Anna Maria Nicolò
On May the 13th, 1978 Law n. 180 on the subject of "Voluntary and mandatory health checks and treatments", (more commonly known as Basaglia law), was made.
This law imposed the closure of mental hospitals and established public mental health services. The struggle that Basaglia and his colleagues, friends and pupils made, was not only a way of restoring dignity to the mentally ill. It also freed them from imprisonment, stigma and from continuous and progressive denial of their identities. As Irving Goffmann once said it was also a revolution at the level of health institutions as it was a new way of conceiving mental disorders. The environment around the patient could be a tool of care, since perhaps it was indeed the root of discomfort.
The asylums of the time in Italy, as indeed all over the world, were inhabited by patients who had lost the hope of rehabilitation, but sometimes even those who had been put there by chance: children born to schizophrenic women and who had been diagnosed at three months to allow them to stay close to their mothers, but who then remained in that cursed place, without stimulation or education; elderly diabetic women whose children had emigrated and had stayed away; people who accidentally stumbled into unfortunate encounters with policemen who misunderstood their intentions and died there by accident. There were just some of the guests whose presence in that infamous place shocked me, on top of the many perturbing patients who showed the mystery of a self-closed in retreat. Basaglia’s law strived to open, not only physical doors to these patients but above all mental doors, forcing the establishment to seek answers that up until that moment had been ignored.
Many young doctors had begun their training under the enthusiastic drive of a reform that was not only a health intervention, but above all a revolutionary way of thinking and thinking about one another. The resurgence of alternative psychiatry, in Italy, Belgium and other European countries * burnt at people’s souls and in this context, there was little place for technique. Psychiatry had become a political fact.
In 1976, in the atrium of a hospital in Ferrara, Italy. a manifesto was posted that was obviously a political proclamation and said "only by placing freedom, rights, and freedom of the internees in the first place, we can all free ourselves".
Psychiatric wards and services were animated by passion, but the above point of view was often refused and the technique looked at it with caution. The Technique for some was also psychoanalysis, which at the time was mostly centred on the intra-psychic and the conception of an "opaque mirror" analyst. However, under this banner there was a lot of work, but also idealization and even fanaticism.
In the 50th issue of "Information Sheets: Liaison and Verification Documents for the Development of Alternative Practices in the Institutional Field", a psychiatric journal that represented the 70s / 80s voice of democratic and anti-institutional psychiatry of the time, Tranchina, one of its directors, argued that, despite the numerous criticisms that could be made, there was a need for an in-depth confrontation with psychoanalysis which, in his opinion, was "one of the fundamental matrixes of the experiences that launched the 180 ".
He recognized "the usefulness of psychoanalysis for the understanding it
opened to madness and for the enhancement of the word and interpersonal relationship against any other instrument of more or less violent care" (Tranchina, 1978, p296). He then continued with a series of criticisms of psychoanalysis, its cost, its massive presence on the level of the culture of newspapers and the press in general. The psychoanalysis of which Tranchina was talking at the time was certainly not the current one, which progressively (unfortunately) came out of universities and many health institutions and is not very present in the press, with a few exceptions. In short, the challenge at the time was how to find a psychoanalysis that was more openly social.
Many psychoanalysts, as well as many psychiatrists and then psychologists, nurses, porters, were to get involved in the work and create an impressive movement.
After the first "heroic" period, there progressively arrived a more balanced dimension characterized by an important group involvement within the institutions, with articulated supervision and accurate work within teams. The training of the operators was imposed as an instrument to care for the patient and his suffering and in parallel, alongside the individual intervention and pharmacological support, attention was drawn to the context in which the patient was born, formed and lived. The work with mental suffering, and especially with psychosis, stimulated the psychoanalysts of those years and brought about changes in them, as well as work in the developmental age with children and adolescents.
Today, Basaglia law is being called into question, but it left an important and indelible sign in our culture.
Cono Aldo Barnà
Basaglia Law or Law 180 (Legge Basaglia, Legge 180) is the Italian Mental Health Act approved by the Parliament of Italy on 13 May 1978 regarding “assessment and involuntary psychiatric treatment”.
Promulgation of both this law and law n.833 on 23 December 1978 which established the National Health Service was an attempt to turn the struggle that Franco Basaglia and a group of technicians, intellectuals and politicians close to him were at that time putting up against segregation of deviance and perpetration of violence in mental hospital treatment into the improvement of Mental Health Service.
Law 180 is the first and only law which obliged the closing of asylums and regulated the Involuntary Psychiatric Treatment by establishing Public Mental Health Services. Italy was the first country in the world to dismantle Psychiatric Hospitals.
Since 1960 Basaglia committed himself to reform the inpatient psychiatric care proposing to overcome the logic of asylums. In 1964 he presented his paper “The Destruction of Mental Hospital as a Place of Institutionalisation” at the first World Congress of Social Psychiatry in London. As early as 1940 calls for a less violent treatment of mentally ill people were proposed all over the world. Therefore Basaglia’s struggle existed long before 1968 and it was inspired by Sartre’s thought, Thomas Szasz’s ideas and Daseinanalyse. To a large extent it represented the libertarian and anti-institutional movement that in those years was evolving all over the world. Having personally taken part, during the years of my psychoanalytic training, to the process of deinstitutionalisation of the Arezzo Psychiatric Hospital and setting up of the territory community Mental Health Services, I can comment as an insider the logic and limits of that experience and the reform that derived from it. There is no doubt that such law represented a scientific and cultural breakthrough in the way mental illness was conceived and a significant condemnation of the basically violent treatment that was taken place in asylums. The political and social vertex that equated Basaglia’s struggle to the ones which aimed to the improvement of Italian society civil rights and especially the direction of the movement arisen from his “preaching” equated the condemnation of the asylums to the proposals made by psychoanalysts on technical and relational improvement in the treatment of those patients who could benefit from psychotherapy.
“Techniques” were regarded as self-righteous conspiratorial mediations of the class conscious, middle-class vision of deviance.
At the time this limited vision partially hindered the potential and fruitful collaboration between anti-