territorial’, which reflects basically the degree to which hospital wards, were connected with and supplemented


Table 7.1 Classification of Italian mental hospitals by province, on scale of ‘territoriality’ (‘traditional’, non-territorial hospital=0), 1975–6 North

Centre

South

Torino Cuneo Varese Brescia Pavia Treviso Trieste Genova Bologna Firenze Arezzo Ancona Roma L’Aquila Caserta Avellino Salerno Potenza Palermo Agrigento Siracusa Sassari

4.3 3.0 5.0 3.0 5.0 3.0 6.0 4.5 1.0 7.0 4.0 4.0 2.0 2.0 2.0 1.0 1.0 2.0 0.0 0.5 0.0 2.0

Source: Centro italiano per la ricerca sanitaria e sociale (CIRSS); see L’assistenza psichiatrica prima e dopo la riforma (1984:74–8)

by day-hospitals, outpatient clinics, community mental health centres, and so on. Such a classification is obviously a very crude measure, but it produces nonetheless a fairly sharply discontinuous pattern (see Table 7.1) with most of the ‘traditional’ hospitals concentrated south of Roma, and a gradient of the degree of ‘territoriality’ passing from minimum values in the South to rising values in the Centre and North. Moreover, the ‘traditional’/ ‘territorial’ classification seems to be a serviceable way of highlighting also the different uses of the two sorts of hospital. In the ‘traditional’ hospitals, data for the 1970s reveal that over 80 per cent of patients were involuntarily committed; in ‘territorial’ hospitals the corresponding figure was 45 per cent. Given such


indications of the pre-reform variations in services, it would be reasonable to expect some comparable variations in the pace and extent of implementation of the law. In fact the regional disparities in care have up to the present remained one of the outstanding problems in putting the reform into force. In the larger trends in how services have been utilized, Italy as a whole has followed a pattern roughly similar to that of other European countries, although a decade or perhaps 15 years behind France and Britain The number of beds and the number of resident inpatients, in public psychiatric hospitals have declined sharply. These were trends which began well before the 1978 reforms, and which the reforms then accelerated. Mental hospital beds had increased until the mid-1960s, levelled off for a period, and then begun to decline, especially from the mid-1970s onwards. In 1963 there were over 98,000 beds, or 173 beds per 100,000 of the (adult) population. In 1983 the number was down to about 43,000, or 76 per 100,000. Over the period 1963–8 there was an average decline of 1,390 beds per year; the decline accelerated between 1973 and 1978 with on average 3,305 beds lost per year, and between 1978 and 1983 4,140 fewer beds per year. The peak number of hospital residents occurred in 1963, with almost 92,000 patients, a rate of 161 per 100,000 inhabitants; the number had declined by 1981 to about 38,000, or a rate of 68 per 100,000 (see Table 7.2). The usual explanations for these trends point to the effects of psychotropic drugs (which were introduced widely into Italy in the late 1950s) and to a new interest in discharging patients associated especially with the alternative psychiatry or with other modernizing currents. How much each of these factors is emphasized is often a sign of a given psychiatrist’s primarily medical or primarily social orientation. Hospital admissions continued to rise after the number of beds and of residents had started to decline, which suggests a changing pattern of hospital use. In fact act in the late 1960s and early 1970s there was a clear trend towards shorter, more frequent admissions—the beginnings, in other words, of the familiar ‘revolving door’ pattern. The peak of admissions came in 1975 after which there was a precipitous decline. Some critics of the 1978 law have argued that many of the patients capable of functioning outside hospital had already been released before the reform. What the reform threatened by implication was the ‘dumping’ of other patients whose conditions required sheltered environments and made them poor candidates for rehabilitation. This was probably true of Trieste, Arezzo, and Perugia, and a few other centres, which for some years had already had a strong push to discharge patients, and had


Table 7.2 Residents of psychiatric hospitals on census day (thousands), Italy, 1955–84 Public 1955 1960 1965 1970 1975 1977 1978 1979 1980 1981 1982 1984

90.9 89.1 91.7 82.5 67.2 58.4 54.3 46.9 42.3 38.4 34.7 30.7

Private

13.9

19.7 17.9 16.9 15.0

Source: Istituto Centrale di Statistica (ISTAT), Statistiche sanitarie

probably reached a ‘residuum’ of patients who were mostly unable to care for themselves. But it would be difficult to sustain this point generally, given the rather uneven character of reforming initiatives and enlightened release policies before 1978—strong in some places, virtually absent in others. Such criticism has, however, usefully highlighted the general problem of those former long-stay patients who were and are unable to manage on their own. This is in fact a heterogeneous group, including the elderly infirm, some of the mentally retarded, and others affected by organic complications, who still numbered over 25,000 in the late 1980s and continued to occupy the exmental hospitals. It does not help the reformers’ case that they sometimes referred to this ‘residual’ group simply as the victims of institutional psychiatry, who would in time die out It was one of the unfortunate aspects of the reform that this group has been too often in effect abandoned. With few prospects for discharge or even limited selfsufficiency, they have had to stay on in ex-hospitals which in some cases no longer provide even decent custodial care. The plight of the remaining long-stay patients may in addition signal more than a temporary problem which is entirely a vestige of the past There was a strong trace of ideology in the reformers’ confidence that chronic, long-stay patients would not exist in the future, once the


‘residuum’ was run down. As Morosini et al. noted, ‘senile dementia and mental handicap, once present in psychiatric hospitals, have now almost disappeared from the psychiatric world; alcoholism too has remarkably decreased. No adequate information is available on how these problems are now handled’ (1985:42). One worrying possibility is that mental health services have eliminated at least some fractions of the ‘chronic’ load, by redefining them administratively as non-mental cases, and hence not their responsibility. Recategorizing problems (if that is what has happened in Italy) will obviously not make them go away. It seems hard not to acknowledge that some portion of the disabilities of those formerly accommodated among the ‘chronic mentally ill’ were more or something other than unfortunate results of institutionalization. The kinds of handicap which those patients suffered continue to occur in the population at large, and will require some variety of protective environment and long-term, round-the-clock care. There are no national data on the fate of ex-patients who have actually left the hospital and been reabsorbed into society. Local studies are no substitute, but they provide at least hints of the failures ailures and successes of reinserting patients into their families amilies and communities. One early study in the Veneto region tracked a sample of discharged ex-patients (three-fifths of whom had been diagnosed with functional psychoses) and found that a small number (about 1, per cent) had committed suicide; 60 per cent were living at home with their families; 74 per cent supported themselves through employment or a pension; 54 per cent were being followed to some extent by local social services; and 84 per cent were taking some sort of psychotropic medication (Centenaro et al. 1981). A somewhat later study in Emilia Romagna covering the years 1981–4 found that a high proportion of the discharged patients there (68 per cent) went to live in group apartments, sheltered communities, or old-age homes.1 There is no way of judging how typical either of these patterns was, although the very fact that the studies were carried out probably suggests that they represent better rather than worse-case examples. There is no doubt that in some areas there has been a much greater incidence of ‘transinstitutionalization’ (the simple passage of inmates from one sort of institution to another) and of sheer abandonment of ex-inmates. With the decline in public beds, there has not been a corresponding increase in private beds, at least not as reflected in the available statistics. What Jones, and Poletti speak about as a ‘mushrooming’ of private accommodations for or ex-patients is at best difficult to document; at worst it is a strong exaggeration (1985a: 206). The number of private


psychiatric beds (as documented by the unfortunately often defective official statistics) has in fact slightly declined in the period since the law. The number of private beds reached its peak in 1972, at about 26,000 beds, and has since slowly declined. The maximum number of residents was about 22,000, also in 1972 Between 1978 and 1983 the number of residents in private hospitals declined by 12 per cent. Admissions have remained fairly stable; in 1987 there were about 51,000 cases. Private beds continue to play an important role especially in the South, and in Roma and the surrounding Lazio region, but this is a situation which long antedated the reform. It should be pointed out, however, that some part of the ex-patients released were simply transferred directly (in the best of cases without interruption of care) into nursing homes; it is hard to be more precise, since such homes do not figure in the psychiatric (or other health) statistics and hard data are mostly lacking. It should also be remembered that private elective psychotherapy has grown quite rapidly in this period in Italy; it is very unlikely, however, that much of this expansion has been a substitute for earlier inpatient services. Criminal asylums (which were not affected by the new law) grew slightly in the period after 1978. By comparison with 1976 as a baseline there was an increase of 3.5 per cent in the number of ‘hospital days’ psychiatric inmates served in 1981. But from 1980 to 1985 the number of psychiatric internees declined by 5.6 per cent, notwithstanding a general increase of 32 per cent over those years in the prison population at large (Daga 1987) The overall number of beds in the six forensic hospitals is fairly small, about 1,900. The more dire predictions that released ex-patients would be shunted into criminal facilities do not seem, on the basis of this evidence, sustainable. This was the array of ‘old’ inpatient services which predated the reform. The new inpatient facilities earmarked by the law were to be established in small, 15-bed maximum, psychiatric units in general hospitals, called ‘Servizi psichiatrici di diagnosi e cura’ (SPDCs). Most of these units were established after the reform, in some locales with rather lengthy delays. As of 1984, there were 236 psychiatric units functioning in general hospitals, with 3,113 beds (5.5 per 100,000 population), only about half the rate of provision which was judged to be the acceptable minimum (10 per 100,000). There was a great deal of variation in the level of provision across the different regions, ranging from high rates in the Veneto region of about 11 beds per 100,000 to the remarkable situation of Roma, with only 45 beds available to a population of 3.7 millions. In the Lazio region as a whole the rate was 1.4 beds per 100,000. Low bed-rates could reflect, however, two quite disparate


situations: delays in implementation, which would imply a general scarcity of facilities (the situation in Roma); or a well-developed existing network of community services which worked so well it needed to depend very little on inpatient facilities (the situation in, for example, parts of Emilia Romagna). There was abundant anecdotal information about the scarcity in different locales of inpatient beds, and the consequent pressures on staff to refuse admissions, or to discharge patients prematurely to free up beds. One study of the situation in Roma found that the average stay of patients in the acute psychiatric wards, was only 9.5 days, which was interpreted as ‘a bad sign’, especially given the general scarcity of other psychiatric facilities. In fact act the very high pressure of admissions with few p sychiatric beds available…forces the psychiatric team on duty to dedicate most of its time to screening admissions (trying to avoid them at all costs!) and not sufficient time and care to the inpatients, who run the risk of receiving nothing more than psychotropic drugs and physical constraint for a few days. (Paparo and Bacigalupi 1982: 440) Sarteschi et al. argued similarly that the median figures for inpatient stays were ‘almost certainly insufficient for treatment of acute psychiatric conditions (1985: 37). In 1984 the national data reported a median stay of only 12.5 days. There has been in any event a rising demand on, and increasing use of, such services; in 1987 there were over 91,000 admissions to SPDCs, a rate of 194 per 100,000 of the population over 15 years of age. Comprehensively, there has been a decline in the rate of hospitalization (counting residents on census day, plus total admissions for a given unit of the population). Taking 1975 as a baseline, the rate was 633 admissions per 100,000 compared with 418 per 100,000 in 1987 Given that the number of admissions to private hospitals has remained stable, the change is almost completely the result of changes in the public sector, whose rate of hospitalization declined from 478 to 278 per 100,000 of the population over 15 years (ISTAT; see also Tansella et al. 1987, and Morosini et al. 1985). The new facilities specifically mandated and endorsed by the reform law are much harder to document. Remarkably, the central statistical office (which had been the main source of official statistics on public and private hospitals) has not gathered systematic information about such facilities; and the information available from the regions is in many cases


sparse, and often not comparable from one region to the next. The best source of information on the new services is a survey carried out in 1984 by an independent research body (CENSIS), which collected information about (1) psychiatric units in general hospitals (the SPDCs); (2) district services or community mental health centres; and (3) ‘intermediate’ structures, including staffed hostels, halfway houses, group apartments, and the like. The survey reported 675 district mental health services operating in 1984, in the 694 USLs. Of these a little more than a third had been opened before 1978, and most of the rest in 1979–81. An additional 132 centres were reported as being planned. As a rule the ratio of services to resident population is more favourable in the North and Centre than in the South, where about one-third of the population lives in USL catchment areas without a community psychiatric service. Nationwide about 15 per cent of the population has no access to district services. In terms of the structure and uses of the services there is again a great variety. Only 13 per cent have beds, and in only 1.8 per cent are the beds intended for overnight stays. Most of the services operate as outpatient clinics, typically like other public offices open only six hours a day. (Such figures suggest that the centres must operate very differently indeed from the model community centres operating in Trieste.) The average number of care episodes per service was 4,094, or 480 per 10,000 population. ‘Differences between areas were substantial: [there were] 656 per 10,000 population in northern regions; 230 and 119 in southern regions and the islands, respectively’ Mosher, and Burti, 1989:229). The differences were ‘even more dramatic if data are broken down according to the site of intervention’: community interventions were 265 per 10,000 inhabitants in the northern regions, and 82 and 28 per 10,000 population respectively in southern regions and the islands (Mosher and Burti 1989: 229). About half the interventions were described as pharmacological, and one-fifth as mostly social. The degree of integration with inpatient facilities does not look very good, even nationwide: only half of services have at least occasional contacts, while 8% have none, ever’ (Mosher and Burti 1989:229). On a reading of these 1984 data, Mosher, and Burti, reached the optimistic conclusion that ‘the CENSIS survey actually provides a picture of a comprehensive network of community services extended to the whole nation—a tangible sign that the implementation of the reform has actually progressed’ (1989:229–30). This is one undoubted measure of progress. In contrast to the first two years after the reform, when many areas lacked alternative, non-hospital services entirely, by 1984 there


was at least a network of community services in place. But the simple existence of such services says little about how the new system actually works, and what levels or varieties of care it manages to provide. On the other side, Cassano et al. lamented that ‘Law 180 has not provided local authorities with adequate means or methodologies for caring for the mentally ill’ (1985:181). In most places the law ‘radically interrupted the functioning of the mental hospitals, but left establishment of appropriate services to local administrators, who were expected to assure continuity of care through a system of regional psychiatry’; in too many cases the local administrators proved woefully inadequate, and moreover ‘no minimum standards were set for the type of care community services were to provide’ (1985:175) Even several years after the passage of the law there is no program for reintegration of patients into the community, which was one of the basic intents of the new law, and should not have been left to improvised, unco-ordinated, and stopgap measures devised by medical and paramedical personnel ill prepared to interpret the concept of community care. (Cassano et al. 1985:175)

There is no simple way to choose between such divergent interpretations. Indeed the available administrative statistics are of only limited help, since even on the most generous interpretations they suggest very little about the actual process and outcomes of care. To answer such questions about the quality of care, the extent of its coverage, the adequacy of follow-up, and so on would require a different sort of study, which until recently even in the ‘model’ experiences of alternative psychiatry had not been undertaken.

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Chapter 8 Current prospects and future dilemmas

From the monotonous and constrained world of the total institution, we have passed in the new [psychiatric] services to the need to confront an ever changing array of complex and varied demands, which require—by contrast to the ‘poverty’ of institutional psychiatry—a rich mix of different kinds of know-how, of resources, of responses. (Tommaso Losavio, quoted in Friscano, et al. 1989b: 8) Over time the sharp ideological edge to the polemics about law 180 has been somewhat dulled. There is now an apparently more pragmatic attitude in most quarters, and a general admission that for all its problems (whether resulting from flaws in its conception, or lapses in and obstacles to its implementation) the law has survived, and remains the framework for delivering mental health services. Even if it was never adequate as a blueprint, the law moreover has brought Italy more into line with psychiatric developments elsewhere. There is also something of a sense of relief that somehow the system has by and large coped. The more dire and sensational predictions about a wave of suicides or violent crimes committed by ex-patients have not been borne out Although the press and other media play up, much as they did before, individual tragedies involving the mentally disordered (this is a staple of the ‘cronaca’ columns of the daily newspapers), the statistics on crimes and suicides do not reveal any dramatic shifts (see Williams et al. 1986). What cannot be quantified are the indirect costs and the increased burdens to families which the 1978 law and the push to release patients into the community have imposed. ‘Into the community’ has meant in Italy, more than elsewhere, back into the family. There is abundant indirect evidence of the burden this has placed on families; and there is


direct evidence of family members’ worries that their mentally disturbed or handicapped relatives have access to care. The associations of families of the mentally disordered have become a vocal force on behalf of mental health issues, as close perhaps to a lobby for mental health as Italy is ever likely to have. But even here the emphases in protests and political initiatives have shifted away from, at the extreme, calls to re-open the asylum, to demands for more systematic community provision and for better quality of care. If, there is a sense that there is no going back ever to the era of the asylum, there is also a recognition now that current policies need urgently to be coordinated, and that both regional and national planning of some sort needs to be developed. What virtues there were in relying on local initiatives and improvisations have had abundant time to appear. There was probably also a kind of realism involved in the permissive and enabling character of the law; given the objective diversity of mental health services in different parts of the country before the reform, it would likely have been impossible to track the disparate starting points by law on to a common path. It would have been impossible to legislate for the country as a whole from the example, say, of Trieste, even if there had been the political will to do so, at either the national or local level. The dilemma now, however, more than a decade after the passage of the law, is to work out some set of general norms and regulations as a basis for assessing and improving present performance, and of planning for future development.1 The uneven way in which the law has been implemented has made the regional disparities in some ways more glaring; and even in areas where provision is generally good, there are some locales which are much more poorly served than others. There have been three general patterns in the implementation of the law, which characterize reasonably well the present state of mental health services (see Ongaro Basaglia 1985). What produced the differences probably had less to do with variations in the energy or political will with which the law was implemented, than with basic structural variables which pre-existed the law.2 The patterns are, roughly speaking, (1) a successful implementation, in the full spirit of law 180, with a progressive shift of services into the community, only limited use of inpatient beds, and a reasonably good coordination of the different forms of care available. This pattern has been limited principally to smalland medium-size towns, especially in the North and Centre, and often where there was a local movement for reform, or at least some effort to modernize services, even before 1978. (2) A partial implementation whose effect has been to create parallel

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tracks, or a diversification, of services. This has been the pattern most typical of large urban centres. Rather than replacing inpatient care, the new services introduced by the law have been developed as additional types of care often utilized by a new clientele. The result is something like a two-track system, with a concentration of the more seriously ill in inpatient services, and only limited coordination between the two tracks which serve to a considerable extent different clienteles. (3) A general failure to implement the reforms, or at least a failure to act on the positive, constructive aspects of the law. This pattern has been especially common in the South where local authorities have continued to rely on agreements with private institutions to provide largely inpatient services. Those community-level institutions which have developed tend to be inadequate to replace inpatient care, and they are likely instead to adopt a role as adjuncts to the predominantly medical services. Social treatments in general are relatively poorly developed. This rough typology obviously captures (and perhaps exaggerates) only some gross differences in the patterns of implementation of the law. But it seems to highlight some important variables. It is striking that the reform has been most successful in the end where it was most promising in the beginning. The law has worked best where there were movements for alternative psychiatry already underway before 1978—principally in centres like Trieste and Arezzo. Those are also the areas where the effects of the reforms have been best studied, and where the positive potential of the law to supplant the asylum has been best documented. Psychiatric case registers, which have been developed in several locales in the North, provide the most systematic information on how the new services envisioned by the law can actually operate.3 While it is too soon to draw any general conclusions, studies of the patterns of utilization of services in these areas have produced some fairly reassuring results; the evidence on the whole probably lends support to the sort of conclusion drawn by Mosher, and Burti, about the Verona Sud services, that ‘in the past eight years the South Verona community psychiatric service has faced all the problems presented by psychiatric patients living in the territory, without the backup of the traditional state hospital’ (1989:292).4 If, the best cases demonstrate what can be done, it still remains to understand how far those encouraging results could be generalized, or how far ar they depend on favourable, exceptional, or specific local circumstances. It is hardly surprising that the reforms have encountered special problems in large urban centres which present both more difficulties for the organization and coordination of services (with up to 20 or more local health sectors in a metropolitan area) and a greater social


and cultural complexity in their populations. In a large city it is likely to be more difficult to work a change in cultural attitudes about the ‘dangerousness’ of the mentally ill; and similarly more difficult to create the social preconditions for reintegrating the ex-mental patient into the ‘community’. This is not to say that the alternative services could not be practicable in a given neighbourhood or quarter; but a neighbourhood does not make a metropolitan area. There is yet a third set of variables which help to explain the real failures in the implementation of the law in other places. In general, resistance to the law has been greatest where mental hospital services were most entrenched. In fact it has been a problem virtually everywhere —throughout Italy and in other countries—to transfer resources and personnel from mental hospitals to community services; in this respect as in so many others Italy has encountered problems with deinstitutionalization which arose earlier in other countries. The resistance was, predictably, especially strong in the Italian South, where many of the entrenched mental hospital services were, and are, private, and hence beyond the control of the local authorities. Given the general difficulties of moving personnel and budgets away from hospitals, it is not surprising that private hospitals long accustomed to and dependent upon public money could outcompete fledgling community services in the struggle for resources. Such structural factors still block any straightforward extension or generalization of the more successful community-care experiences; indeed, even assuming the political will to extend the reforms, they probably require some considerable adaptation to diverse local conditions. Working out how to bring lagging areas up to at least some minimum standard of provision remains the major practical problem in realizing the reform. There is also, however, the wider question of how Italy will come to terms with the legacy of the movement which produced the new law. This is an outstanding and still important problem, which may require reopening some of the ideological conflicts of the recent past As painful as that would be, it may be necessary, since despite the new-found spirit of pragmatism, the reform is still in need of a clear philosophy of care. The movement provided one way of thinking about how psychiatric services should function, but that may no longer be an adequate or appropriate image (if it ever was entirely) for the practical tasks which the Italian mental health system faces. There are broadly two ways in which the radical psychiatric movement which inspired and informed the new law is presently interpreted. On

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one view the movement was Italy’s particular way of modernizing its psychiatric services. Flawed as it was, law 180 nonetheless enabled Italy to develop a more diversified mental health system which is closer to the European norm. The radical character of the movement may have been regrettable, but it probably emerged as the counterpart to the backwardness and rigidity of the old system which blocked a more gradual modernization. And yet the ideological character of the Italian movement was a high price to pay. It would be best, on this first view, to liquidate the ideological legacy of the movement as rapidly as possible, and to try to take the situation in hand pragmatically, with the full participation of all segments of the psychiatric community. On a second view, however, the movement represents what is unique about Italy’s potentially revolutionary experiment; the movement itself was not only the means, but also an important expression of the contents of the reform. The abolition of the asylum was not only an ideological slogan to clear away an outmoded system, but a way to change society’s relation to the insane. This second view has had to cope with several obvious difficulties: while it is true that the old asylum is gone and unlamented, and that there are at least some signs of a successful ‘normalization’ of the mentally ill, there has not been the hoped-for (utopian) cultural shift in attitudes, and there remain the considerable practical problems of replacing with alternatives the real functions of the asylum. The question is, in what spirit can or should these practical tasks be addressed? The ‘political’ message of the movement, beyond abolishing the asylum, had been to ‘de-psychiatrize’ the response to mental illness. As a challenge, or a corrective, to prevailing practices, the movement mounted a powerful critique. The difficulty is that the critique provides only very limited guidance about how positively to reconstruct ‘help’ to the psychologically suffering. The first principle of the alternative psychiatry had been to try to understand psychological crises and breakdowns in situ, in the concrete situations in which they occurred. This was the key to interpreting the unfulfilled, unexpressed or partially expressed and distorted ‘needs’ which lay behind psychological suffering. The theoretical development of the new psychiatry hardly passed, however, beyond that point. The effort to ‘treat a person, not an illness’ implied a certain style of working (initiated often by crisis intervention) but it implied little about the character or contents of psychiatry’s intervention. The strong activist character of the interventions, whatever its positive and attractive features, was also a cover for a lack of theoretical production. To the charge that the new


psychiatry seemed to attend principally to the material needs of clients, the response was, justly enough, that those were real problems with which no one, least of all a mental patient, should be burdened. This was, however, the weak point of the new approach. It was clear that the purpose of ‘alternative’ interventions was to prevent institutionalization: avoiding that evil was a good in itself. But beyond eliminating the harm of institutionalization, what the alternative psychiatrists tended to evoke positively as their goal was a so-called ‘philosophy of the social’, which recalls in many ways the unrealistic (and often unexamined) assumptions made elsewhere about the powers and virtues of ‘community care’. The hope of building up a new sort of social support network for ex-mental patients and for psychologically suffering individuals has in fact been realized in Italy—locally and briefly—in some extraordinary experiments. In most places the experiments have proven difficult, however, to reproduce predictably and reliably over time, which is what a social policy is called upon to do. What the psychiatric movement in Italy has not been able to produce is a sense of permanent mobilization of ‘the social’ in the interests of caring for the mentally disordered. That is hardly a failure, so much as a sign that the movement’s goals were utopian and that its cycle of activism is winding down. What that implies, however, is that the job of building up psychiatric services is unlikely in the future to follow the prescriptions of the movement and its ideals. The image evoked, for instance, by the partisans of Psichiatria Democratica of a flexible, global response to the undifferentiated ‘need’ of a suffering client cannot realistically become the motto of a specialist service. The legacy of the movement is important because in one fashion or another Italian psychiatry will have to come to terms with the critique of professionalism and expertise that the movement advanced. If, psychiatry now is still suffering from a prolonged ‘crisis of identity’, that situation cannot continue indefinitely. It remains to be seen, however, how a new set of images for psychiatry and mental health services will emerge.

APPENDIX Documents from the movement Translated by A.Bastow and M.Donnelly

Giovanni Jervis, ‘Psychiatrists and politics’ (This is a revised and expanded version of a talk delivered at the conference ‘Dialectics of Liberation’ in a session on problems of psychiatry. The conference was organized by four psychiatrists, Drs R.D. Laing, David Cooper, Joseph Berke, and Leon Redler; it was held in London in July 1967. A selection of some of the principal addresses to the conference, erence, edited by David Cooper, was published under the title The Dialectics of Liberation by Penguin Books in 1968. It includes contributions from among others Cooper, and Laing, and Gregory Bateson, Jules Henry, Paul Sweezy, Paul Goodman, Stokely Carmichael, and Herbert Marcuse.) The fact that a group of psychiatrists has organized a conference where psychiatry is barely talked about may seem extraordinary, but it is not fortuitous. It is not easy to give a brief and full explanation, but in some way this must be seen as a sign of the times; only a few years ago such an idea would have been unthinkable. There are a number of general explanations which have been put forward: that there is a crisis of values, that no one any longer knows what is normal and what not, that society has gone mad. and that we have to find ourselves again. These pronouncements do not seem very useful to me. I would prefer to begin from a different point: that it is psychiatry that is in crisis, and that as psychiatrists we no longer know what we are doing. One could go on at length about the crisis in psychiatry. There are those who pretend that there is no crisis, but that is not the case. Many psychiatrists continue to pursue the paths of traditional psychiatry simply because they have given up looking for alternatives, or because they do not understand the situation. Others still believe in the novelty of psychoanalysis, or are trying to sound out new interpretations of the

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Freudian message. The latter, though, are simply perpetuating an old affliction (the ‘malaise of psychoanalysis’ has been evident for the past 20 years at least) while at the same time reinforcing an inevitable decline and attenuation in the more genuinely innovatory aspects of traditional Freudian ideas. Anthropo-phenomenological psychiatry seems to have said everything that it had to say, and proves to be full of reactionary ideologies; the neo-Pavlovians for their part have still not produced anything that can be considered genuinely new. As psychiatrists, we no longer know where to turn at the very moment when we are realizing that traditional psychiatry doesn’t work any more. At international conferences one has the impression that psychiatry is dead rather than in crisis. But this is not a sudden affliction. We should have recognized it before, as it is now clear that there has been a prolonged agony, a sickness that has had several of its own critical peaks and developmental lines. First of all, there is the crisis in institutional psychiatry. In the last few years people have been rediscovering that the mad in asylums have only become so, not because of the evolution of some morbid process, but rather because traditional psychiatric hospitals are factories for making people sick. The mentally ill are not, as the law would have it, a ‘danger’ to others. Although they are systematically made dangerous by the treatment in asylums, on a statistical basis they continue to commit a smaller number of criminal acts than people who are considered sane, and a much smaller number of ‘motiveless’ crimes (although in reality motiveless crimes do not exist) than those committed alone by, say, ‘normal’ motorists. Moreover, if these crimes are sometimes ‘publicly scandalous’ or asocial or antisocial, this does not mean that they should be held responsible. Amongst other things, the cultural conventions which control these formulae are extremely variable, and they certainly have nothing to do with anything objectively definable on a psychological and psychopathological level. The mentally ill are cut off from ordinary civil life, first and foremost by the mere fact of being excluded. In traditional psychiatric hospitals they are dehumanized almost to the point of being reduced to human larvae. This occurs primarily because a particular socio-familial dynamic (which is only now beginning to come to light) has constrained them to behave in a way labelled as pathological and ultimately consigned them to the pseudoscientific violence of asylums which have proved instrumental in confirming and furthering a process of psychological breakdown. Since we know practically nothing about schizophrenia (which affects 1, per cent of the population, filling up psychiatric institutions) and very little about other mental illnesses, and since our therapeutic methods are


extraordinarily empirical and unreliable, we continue to define the object of psychiatry through a series of tautologies which in the end can be reduced to this single absurd formula: ‘altered behaviour defined in psychiatric terms’. We are now beginning to become aware of all this, but we do not know on what to ground the criteria for reform. The relationship between psychiatry and medicine has been in profound crisis for some time, and since the latter offers us hardly any assistance or useful criteria, our attention has turned to sociology. But even here we fall into a sea of contradictions. On a different tack, the history of the crisis of modern theoretical psychiatry is very clear. Several dominant lines in psychiatry over the last dozen years or so have been converging in a fairly definite direction —highlighting the loss of inner autonomy in psychological disorder, with increasingly marked attention to the interpersonal dynamics involved in the genesis, development, and possible treatment of the psychopathological phenomenon. Psychoanalysis has been ‘interpersonalized’; the psychology of groups and the psychology of communication have made their own very important contributions; the psychiatry derived from existentialism and phenomenology has accentuated this process in its own ways; a transcultural psychiatry has emerged. All this has contributed to the erosion of the traditional concept of individual illness. The appropriate response seems to be implied in the crisis itself—it is social psychiatry, or a psychiatry focused on groups, families, communities. At this point it is well to ask what the political system demands of psychiatry, and if by chance the role demanded from psychiatrists by the powers that be is not rather more significant now than it was in the past. There is in fact an ideology in our society which expresses quite clearly the demands of the powers that be, and which relies on tools directly relevant to psychiatry. Psychiatry has always been a repressive and conformity-producing technology, a more or less harsh instrument of segregation or, in the best instance, of re-education. In this century, after the advent of psychoanalysis, psychiatry has created for itself a genuine ideology, a morality, a complex societal ethic which appears more or less explicitly, depending on who is articulating it. Psychiatry has refined its methods and targets, and extended and ‘capillarized’ its aims. In the United States the most eminent psychiatrists have, for some time now, been openly pronouncing upon the political tasks of psychiatry as a discipline called upon to resolve not only individual but also social conflicts, to treat not only the classical pathologies, but also the anxieties, failings, and difficulties which everyone, which entire groups, face in the

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process of coping with daily life. Psychiatry grounds itself on the value of integration. All this conforms to the demands of the system. A number of basic characteristics in the ideology of advanced capitalism go hand in hand with the development of psychiatry. In the absence of a systematic analysis, a simple list of tendencies can suffice: the tendency to conceal social problems behind individual ones (and to make social problems seem to derive from individual ones); to deny objective conflicts (such as those between the classes) by passing them off as psychological conflicts; to deny the dynamics of history by representing history as if it were a constant repetition, driven by the same processes deriving ultimately from a human nature which is assumed to be always the same; to explain social phenomena and try to modify them through recourse to irrational factors of the unconscious rather than to the conscious and the rational; to endorse the interchangeability of individuals in the name of some value-free quantifying calculus; to reduce social phenomena to depoliticized structural schemes; to reduce the problem of freedom to adaptation to an inevitably predetermined socio-environmental reality, and so on. Bourgeois ideology ‘tends in general to hide the individual’s responsibility in the political sphere, delegating it to experts, and to force individuals to give vent to their feelings in a private sphere in which every possible malfunction can be corrected in the most appropriate way. Recourse to the false, apparently neutral and dogmatic ‘scientism’ of psychological and psychiatric investigation is now being dressed up in new philosophical clothes, and even structuralism is tending to ally itself (in Althusser) with Marxism as a way of relaunching ‘scientific’ materialism, always a useful way of hiding the reality of the problem, which is still a problem of personal choices and political analyses, not an abstract technical-structural problem. One could go even further—the integrating and totalizing drive of the repressive apparatus only accentuates trends already developing. Advertising, propaganda, prepackaged information, the education of the young along the same lines as the continuing re-education of adults through instruments of mass communication, confer upon psychologists and psychiatrists greater power and a more direct responsibility. The contradictions of advanced capitalism create new psychological problems, which make the need for stricter control more important. A social engineering is emerging, even a psychiatric engineering. With the [Vietnam] war, the militarization of American society has brought the responsibility of consensus experts yet another step forward.


A call for a complete reversal [of these trends] has been put forward by those who have organized this conference, and in particular by the theoretical works and communitarian experiments of Ronald Laing and David Cooper. First of all, I would like to point out that there is nothing paradoxical about the opinions of these psychiatrists; they are entirely consistent with the lines of development in modern psychiatry. By extending these lines only a bit further one comes to recognize the failure of psychiatry and the need to reformulate everything on new principles; or, as Cooper, says, to create an anti-psychiatry. On the other hand, one should not forget that our society today is making increasingly heavy demands on psychiatrists; an anti-psychiatry could only imply a refusal to serve the system. The demand of Laing and Cooper, first and foremost to deny the false objectivity of the expert, the cover which conceals the power dynamics in which psychiatry is implicated, is thus wholly justified. Psychiatry, if it refuses to serve, must inevitably deny itself and become political action. Deviant forms of behaviour which have conventionally been labelled as psychiatric are forms of reactive behaviour which the system will not tolerate but which, on the other hand, are not directly controlled through the traditional use of police repression. From recognizing the broadly conventional character of the psychiatric treatment of deviant behaviour we need to return to a radical critique of the psychological and psychopathological criteria of deviance. The specific meaning of the term ‘deviance’ upon which modern psychiatry rests is not in fact scientific, although the very same psychiatrists who are coming to realize this are, at the same time, encouraged to extend their pseudo-science yet further, making it also less penetrable to political and non-specialist criticism. This clear contradiction does not mean, on the other hand, that legal repression is always preferable to psychiatric repression. In reality these are not real alternatives, nor is there a radical opposition between police law and psychiatric law. Military psychiatry shows us the integrating logic of a complex authoritarian mechanism, which ‘tends to make complementary and compatible the prison with the asylum, and the role of legal authority with that of psychiatry. Psychiatry, therefore, tends to project itself as a facet and a forewarning of a ‘totalizing’ society; and this role reinforces at the ‘therapeutic’ level what is already true at the psychopathological level—deviant behaviours which come under the purview of psychiatry have been largely induced by the unconscious operation of well-established psychological mechanisms set in motion by those who in the ‘sane’ environment (and

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especially within families) are blind and jealous defenders of order and the established cultural values. Here the analysis forks in two. On the one hand it is important to recognize that deviant behaviours ‘considered as psychiatric’ contain a certain dialectical truth in them and present a paradoxical, subversive potential. On the other hand, one cannot close one’s eyes to the fact that these behaviours are not the clear sign of self-expression and personal liberty, but that they have been presented to us, right from the start, under the dark, regressive, and disordered guise of a suffering so serious as to forbid any new ‘praise of folly’. I fear that Laing and Cooper, have been misled here. For them, psychosis contains a truth which is denied to the sane, to those who are genuinely responsible for a society gone mad. This leads, on the one hand, to a denial of the historical and political (not psychological) nature of certain repugnant aspects of the society in which we live; and, on the other hand, to a re-evaluation of the psychotic experience in the only way in which psychosis could be taken to symbolize a categorical and non-dialectical reversal of prevailing standards, namely, by attributing to psychosis the value of religious experience. According to Laing, a schizophrenic episode is one of the most dangerous, but also one of the richest, experiences which can lead to the perception of perennial truths; there are other paths available, laid down by the great mystics, and perhaps nowadays also through an appropriate use of psychedelic drugs. We should not get too involved in details here. I only wish to remark that the proposals arising out of this conception are not at all dysfunctional to the mystificatory, psychologizing, and anti-political ideology of modern capitalism; indeed these notions tend to reinforce the mystifications. It is not fortuitous that Laing should propose, as an alternative to the usual treatment of the mentally ill, solutions which instead of opposing the system lie outside it. According to Laing and his colleagues, psychotics should gather together in private communities in which each person is free to express himself, without restriction, in his own psychosis. These communities would follow the ways of mysticism, linking up with each other in a worldwide network, traversed by individuals already more free and wise from their own inner illumination. We clearly disagree with this. It should not be forgotten, however, that Laing represents today the most advanced point in world psychiatry, and that he is a theorist of great value. His conclusion is, in some way, a necessary one. But these positions, I want to insist, do not offer a real alternative. We are fully aware that psychiatrists who refuse to serve the system have no


clearer alternatives to put forward. We must recognize frankly that if we refuse to follow Laing, Cooper, and Berke, and likewise consistently refuse the integrating role that society demands of us, then there remains very little margin for action. Psychiatry comes across to us today as a discipline that is ‘naturally’ integrating and reactionary, and if it is our responsibility to do something with the (socalled) mentally ill, we cannot be so ingenuous as to believe that it is our job to change madmen into revolutionaries overnight. I can only refer in a very schematic way to the difficulties which arise at this point. In the first place it is possible to consider mental disorder as a complex socio-psychological situation characterized by lack of freedom, the lack both of psychological and of politicosocial freedom. The patient exists and is treated as such in so far as he is reified in a situation which leaves him no alternatives. This situation is exemplified in its most typical and harsh form, by the condition of the mental patient in an asylum. Since this lack of freedom is an individual aspect of a broader social violence, the patient can reacquire the capacity to act again as an agent only to the extent that he comes to understand his situation, and begins to challenge and contest it. This is not easy, for a variety of reasons. But it is important to note two ambiguities which emerge at this point. The first is that the coming to awareness, and the contestation, of the mentally ill individual don’t spring from the patient himself, but at the urgings of ‘progressive’ psychiatry, which thus assumes an active pedagogical role. The psychiatrist acts as the agent in the process of liberating the patient, before the patient is capable of doing it for himself. The psychiatrist can only hope to abandon his real liberating role in so far as the patient, by assuming increasing control over his own liberation, comes to contest the psychiatrist’s ‘pedagogic’ role. The second ambiguity arises from the social role. of the ‘progressive’ psychiatrist, and from the organizational and politico-social conditions in which he is allowed to operate. What comes out very clearly from what has been said is that it is impossible to put forward an ‘anti-psychiatry’ on the basis of a highly selective, ‘conveniently’ chosen case load, much less by treating middle-class patients in the closed protection of a private clinic, where every revolutionary experience seems possible just because the setting is so separated from contact with the violence of the external world. The choice of the public psychiatric hospital as a place of action is therefore inevitable. On the other hand, psychiatry finds itself there fully integrated into a repressive system; claiming to undermine it from within is no way of escaping from the risks of reformism and from the

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ambiguities of acting; to act requires a measure of power, which is already inevitably compromised by the same social violence which tends to reify the mentally ill individual. The psychiatrist thus finds himself in a difficult situation. On the one hand, he is bound to reveal the scientific incoherence of his discipline and to criticize its mystifying role. within the system; on the other hand he is unable to put forward (except with great difficulty) genuinely subversive alternatives, or to assume a politically revolutionary role. In my opinion there are only two possibilities of political action within psychiatry. The first concerns the denunciation of the hidden violence of the social system, through a demonstration of the links which bind the extraordinary and manifest violence exercised upon patients in traditional psychiatric hospitals, with the more general repressive demands of society. The asylum is criticized as a specific institutional structure, but it is one which, for or this very reason, allows the demystification of a number of psychological mechanisms, and even more to the point of politico-social mechanisms (like the mechanisms of exclusion), which operate in a less visible way outside the walls of the asylum. The second possibility consists in advancing the process of dismantling and reforming public psychiatric ‘help’ and the revolutionizing of theoretical psychiatry towards ever more advanced alternatives, to the point of involving political demands which the system as constituted is no longer able to concede, at least without falling into contradictions with other more fundamental principles. This second alternative must not be taken for granted. Anti-psychiatry is continually at risk of being reabsorbed by the system, i.e. of putting forward demystifying notions which, because they are anti-conformist and non-authoritarian, can invariably be used by established authority to control and channel dissent in the most subtle, narcotizing and effective ways; or by demonstrating a false liberality of institutions by pointing to their toleration of a dissent kept carefully on the sidelines. Franco (Basaglia) Franca Ongaro Basaglia Domenico Casagrande, Giovanni Jervis, Letizia Jervis Comba, Agostino Pirella, Lucio Schittar, and Antonio Slavich; excerpt from ‘Considerations on a communitarian experience’ (1967–8): ‘Reality and contradictions in the process of institutional renewal’ The passage from a traditional psychiatric hospital to new forms of organization and care can take various paths; if the point of departure


‘tends to be a common one with few variations, the point of arrival, which would be the psychiatry of tomorrow, is still unknown. The common point of departure is the rejection of the traditional psychiatric hospital. This institution has by now been studied in depth, but only recently has its real social-psychological character and structure been understood. What the structures of the future will be has yet to be determined. The prospects for reform are becoming, however, so radical (also in a number of foreign studies) as to induce us to consider seriously that the very notions of ‘psychiatric care’ and ‘organizational structure’, as well as ‘therapy’ itself, may need to be rethought and reformulated on completely new lines. In the various experiments to reform and break away from traditional psychiatric hospitals, there are a number of patterns and stages of transition, which recur with surprising frequency given that the experiments are based upon different theoretical premises. In particular, the British and American experiments (which are predominantly practical and empirical, based to some degree on sociology), the French experiments (of which the most advanced are derived directly from psychoanalysis), and our own experience in Gorizia, all have a number of similar characteristics. The experiment in Gorizia, for instance, though following lines similar to those in the British experiences of ‘therapeutic community’, also found itself confronting a number of themes familiar in French-style ‘institutional psychotherapy’. The renewal of psychiatric structures can only proceed by continual crises and self-criticism, or by a dialectical supersession of stages, which prevents any premature closure or crystallization of change into new immobile institutions, even if these may be more modern, efficient, ‘democratic’, ‘communitarian’. Once we have gone beyond the traditional concept of the psychiatric hospital as simply a place of custody, we come upon the familiar notions of the hospital as a place of therapy and social reintegration. But modern psychiatry is in the midst of a crisis; and the transformations of the psychiatric hospital which have emerged in the most recent experiments have virtually destroyed the idea that a mental hospital’s ‘guests’ are simply going to be treated. The reality that we face is quite different and more complex. We are dealing with groups of individuals who have been confined for many different reasons, and for whom the label ‘mentally ill’ does not correspond to anything that can be scientifically defined. With such individuals, the medical team must find both a way of criticizing the institution, and of coming to terms with the contradictions in the society at large which lead to exclusion— with those contradictions that have forced those labelled ‘mentally ill’

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into the blind alley which has traditionally made ‘mental illness’ a sentence to be confined in a closed and isolated institution. At a time when modern psychiatry no longer knows what mental illness is (and therefore does not know what it would be to cure) the critique of the institution has discovered that the role of the hospital is no longer simply one of reintegrating the patient into an unjust society. The transformation and destruction of psychiatric hospitals is not something that is being done in preordained and linear stages. If, there are similarities between the experiments in different countries, this is so for many different reasons, but in part because certain common premises seem to enter into every psychiatric reform. These premises can be generally summarized as a rejection of violence and of the traditional hierarchical roles. …If reformers often start from a similar sense of what needs to be done (even though, subsequently, reforms may be justified according to the theories of completely different schools of thinking), then the difficulties which reforms encounter may well have similar features. The hostilities towards change expressed in many environments (whether within or external to psychiatry), although they must be identified concretely as they actually emerge within a given cultural and historico-political reality, present such immutable characteristics, both of a psychological and sociological order, that they inevitably contribute towards determining indirectly a certain common pattern in the stages of change. This demonstrates, amongst other things, that change in the psychiatric hospital does not follow strictly from general and fixed technical exigencies, as would be the case, for instance, in the rationalization of a firm. The process of renewal and reform moves rather in response to factors which are largely external to the pure and simple organizational requirements of the institution, since those factors have their roots in society. Beyond the need to ‘negate’ the traditional psychiatric hospital, there is also the need for a moral renewal. Indignation at the violence visited upon the mentally ill is part of the reforming impulse which draws on (traditional) democratic sentiments internalized in education (traditional in the sense of ‘habeas corpus’, respect for and attention to the suffering, a sense of human dignity, the desire to allow the members of whatever community to benefit from democracy, and so on). The psychiatric hospital in the image of a ‘snake-pit’ evokes not only anger of the compassionate and charitable sort, but also, in so far as the social conscience begins to develop, a push for practical reforms. The presence of a group of reformers particularly conscious of this democratizing demand, and the gap separating such reformers from the


majority of the population, from the orientation of the civil authorities, and from those who hold power within psychiatry, make it all the more likely for open conflicts to arise between the supporters and opponents of psychiatric reform. It is also clear that where psychiatric reform has been most harmoniously incorporated, in countries with long-standing democratic traditions, into the gradual evolution of civic culture, that reform tends to be gradual and incrementalist; on the contrary, where there is a strong contrast between the goals’, of reform and the prevailing political and ‘civil’ backwardness of the country, it is natural to expect a radicalization of the avant-garde of institutional reformers. When hospital reform goes beyond the stage of being merely humanitarian, it is transformed from being a generically ‘civilized’ change to a genuinely innovatory one. What then remains of the ‘psychiatric’ in the transformation of an old asylum into an institution of a new type is difficult to pin down. Indeed, it is not easy to define at what point the ‘democratic’ and ‘humanitarian’ rationales for transforming the modern hospital cease to be articulated and justified in terms of what is ‘the most effective’ therapy for the mental patient The process of institutional psychiatric reform…runs right from the outset against certain specific limits which it is important to highlight. The fact that there are individuals who are permanently unfree (the mentally ill as second-class citizens) itself constitutes an obstacle in the process of institutional democratization. This situation presents structural features which make it difficult (though not impossible) to overcome a humanitarian approach imposed from above and a paternalistic democratization; long-stay patients in an institution find it difficult from the start to become protagonists in a reform which concerns them directly. Moreover the reform tends unfortunately to be presented at the beginning as an operation from the top down, imposed from above. The problem, which is not so serious when the hospital is just beginning to revise the old authoritarian procedures, becomes serious when the experiment is sufficiently advanced to propose in more radical terms the need for the genuine freedom (not merely a conferred one) of patients. But it is precisely at this point that the theorization of the hospital community must become tougher and go beyond the limits of mere superficial humanitarianism. The fact that one may want to initiate in the community an education for freedom does not necessarily prevent the risk that the authority of the established power remains unchallenged. According to the capitalistic scheme of things (which has been frequently and very justly criticized) subalterns can be conceded freedom of opinion and of

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action provided that they learn the rules of the game, and thus remain within the confines laid down by the system. The greatest criticism against liberalism is to be found not so much in its areas of ‘illiberality’, as in its tendency towards integration; in other words, in the false liberty which trains its subjects to make only ‘reasonable’ demands. The therapeutic hospital community must fight against the risk of adhering too closely to this scheme. On the one hand, it seems essential to give patients a maximum amount of freedom and autonomy, and to impose a minimum number of restrictions and no punitive measures at all. On the other hand, it is impossible to deny that the force required to push chronic patients, abulics, and the heavily sedated towards freedom (that is towards choices, activities, participation, criticism) goes beyond the real situation, thus painting for many patients within the hospital a fictitious picture of freedom. They are sometimes the first to recognize this, and it is often the case that it is precisely those patients who are the least participatory who express the shortcomings of the whole situation, with the insight that: ‘You’re wasting your time trying to get me to take part in the discussion, to cast my vote. Don’t tell me we’re all equal. You’re the doctors and we’re the patients; we’re locked up and depend on you’ This does not mean that such situations and difficulties cannot be faced up to, discussed, and continually reassessed. The very fact act of acknowledging them as problems, in other words, of living them as difficulties ficulties at every level of the hospital community, is one of the most valuable of all stimuli and one of the spurs towards ever greater levels of criticism and awareness. For example, it is well known that there is a danger of substituting for the abulic inertia and passivity of patients in traditional psychiatric hospitals an activism which is equally unconscious, uncritical, and routine. This danger can be overcome and corrected, at least in part, by stressing the possibilities of choice and alternatives (including, indeed, the refusal of patients to take part in patient activities). The fact act that patients can choose or refuse use not just a single activity or a single role, but various roles, is one of the cornerstones of, and necessary stages in, the evolution of a therapeutic community. These possibilities of choice constitute the practical side of discussions, and inevitably lead to a state of critical awareness, that is, to the stage of challenging institutional limits which the very existence of the psychiatric hospital places on the activities of its patients. Even here there arises an apparently insurmountable difficulty. While within the hospital every freedom seems to become possible (not in the


sense of individual licence, but freedom to organize collectively their own time), the fact that the mental hospital is still constrained by the law, and the physical separation between the hospital and the outside world of ‘sane’ society, constitute a new barrier. This barrier is real and actual. The danger of seeing the hospital as a ‘village’ and as a ‘golden retreat’, although it is one that arises continually, can in fact easily be overcome and avoided in so far as every internal problem be tackled as such, and lived through as a crisis affecting not only patients, but also by the medical staff; this dialectic, rather than creating an uncritical acquiescence on the part of patients in some comfortable compromise, necessarily leads on to a confrontation with reality. Indeed the confronting of reality becomes increasingly serious and profound, and leads ultimately to a confrontation with the most genuine and painful reality of all, not that of the injustices and suffering within, but of the effective impossibility of the hospital’s opening itself up totally to the outside world. The fact that the law does not allow patients to leave the hospital on their own, the fact that real, productive, and vital exchanges are not possible with the socioeconomic reality of the outside world, the fact that public opinion continues to be heavily prejudiced against patients —these constitute a very serious limit to the ‘freedom’ which those confined ined to an asylum enjoy, and they tend even to negate and trivialize their achievements. These issues resolve themselves, however, in a new awareness of the situation. At this point it is necessary to clear away a possible misunderstanding. A number of people who have visited our hospital have asked us if there is not a danger of making patients accustomed to a smoothly functioning, artificial, and idyllic democracy within, to the point where we ‘create misfits’ unprepared for the prevailing harshness of the ‘sane’ world. This danger does exist, but in our opinion it is very much a secondary danger. In the first place, the internal dynamics of the hospital community are much less unrealistic, saccharine, and artificial than one would imagine (on the contrary, the dialectic which generates discussions and practical solutions arises from the often exasperating contrast between internal tensions and the difficulties arising from demands placed by the outside world, of which the administration of the hospital with all its financial and bureaucratic demands is a typical example). Secondly, the education towards democracy and anti-authoritarianism of patients (and also, often in a very conspicuous way, of the therapeutic staff) is not an easy or merely ‘comfortable’ habit such as would likely be crushed by the harsher laws of competitive society. On the contrary, it provides a positive and useful force for confronting and reinforcing the possibilities of personal

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interaction and conflict. This can only favour an active reintegration beyond the hospital walls. If, anything, the difficulty lies elsewhere. The social mandate to which the hospital as an institution answers is, in the worst of cases, punitive and custodial, and in the best, purely integrating. If, as is the case, the specific task of the psychiatric institution and of psychiatry in general is to reintegrate the patient into the normal intercourse of society, then it is unavoidable that this involves a whole series of efforts which are necessarily integrating (and therefore not confrontational), and in the extreme are decidedly conformist There clearly exists, therefore, a contrast between the community and the very definition of psychiatry. Psychiatry is still a’therapeutic’ discipline which is premised on integration as a value, that is, on the control and re-education of socially deviant behaviour as a means of adaptation to conventionally accepted social forms. The way that an advanced hospital community takes shape, on the other hand, ‘tends to discourage conformism and dependence, and to encourage contestation and criticism. Thus, the objection can be made here that the danger is not so much in creating people who are maladjusted as in creating rebels. And one might even go as far as to say that this is desirable. If, there is a real impossibility at this point, then it does not have to do with failings of the personnel or with the organizational design, but rather with intrinsic structural characteristics of psychiatric and hospital work as those activities are currently understood. Sadly we still continue to be influenced by a psychiatric tradition which has yet to invent a reliable and valid anti-psychiatry. Hence we are still bound to conceptions of health, of mental illness, and of treatment which are permeated with socially and historically determined values and judgements…. The doctor belongs to an external society which he may not agree with or like, but which is the source of the social power which allows him to be a reformer during his time at the hospital. The liberation of the patient is not necessarily his cause, and moreover the doctor cannot so easily accept giving up completely his own role. entitling the patient to challenge totally his very presence. The doctor has a professional and, unfortunately, bourgeois mentality; he plays a role which has already been compromised even before he steps into the hospital, by the custodial and integrating social mandate of psychiatry. Even worse, he adopts a role within the hospital which, having little about it that it scientifically grounded, puts him constantly in the position of exercising his power (which is social, political power) over the patient. In theory there is a formula which aims to overcome these difficulties. The various roles, of doctors, nurses, and the entire medical team could


be divided into social roles, and technical roles, where the latter would not involve real powers to strip another individual of his liberty. It can be said, in a similar way, that if there are always asymmetries in relationships (in the sense that decisionmaking disposes some individuals to act on others, inevitably conferring greater power on some than on others), then this only occurs in so far as the qualitative differences in technical duties are continually limited and controlled by the fact that they are always absolutely explicit and, above all, accepted as necessary by free collective agreement The distinction between technical power and political power is, however, one of the most typical mystifications of power. Considering that, outside the hospital, the defence of the ‘unquestionable’ neutrality of experts and technicians has always been an argument of reactionaries, we are forced to ask ourselves whether, first, any conceptual distinction can be made between technical power and political power (or between the technical ‘psychiatric’ role and an authoritarian role or, as others would have it, between authority and authoritarianism), and, second, whether ‘technical’ power does not continually confer on the individual who wields it the opportunity and temptation of an arrogant ‘super-power’ which risks being reproduced in a more or less hidden way. The discussion has gone on long enough. What we should point out is that the problem needs to be turned around. We need to know why some people, and not others, have ‘technical’ power, and whether the acquisition and maintenance of this power is not already linked to social privilege, and to the mentality of those who use this privilege and who adhere to values defined as ‘sane’ by society. Added to this, the unchallenged and authoritarian power of doctors tends unfortunately to become more subtly psychological, more covert and resilient, as authoritarianism comes to appear less explicitly and less obviously violent than before. The decision to destroy the comfortable, convenient custodial (or paternalistic) status of traditional hospitals arises out of a personal choice which demands very specific sacrifices on the part of the hospital authorities; the choice is connected both to the humanitarian impulses (‘moral’ and ‘civilized’) mentioned above and to the need to ascertain in the only way possible (in the actual field where psychiatry is practised) how traditional psychiatry can be superseded. It has by now become clear that so-called scientific psychiatry, based on the clinical individual case as a problem divorced from the actual reality of socially managing the mentally ill: individual, is an exercise which is absurd and lacking in any real verifiable possibilities. Within the psychiatric hospital, there is a contrast between the ‘therapeutic’ theorizing of traditional and modern academic psychiatry,

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and the world of real difficulties in which mental illness exists, in its reality of violence and oppression. Awareness of this fact prompts a choice between a method of descriptive enquiry, which is technical and ahistorically ‘neutral’ (represented in the present-day philosophy of structuralism), and an enquiry which fits into the historical-political world, one implying personal involvement, commitment to a field of action in which politics is irrevocably linked to research and to the practice of reflecting on that practice. Our choice is therefore for commitment We must be conscious of the fact that whoever proposes reform of a psychiatric institution will come up against the need to change the prevailing productivist, consumptionist, and hyper-individualist criteria which effectively regulate our society. The official social mandate, the task delegated by society to the psychiatric hospital doctor, is obviously not intended to abolish the institutional asylum, but rather to maintain it; not to relinquish the doctor’s power, but to utilize it. It is not intended to criticize the oppressive and socially integrating role of psychiatry, nor to encourage the capacity to challenge authority among internees and the oppressed, but to defend the privileges and techniques of those who confine and oppress. It is not intended to create a ‘horizontal’ structure in the hospital, but to reflect, even in an exaggerated way, the oppressive hierarchy of the outside world. Nor is it intended to place the manipulation of consciousness for which the medical intelligence is responsible and culpable under continual criticism and self-criticism; rather it is to provide society with a curative machine which is functional to it, and which is designed not to interfere with the privileges of those who do not want society to change its oppressive face. This has two important consequences. In the first place, this type of alternative choice ‘tends not to create a non-authoritarian island in an authoritarian society, but rather to foster a self-conscious and experimental dialectic between authoritarianism and hierarchy (criticized and uncertain) on the one side, and certain new opportunities for contestation which arise directly from demystifying the traditional role. of the doctor. Secondly, the choice of a non-authoritarian and nonhierarchical alternative must be posed as a personal choice, which will involve an individual crisis in those who decide to promote psychiatric institutional reform. All advanced therapeutic community experiments, of whatever doctrinal origin (psychoanalysis, sociology, politics, humanitarian), converge at a certain point in their evolution upon the need to destroy traditional therapeutic roles, but not all of them recognize that this choice is connected in an organic and inevitable way with an


existential choice which goes beyond the pure and simple application of an organizational method. In this sense, the false democratic technicism put forward and theorized as an ideal means of ‘managing’ groups and communities of mentally ill and sane individuals can only confirm both the dependence of this ‘scientific’ formula on an academic tradition which has always been (in factories actories as well as in asylums) at the service of established power, and the permanent subjection of the mentally ill (as subject-objects) to the most subtle organizational intelligence of the community leader. Our task, therefore, is quite a different one. In today’s political world clear paths are being paved for a new subjective element, for an experience of crisis, and an attempt at personal reform as a premise for and means of carrying forward every attempt to evade or subvert the established order. Until a few years ago this theme was not even discussed; today there is increasing talk of a new type of consciousness involving not only the need to maintain, within a political revolution, a subjective tension and a personal need to reject the mental categories and the cultural conventions of the past, but also involving the right to challenge from this moment onwards, in the tasks of research and struggle, the current cultural conventions in which authoritarianism, hierarchy, and the violence of power play a constituent part. Egalitarianism is no longer a myth to be consigned to the future, nor is it a habit to be artificially cultivated beyond the reach of external influences; rather it is a need born out of specific practical experience, one which puts forward this experience as a criterion for challenging the values of authority, exploitation, and exclusion upon which the outside world bases itself, and which (in a more direct, harsh, and obvious way) ground every asylum system. The choice of egalitarianism is therefore, first, one which must be carried out by the therapeutic team in the hospital, but this involves a subjective tension which goes beyond the traditional notions of psychiatric reform. If, as is clear, there cannot be movement towards contestation on the part of patients without there being a similar, free, and vital capacity for or contestation on the part of the therapeutic team (and rising from within it), then it is equally clear that the ‘reality confrontation’ upon which all advanced therapeutic community experiments are based cannot be limited to a cautious working out of frustrations, but must be translated into a conflict between a strong antihierarchical, anti-authoritarian, and egalitarian push and those hierarchical and authoritarian pressures which come from the outside world and which survive in each of us, even in our daily work.

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The major difficulty with institutional reform, therefore, is not in the task of ‘organizing’ on newly ‘liberalized’ lines the daily regimen of inmates, but in the obstacles that the therapeutic team (and here we also include nurses) will encounter in reforming itself alongside the patients, in a common struggle to reappropriate their own subjective and objective freedom by contesting the lack of freedom in the laws and prejudices of society. The therapeutic team will only be contested by patients to the extent that it is able to open itself up from within to an unconstrained dynamic of self-criticism and self-challenging. Otherwise its ‘liberalizing’ role with regard to the patients will be applied in a ‘technical’ way and in bad faith. On the other hand, one can quite easily understand why the medical staff tend to defend themselves, their own autonomy and integrity, and their own personal motivations for success, prestige, power, money, and career. This tendency cannot be overcome by a pure and simple appeal for individual moral reform, which on its own risks being purely ideological and producing a series of false attitudes which are virtuous, self-sacrificing, moralizing, individualistically voluntarist, hyperactivist, and frankly neurotic. On the contrary, what is required here is a role of reflection and criticism which should be linked up to collective practice, and articulated into research work with patients who are capable of revealing, in the most objective way, the play of social and psychological dynamics within the hospital community during the course of its development. The most obvious (but not the most serious) limit to this criticism and reflection lies in the difficulty of destroying the distinction between treating and being treated, on which psychiatric privilege is based—psychiatry, in other words, as the power of one person over another in which ‘technical’ power has traditionally been mystified as neutral. The most serious difficulty, however, lies elsewhere, in the fact that hospital practices, however innovatory they might be, are difficult to articulate in a political discourse as the elaboration of revolutionary activity, but risk remaining perpetually confined within the limits of a pure reformism. Since the medical team cannot ally itself to a movement that is genuinely revolutionary and subversive at the social level, it is not even able to change its own mentality, its own morality, its own conception of the world. This drawback is particularly serious when the national context within which the team functions does not allow a reform which goes beyond the superstructure and the sphere of ‘services’. If, a revolutionary struggle is lacking (that is, a political battle in the strict sense of the word), then the medical team will be unable to


fashion the instruments for their own internal reform. They will remain a bourgeois team in a bourgeois world. Such a team can only aspire to prefigure what entirely different social relations would be like, but not to put them into effect; its work is partial and indicative. On the other hand, even in this context, coming to an awareness of the psychological and cultural contradictions in capitalist society, as these are reflected in the particular sector of psychiatric ideology and psychiatric treatment, will contribute to providing critical tools which may be useful in the future in developing a consciousness capable of creating entirely different interpersonal relationships. The programme of Psichiatria Democratica (1973) (After numerous meetings over the course of the past year, an organizing committee [Franca Basaglia, Franco Basaglia, Domenico Casagrande, Franco di Cecco, Tullio Fragiacomo, Vieri Marzi, Gian Franco Minguzzi, Piera Piatti, Agostino Pirella, Michele Risso, Lucio Schittar, Antonio Slavich] have constituted in Bologna the first nucleus of a group called ‘Democratic Psychiatry’. This document sets out the group’s analysis of the present situation and its broader aims.) For mental health workers to accept the logic of internment. amounts to their accepting the aggression which is thereby directed at inmates. To work in a psychiatric institution or in psychiatric services which maintain this logic—a logic based on a clear and sharp separation between the sane and the sick, and on the instrumental use of the mental patient implicit in this separation—must lead mental health workers who want to oppose these conditions to reject the very institutions which are the means of custody and control. Confinement to mental hospital and imprisonment represent a uniform response to human experiences, illness and delinquency, which have different origins and which ought to be differently treated. In our social system these experiences are in fact not treated directly as such; their real character is obscured by the repressive measures which, by forcing them into the same institutional mould, effectively seal their common social fate. The uniform nature of the response to ‘illness’ and to ‘delinquency’ reflects the point of view from which each is judged only in its relation to social order, as a transgression against the limits of established norms. In practice, the social system, while ascribing to different sciences the task of dealing discriminately with the (apparently) different contradictions which the system must confront, actually responds to problems of social marginality in a global, uniform, and purely defensive

120 APPENDIX

fashion. In this way the system’s repressive response manages to structure and contain a contradiction which can never be experienced as such. ‘Therapy’ on the one hand, and ‘rehabilitation and social re-education’ on the other, are the formal justifications for internment; but internment. is effectively an unconstitutional practice because it results in the destruction of citizens who really need therapy and rehabilitation. The task of the mental health worker is therefore to establish the appropriate and specific therapeutic character of an institution and a relationship which, under the cover of apparently scientific rationales, have really been concerned only with control and custody. This task would be put into effect by ‘recovering’ a specific therapeutic function which the health services have never really played vis-à-vis mental illness; and at the same time, by ‘depsychiatrizing’ these services, exposing the repressive and discriminatory practices that they have involved which have nothing to do with curing illness. For practitioners this means: 1 To identify and struggle against their own power over the ‘users’ of their services. 2 To identify in the individual [client] the unsatisfied social needs which confinement has up to now suppressed by hiding them under the diagnosis of illness. 3 To identify the therapeutic tools implicitly available in a specific professional role. once this role. has been liberated from the mandate of social control laid on it by the social system. 4 To identify and link up with those individuals and social forces already involved, or who might become involved, in this struggle. On this analysis, the technician (tecnico) must offer a practice which will put to the test and keep a check on political initiatives and experiences, not only in the health field, and certainly not only with regard to psychiatry. A group of mental health workers who decide to be active in this way will not be constituting themselves as a political group, nor could they. The political element of their action would consist in finding a terrain on which they as technicians can confront political actors, for instance by creating novel, alternative situations in which the real social class lines can be drawn clearly, thus sharpening the prospects for ‘class struggle’ which within the closed logic of the institution can look vague or unfocused.


If, for example, the inmates belong to the same social class as nurses and part of the other mental health workers, then the lining up of those nurses and workers on the side of the struggle for the inmates is the only valid basis for extending the psychiatric battle and its political significance. In fact, if the struggle is limited to the movement of a few psychiatrists, who (notwithstanding difficulties and misunderstandings) continue to reveal the real functions of the asylum in controlling not only mental illness but a whole gamut of anti-social behaviours, that struggle risks becoming sterile and frustrating, as if it were only a symbolic evocation of what a therapeutic institution or relationship could really be. The struggle could be reduced in that way to the search for a simple ‘technical’ reform, which would leave unchanged the power structures and the dynamic of oppression. The democratic psychiatry group therefore proposes: 1 To continue to fight against exclusion, by analysing and rejecting its sources in the social structure (the social relations of production) and in the superstructures (norms and values) of our society. This struggle can be carried on only by combining all the forces and movements which, sharing these analyses, act concretely to transform the social order. 2 To continue the struggle against the ‘asylum’ as the place where exclusion finds its most obvious and violent expression, as well as the practical means of reproducing the mechanisms of social marginalization. Even if this is often considered to be a backward struggle, psychiatric hospitals do indeed exist throughout the whole country and, apart from rare cases where psychiatric practitioners or administrators are attempting transformations, the situation for the majority remains static and unchanged. 3 To underline the dangers of reproducing segregating institutional structures, even in the mental health services created outside the hospital. Any alternative structure ‘tends in fact to assume a similar shape and form, to what has been the dominant institutional form, so long as that continues to exist. Any artificial competitive separation between mental health services and the psychiatric hospital only aids the argument for reinstating asylum internment. This does not mean that we should have reservations about autonomous psychiatric services on the sectoral or territorial model, just as the linking together of these services seems to be a necessary, but not a sufficient, condition for realizing the end which territorial psychiatry prefigures—to identify the real problems, once they can

122 APPENDIX

be liberated from the institutional, social, and cultural incrustations which have formed around them and have distorted their expression. 4 To make explicit, in a practical way, the link between acting in the specific psychiatric field and the more general problem of medical care, by demanding a unified action (beyond the division of labour and skills) which in the specific struggle for the promotion of mental health involves us in the broadest possible struggle for a concrete and necessary health reform based on, and expressing, a new social logic. It is this need for a new social logic which must oblige the group to ally themselves with all the forces concretely pursuing this goal. Bologna, 8 October 1973

Notes

PREFACE 1 Significantly, this politics of advocacy has been, in Britain and the USA at least, principally a lay affair. Psychiatrists and others professionally involved in caring for the mentally disordered, for their part, were not in general politically visible; in a strong sense they did not need to be politicized, since by and large their expert competence and professional prerogatives were more or less automatically deferred to. Hospital superintendents organized hospitals, and psychiatrists prescribed for and treated patients, with little more oversight or interference than the occasional, discreet review by their professional peers. 2 The ‘consensus’ described here is only a rough generalization, and no substitute for detailed historical reconstruction of how the actual treatment of the insane evolved. There were in fact important national variations in how the consensus was struck The term ‘insanity’, moreover, needs to be understood in context; it is yet another task for historians to understand how that category was constructed in different times and places, and to guard against an ahistorical naturalism which would assume that ‘insanity’ can be simply equated with present-day categories of mental disorder. 3 There were, furthermore, misleading suggestions that there was a huge, undetected and untreated, ‘dark figure’ of mental disturbance in the population at large, which implied that mental illness was both more common and more tolerable or familiar than it appeared to be in the grosser stereotypes of insanity.

1 TRENDS IN MENTAL HEALTH CARE 1 See Klerman (1982) for a typical description of ‘the psychiatric revolution of the past twenty-five years’. He estimated that ‘there has been at least a


2

3

4

5 6

7

8 9

10

sixfold increase in the utilization of psychiatric and other mental health services by the [USA] population’ across the period 1955–80 (1982:178). In 1947 there were about 4,700 psychiatrists in the USA; by the early 1970s there were more than 25,000 (see Brown 1977). On the assumption that roughly two-thirds of psychiatrists practised psychotherapy, Klerman estimated (conservatively) that there were about 100,000 ‘practitioners of psychotherapy’ in the USA in 1980 (1982:186). One index of the participation of non-physicians is ‘the increasing reimbursement of nonpsychiatric practitioners by various third-party payments. It is estimated that…only about 50 percent is given to the psychiatrist, the remainder going to psychologists, social workers, and other practitioners’ (Klerman 1982: 184); see also Mechanic (1980:9–10). See Rose, ‘Psychiatry: The discipline of mental health’ in Miller and Rose (1986), and Rose (1990) for an argument about the broader context of this transformation. For a discussion of what is involved in comparing different ‘models’ of mental disorder, see Moreno and Glassner (1982). See Jones, (1988:80). Jones, and Fowles (1984) review much of the critical literature on institutions for long-term care and custody which has appeared since the 1950s. Psychiatry developed in many ways as an offshoot of the asylum system. Until recently psychiatrists have for the most part been employed by asylums or mental hospitals. The profession itself was organized largely as a means of gaining recognition for, and upgrading the status of, asylum doctors. For most of its history psychiatry has owed its acknowledged role. in defending society, and much of its prestige and professional power, to its organizational base in the asylum. The varieties of expertise which have distinguished psychiatry have likewise been closely tied to asylum conditions. This is obvious enough for the whole field of administrative psychiatry (or what was called earlier ‘moral treatment’) which effectively rationalized the hard-won practical skills of asylum-keepers. But it is equally true that the great descriptive classifications and systems of nineteenth-century psychiatry would have been inconceivable without the controlled field of observation which the asylum provided. Even the laboratory and dissecting table were in that sense adjuncts of the asylum. See Grob (1987b); for a much broader argument about the role. of psychology in wartime Britain, see Rose (1990:15–52). See also Orlansky (1948) for a description of the mental hospital as ‘an American death camp’. A similar rhetoric was used more than 20 years later in Italy when asylums were described as ‘lager’. This account follows closely Perrow’s review of the literature (1965) Perrow provides a useful framework for discussing the mental hospital by distinguishing three variables in its organization: a culturally defined goal which determines the organization’s aims; the ‘technology’ available for

NOTES 125

11

12

13 14

15

16

realizing those aims; and a ‘social structure’ in which the technology is embedded. A hospital has in principle therapeutic goals it performs work on human material, and like other ‘people-changing’ organizations it is therefore bound to ‘use techniques appropriate to the perceived nature of the material’ (Perrow 1965:914). The question Perrow raises is whether the vogue for the therapeutic community and milieu therapy really constitutes the discovery of a new, efficacious technology for the mental hospital, or whether such administrative measures are more on the order of pleasing, but ultimately superficial, ideological changes. Many people have noted the remarkable similarity between the goals of 1950s administrative psychiatry, and the movement in the early nineteenth century for ‘moral treatment’ of the insane; see, for instance, Bockoven (1957 and 1963). An historically minded observer would add that this similarity probably suggests a good deal about the limits inherent in administrative psychiatry. ‘Moral treatment’ was really only practicable in relatively small, well-staffed, domestic-style institutions. The same factors which historically defeated the moral treatment ideal (overcrowding, economies of scale, routinized supervision) are likely to remain problems in large-scale contemporary mental hospitals. The techniques were more widely and successfully applied in Britain; see Gruenberg (1983). Despite the enthusiasm for administrative psychiatry in the USA in the mid-1950s and after, many of the sustained, successful efforts were limited to small, elite, intensive private institutions. Perrow suggests caustically that there simply is no effective therapeutic technology available for the large mental hospital (1965:925). Note the qualifications with which Goffman begins Asylums: ‘none of the elements I will describe seems peculiar to total institutions, and none seems to be shared by every one of them; what is distinctive about total institutions is that each exhibits to an intense degree many items in this family of attributes…. [T]his permits using the method of ideal types, establishing common features with the hope of highlighting significant differences later’ (1961:5). Unfortunately Goffman never turned to this second, later task of identifying differences. As a result his conception of the total institution remains static and undifferentiated; it does not admit of degrees, and seems fundamentally unreformable. Some proponents of the therapeutic community regarded Goffman’s conception of the total institution as its polar opposite. The more usual tendency has been, however, to link and even conflate criticisms of the therapeutic community in practice with many of Goffman’s points about the totalizing character of custodial regimes. Wing and Brown, acknowledge, for instance, ‘that the concept of schizophrenic deterioration is deeply ingrained in psychiatric thought even though it is difficult to demonstrate’ (1970:13). The implication is that if one were trying to understand ‘how far the typical symptoms of


[schizophrenia] (in which shallowness of emotional response and lack of motivation are common symptoms even when the patient has never been admitted to hospital) can be distinguished from the aspects of behaviour and attitudes which are said to be characteristic of institutionalism’ (Wing and Brown, 1970:14–15), the psychiatrist, even if convinced of the reality of institutionalism, is liable to continue to think in terms of individual pathology, while the sociologist (Goffman, for instance) ‘tends to explain patients’ behaviour solely in terms of their reactions to the social environment’ (1970:13). 17 For a recent, comprehensive discussion of deinstitutionalization in the USA, see Mechanic and Rochefort (1990). 18See Lerman (1982) for a discussion of planning in two of the states, California and New York: which pioneered policies of deinstitutionalization. 19 See, for instance, Scull (1977) and Musto (1975)

2 THE HISTORICAL BACKGROUND OF ITALIAN PSYCHIATRY 1 For general accounts of psychiatry in nineteenth-century Italy, see De Peri (1984), Babini, et al. (1982), Stok (1981), and Canosa, (1979) Two useful, although limited, essays in English are Tagliavini (1985) and Guarnieri (1988); Mora (1975) is a more general survey. 2 As an example of local studies of the pre-unification history of the asylum, De Bernardi et al. (1980) is a useful source on the history of asylums in Milano. 3 For contemporary descriptions of asylums in Italy, see Brierre de Boismont (1864) and Tamburini et al. (1918). Gualandi (1823) presented highly critical impressions of the asylum at Aversa. 4 This was only a partial return, lacking at least most of the information about asylums in the South; see Canosa, (1979:87). 5 Such figures must be interpreted with a degree of latitude. Many of the early statistics about the insane are obviously defective and incomplete; there was also considerable wavering about how to establish the categories to count. Should a hospice where a handful of insane patients were housed be counted as an asylum? Should idiots be enumerated among the insane, or in a separate category?—and so on. On the general changes which the figures illustrate clearly enough, see, however, Tamburini et al. (1918: 207). 6 For a more detailed discussion of this strategy, see De Peri (1984: 1080– 92), and Canosa, (1979:58–86). 7 On the contemporary significance of ‘positivism’ in nineteenth-century Italy, see Asor Rosa (1975) There is some debate among historians about

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8

9

10

11 12

the extent of influence of positivism on Italian psychiatry’s development. See Giacanelli and Campoli (1973) for the strong thesis; Canosa, takes the opposite view, that positivism contributed nothing novel or lasting (1979: 59). Tagliavini suggests correctly that ‘we should exercise care in evaluating the effect on psychiatry of certain key themes in positivist culture’ (1985:190); but she surely exaggerates in reducing positivism to a generic ‘scientific naturalism’: ‘what was taken from positivism, and developed and exalted by psychiatry, was the validity and certainty of scientific knowledge and its practical value in solving social problems’ (1985:190). It is more likely that some of the peculiarities, strengths, and weaknesses of Italian psychiatry were indeed linked to ‘positivismo’, understood in a more robust way. In 1896 the Rivista di patologia nervosa e mentale was established, as a harbinger of sorts for the emergence of an independent discipline of neurology. It is significant, however, that neurology, and psychiatry in Italy maintained unusually close ties, particularly in medical teaching faculties. It was only in the 1960s that the teaching of psychiatry achieved a parity of sorts with neurology. Giacanelli, makes a similar point while drawing more explicitly its political implications; the psychiatrists seemed to embody ‘that enlightened bourgeoisie which made science the instrument of social progress as well as of its own hegemony, battling as it did on the one hand with the dark forces of the past, and on the other the threatening new proletarian movements’ (1975: xxx). This is probably a more apt description of psychiatrists at the turn of the century, when their attitudes became more conservative, and when psychiatrists as a group were more explicitly identified with the ‘forces of order’. Pick presents a forceful reading of Lombroso’s criminal anthropology as an attempt ‘to formulate the definition of a political subject by elaborating ever more closely the criteria for political exclusion’ (1986: 76). Thus Lombroso ‘endeavoured not only to turn “peasants into Italians”, but also to separate out those who were incapable of such a conversion’ (1986: 63). It would be difficult to make a similar argument about the psychiatry of the period as a whole, although it applies well enough to certain individuals. The phrase was Massimo d’Azeglio’s; it is quoted in Clark (1984: 2) There were psychiatrists who were resigned to accept just such a role. See, the revealing comments of the senator and psychiatrist Leonardo Bianchi in the presentation of the 1904 bill: ‘the madman, after all, is a weakling in the struggle for existence; the crowding in asylums now is due to the growing number of such beings who, for the most varied reasons (many of them biological), would never be able to live out their lives in their ordinary surroundings’ (cited in Lonni 1982: 278). The frank social Darwinist tone of such comments represents one variety of the widespread evolutionism.


13 On the early resistanee to psychoanalysis and its subsequent history in Italy, see David, (1966). It is interesting to compare the view of Cerletti, who as a representative of mainstream psychiatry expresses the situation and predicament of psychoanalysis in Italy very succinctly: ‘The traditional organic trend in Italian psychiatry ignored the question of the genesis and mechanism of man’s psychic economy, and was satisfied merely to establish a cause-and-effect relationship between psyche and soma. Accordingly, each modification of the psyche had to correspond to, and derive from, an organic alteration of the nerve centers. Such an orientation could not favor the development in Italy of the dynamic psychopathology formulated by Freud and his pupils …’ (1961: 197). 14 The use of somatic treatments was an important, but characteristic, exception. See, the summary description of the state of Italian psychiatry in the 1950s by one of the inventors of electro-shock therapy, Ugo Cerletti (1961).

3 PILOT EXPERIMENT WITH ‘ALTERNATIVE’ PSYCHIATRY IN THE 1960s 1 There was a clear element of generational conflict in Italian psychiatry of the 1960s which would warrant more systematic study. 2 On the other hand, while being relatively free of university-based psychiatry, hospital administrators were much more directly subject to provincial, and later to regional, political authorities. The political support or toleration of local authorities was a critical factor in launching new initiatives, and even more in sustaining them. 3 As his wife later noted he had at the time apparently never before seen the inside of an asylum (Ongaro Basaglia cited in Scheper-Hughes and Lovell (1987: xii). 4 The main sources on Gorizia are two collaborative volumes edited by Basaglia (1968) and (1973); see also the excerpt from an essay by the Gorizia group, ‘Considerazioni su un’esperienza comunitaria’, translated in the Appendix. 5 This account follows closely on Basaglia’s own reconstruction of the stages through which his thinking developed. Slavich (1968) presents more information on the actual details of what was done, and on the timing of the different phases through which the experiment passed. He too was a participant, and was party to the group’s collective discussions. It would be interesting to have other, less theoretically worked-up descriptions of the experience; but by and large the view of Gorizia which has been diffused and popularized grew directly out of the group discussions and the joint publication L’istituzione negata (Basaglia 1968).

NOTES 129

6 After Basaglia’s departure in 1969 the experiment did not in fact end. In 1972, however, the remaining staff members who considered themselves part of the Basaglia era publicly resigned en masse, citing as their reason political opposition to the Gorizia experiment from local authorities. See Fogli di informazione, no. 3 (1972). 7 Among the sources on Reggio Emilia see Jervis (1975:11–13 and 132–5), Jervis (1977:28–42), and Collettivo operatori del Cim di Reggio Emilia, ‘Esperienze sul territorio. in Inchiesta no. 2 (1971). Jervis (1973) is a report of research carried out on the psychological problems of factory workers, in the context of the Reggio Emilia experiment. 8 On the conflicts which developed in Reggio Emilia and elsewhere between alternative psychiatric teams and left-wing local administrators, see Manacorda and Montella (1977:97) and Bartolomei and Lombardo (1981: 98).

4 TOWARDS AN IDEOLOGY FOR DEMOCRATIC PSYCHIATRY 1 See for instance the (1967) essay ‘Che cos’è la psichiatria, (What is psychiatry?) in Basaglia (1973); the title is chosen to echo Sartre’s famous essay ‘What is literature?’. The anthology of Basaglia’s writings compiled by N. Scheper-Hughes, and A. Lovell, provides a useful selection of other Sartrean-like texts. It is significant that Sartre followed Basaglia’s work and anti-psychiatry more generally with considerable interest; see his Foreward to Reason and Violence, Laing and Cooper’s (1964) exposition of his writings. 2The group at Gorizia, although they were generally on the left, had been in fact quite diverse in their political orientations (see, for instance, Jervis (1977:22). The problem of how to represent their experience in broader political terms was one of the issues which in the end profoundly divided the group. Notwithstanding the disagreements, the set of notions which emerged eventually became identified, appropriately enough, as the ‘Basaglian ideology’. 3 One source for the term was a (1969) paper by J. Ruesch which reported that roughly one-third of the US population were unable to work for physical or psychiatric reasons; since another third of the population were too old or too young to be in the workforce, Ruesch concluded that the majority of the population were unproductive; see Papeschi (1985) 4 This argument is more fully developed in Basaglia (1980); the quasiManxist themes, especially the emphasis on the logic of productivism, were not nearly so prominent in Basaglia’s writings before 1968. 5 There were important conflicts between alternative psychiatrists and nurses and attendants, but the issues there had to do with protecting jobs and resisting taking on new and ill-defined responsibilities.


6 One result of the conflict as it was expressed in Italy was the formation of a new professional society representing the point of view and interests of biological psychiatry.

5 THE TRIESTE MODEL 1 The best source on the psychiatric reforms at Trieste is Mauri (1983); see also a special number of Fogli di Informazione no. 23–4 (1975) dedicated to Trieste. In English Lovell (1985) and Bennett (1985) provide the best descriptions. 2 On the phases of deinstitutionalization at Trieste, see the detailed account by G. Gallio, and the chronology, in Mauri (1983:17–40 and 259–91). 3 The status of voluntary patient had been established by a reform in 1968, which was in some ways a legal recognition of changing psychiatric practices and priorities. On the provisions of the 1968 law, the first to modify the law of 1904, and its limitations in practice, see Maj (1985). 4 The first co-operative was legally incorporated in 1974. See, a special number of Fogli di Informazione, no. 17 (1974) on the strategy of cooperatives. 5 See, the report of the joint press conference in Corriere della Sera, 24 January 1977. Basaglia held out the prospect of rechannelling public expenditure away from the wasteful and outmoded asylums. It was significant, however, how little such allusions to the fiscal realities of mental health care figured in the reform campaign. In general there was far less direct concern with fiscal pressures for deinstitutionalization in Italy than elsewhere. 6 See, the volume edited by Scabia (1977) 7 For a detailed description of one of the centres, including an analysis of typical staff time-budgets, see Mauri, (1983:147–63). 8 For information on the subsequent development of Trieste’s services after 1978, see WHO (1987).

6 THE ENACTMENT OF LAW 180 1 See Canosa (1979: 181); and for a forcefully expressed view of one side in the controversy, Jervis in Onnis and Lo Russo (1980). 2 See, for instance, Mosher (1982: 201). 3 For the text of the resolution see Mosher and Burti (1989: 404–5).

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4 The emphasis on civil rights issues was especially important in the 1975 local administrative elections, which were a considerable victory for the left-wing parties, and an important factor in the background of the later success of law 180. 5 Only the neo-fascist MSI voted against the bill. 6 Basaglia argued for instance that there was a tension in the very design of the law. On the one hand it affirmed the principle of community care, which would require a considerable transformation in the conventional authority, style of working, prerogatives, and so on of psychiatrists and nurses. To work in the community they would perforce have to develop a new sort of relation with their clients and with local communities. On the other hand the law called for new psychiatric units integrated into the structure of general hospitals. But given the complex division of labour in the general hospital, this would mean creating a hyperspecialized psychiatric service whose hospital orientation would make it quite incapable of co-operating with or even communicating with the ‘demedicalized’ community services. The likely outcome Basaglia foresaw was that the new psychiatric units would begin to act independently of both the general hospital and of the community services; the risk, in other words, was to recreate the separate world of the asylum under another name, and to institutionalize a set of psychiatric practices integrated neither into general medicine nor into the community services; see La Repubblica, 15 June 1978.

7 THE IMPLEMENTATION OF THE LAW 1 Other local studies tracking the fate of released patients include Becker (1985) and Casi et al. (1984).

8 CURRENT PROSPECTS AND FUTURE DILEMMAS 1 The open question remains what the content of those norms should be, and what mechanisms would be appropriate or adequate to ensure compliance and to assess the quality of services and outcomes. Those are in fact still contentious matters, about which opinion divides sharply. In that sense there is still large scope for a ‘politics’ of mental health. For all the appearance of a new pragmatic attitude, there are likely to be continuing struggles ahead; and the parties to the dispute are likely to continue to be divided by how they understand the direction and larger aims of the reform. 2 The permissiveness of the law was also obviously a factor, perhaps an unavoidable one. ‘Given the chronic Italian economic crisis, and the different political and cultural reality of each region, the Law [180] is


likely to be interpreted as a good frame for the acting out of either 1) a revolutionary plan (minimal use of the hospital, beds in general wards, maximum improvement of community services) or 2) a reform scheme (hospital for social cases and incurable[s], psychiatric units in General Hospitals, improvement of community services), and again 3) an anti-law application of the Law (maximum use of the hospital and minimum resocialization of patients, fewer psychiatric units in General Hospitals, poor community services, and the blossoming of a lucrative private industry)’ (Freschi 1986: 48). 3 See, for instance, Mosher and Burti (1989: 264–98), and Torre et al (1982). 4 Their general conclusion, however, seems more questionable: ‘In sum, data seem to confirm the expectation that a comprehensive, communitybased psychiatric service providing both crisis intervention and continuity of care in the community can effectively reduce the need for hospitalization of psychiatric patients, including the most serious ones, who traditionally spent long periods of their lives in closed institutions’ (Mosher and Burti 1989: 293). What is not clear is how widely that ‘expectation’ is warranted; is it only where model services are in place?

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Name index

Agnetti, G. 27, 34 Althusser, L. 103

De Plato, G. 32 Deutsch, A. 4 di Cecco, F. 118 Dunham, H.W. 6 Dunham, W. 5,

Bachrach, L. 2 Bacigalupi, M. 83–5, 90 Barbato, A. 27, 34 Basaglia, F. xi, 38–8, 49–5, 55, 60, 68, 74, 108, 118 Bateman, J.F. 6 Bateson, G. 100 Belknap, I. 4, 6 Bennett, D.H. 61, 64, 66–68 Berke, J. 100, 106 Betti, M. 73 Brown, E.L. 5, Brown, G. 5 Burti, L. 92, 96–8

Elkhaim, M. 60 Fragiacomo, T. 118 Friscano, R. 93 Giacanelli, F. 27, 33 Glazier, E. 19 Goffman E. 12, 13 Goodman, P. 100 Greenblatt, M. 5, 7, 19 Henry, J. 100 Hunter, T.D. 17

Cameron, D.E. 17 Campoli, G. 33 Canosa, R. 25, 30, 32, 71 Carmichael, S. 100 Casagrande, D. 108, 118 Cassano, G.B. 92 Castel, R. 45 Caudill, W. 5 Centenaro, M.A. 88 Chiarugi, V. 23 Cooper, D. 100, 104–8

Jervis Comba, L. 108 Jervis, G. 39, 47, 48, 100, 108 Jones, K. 2 22, 89 Jones, M. 5, Kennedy, J.F. 20 Laing, R.D. 37, 100, 104–8 Levine, M. 21 Livi, C. 28–1 Lombroso, C. 29 Lo Russo, G. 42, 48

Daga, L. 89 De Peri, R. 28–1 151

152 NAME INDEX

Losavio, T. 93 Lovell, A. 44, 54, 66

Williams, P. 93 Wing, J. 5

Macri, V. 79 Maj, M. 31, 73, 79 Marcuse, H. 100 Marzi, V. 118 Mechanic, D. 15 Minguzzi, G.F. 32, 118 Minto, A. 15 Mollica, R. 52 Morgagni, G. 27 Morosini, P.L. 88, 91 Mosher, L. 92, 96–8

York, R.H. 5

Ongaro Basaglia, F. 46, 95, 108, 118 Onnis, L. 42, 48 Paparo, F. 83–5, 90 Perrow, C8, 9–10 Peny, N. vi Piatti, P. 118 Pirella, A. 23, 56, 71, 80, 82, 108, 118 Poletti, A. 89 Redler, L. 100 Risso, M. 118 Sarteschi, P. 83, 90 Scarcella, M. 79 Scheper-Hughes, N. 44, 54, 66 Schittar, L. 108, 118 Schwartz, M. 5, Slavich, A. 40, 108, 118 Stanton, A.H. 5, Sweezy, P. 100 Tagliavini, A. 29 Tansella, M. 91 Tranchina, P. 43–6, 75–7 Valsalva, A.M. 27 Weinberg, S. 5

Zanetti, M. 71, Zeitlyn, B.B. 9

Subject index

administration in mental hospitals 6– 8, 11, 14, 17, 31–4, 38, 43–6, 116 administrative psychiatry 7–11, 49 anthropology ix, 28–1 anti-psychiatry xi, 37, 56–9, 104–10, 113 Arezzo 55, 69, 87, 96 asylums vi, 2, 4, 10; in nineteenth- century Italy 23–7, 30–7 Asylums (Goffman) 12, 13 Aversa 23

civil status of inmates 62–6, 71, 75, 111 criminal asylums 89 custodialism 5–7, 10, 12, 22, 44–7, 112 dangerousness 23, 30–5, 35–9, 72–4, 82, 97, 101 deinstitutionalizalion x, 2–3, 15, 17– 19, 23, 62, 66, 78–79, 82, 97 economics of mental health care vii, xv, 14, 17 emarginati xi, 51–7 exclusion, effects of viii, 20; mechanisms of 35, 44–7, 51–4, 54– 8, 58, 64–7, 76, 101, 108–11, 119, 121 existential psychiatry xi, 40–4, 52, 102

Britain ix–x, 3, 16, 18–1, 22, 35, 43, 56–9, 86, 109 Christian Democratic Party (DC) 71– 3, 74 chronic mental illness v, 13, 15, 22, 31–4, 34–7, 37–38, 68, 74, 80, 87–9 church-run asylums and hospitals 26– 9, 84 Communist Party (PCI) 47, 48, 69–3, 74 community care viii, x, xii, xv–3, 14– 23, 47, 48, 56, 59, 61, 63–6, 66–68, 74–8, 79–1, 82, 85, 92, 95, 97, 99 Community Mental Health Centers (USA) 21–4, 35, 61–4 compulsory commitment 31, 73–7, 82–4, 86;

Ferrara 69 France x, 37, 86, 109 general hospitals, psychiatry in xv, 15, 22, 64, 66, 74–7, 90–2 geriatric patients 18, 21, 87–9 Gorizia 38–9, 49, 52–5, 55, 60, 108–11 insanity v, xv–1,26, 27 institutional care vi, 1–3, 5, 12–14, 18, 20, 32, 37, 42–5, 59, 62, 68, 74, 76, 88

153

154 SUBJECT INDEX

institutionalism 1, 5, 12–13, 17, 20, 41–4 Joint Commission on Mental Health and Illness 2 Kingsley Hall 37 labelling theory 12–12 law 180 x, 60, 72–82, 92–7, 98 L’istituzione negata (Basaglia) xi, 46, 53 medical model of mental illness ix, 11– 12, 15–16, 57, 76 mental health centres, district (Italy) 63–6, 66–68, 76, 83, 91 mental health law v, viii, 71; 1904 law in Italy 23, 30–8, 38, 72; see also law mental health professions vii-ix, xv–1, 15–16, 21–4, 57, 66, 68 Milano 26 milieu therapy 7, 9 moral treatment 9, 34 Naples, Kingdom of 23 Napoli 55, 69 National Health Service (Britain) 22; (Italy) 71, 76 neuropsychiatry x, 37–38 new class theory 53–6 nursing homes 89 nursing staff 39, 43, 63, 66, 82, 114, 117, 120 open door policy 14, 16–17 organicist psychiatry x–xi, 27–29, 33– 7, 40, 76 Parma 55, 69 Perugia 55, 69, 87 phenomenology xi, 40–4, 44–7, 55, 101–4

positivism 26–29, 40–4 Psichiatria Democratica 55–59, 68, 71, 74–9, 82, 83, 100, 118–1 psychiatric aides 6–7, 9, 12, 39 psychiatric profession vi–ix, xv–2, 6, 9, 12–15, 21, 56–9, 103, 107; in Italy x, 23–30, 32–38, 56–59, 71, 80, 99–1; in nineteenth century 2; in World War II 3 psychoanalysis ix–x, 34, 40–3, 101–4, 116 psychology x, xv, 27–28, 34, 57, 102– 6; Sartrean 51–5 psychotropic drugs 14–17, 22–5, 83, 86, 92 Radical Party 72 Reggio Emilia 26, 46–48, 55, 60 regional differences in Italy xii, 29–2, 79, 83–6, 92, 95 rehabilitation of mental patients 3–4, 12–14, 67–68, 74 revolving door 3, 14, 17, 86–8 Risorgimento 26, 29 Roma 85, 89–1 Royal Commission on the Law Relating to Mental Illness 1, social movements: and mental health x, xii, 23, 57, 75, 77–79, 96, 98–100; students’ and workers’ xi, 42, 53–7 social psychiatry x, 3, 7–8, 11, 14–15, 22, 37, 39, 47, 49, 102 Società Italiana di Freniatria 23, 28 Società Italiana di Psichiatria 71, 74, 76 sociogenetic view of mental illness ix, 11–14, 42, 57, 76, 101–4 sociology ix, 4–5, 10–13, 47, 116 territorial services 37, 46–48, 121

155

therapeutic community xi, 5, 7–9, 12, 42–7, 108–21 total institution vi, 5, 13, 41–4, 56, 109, 121 Trieste 55, 60–71, 74, 78–79, 83–5, 87, 91, 95–7 Tuscany, Grand Duchy of 23 university clinics 37–38 USA ix-x, xii, 3, 2O4, 35, 56–9, 61, 103–6, 109 Verona 96 welfare functions of asylum v–vi, 2, 31–4 World Health Organization 1, 60, 66–9

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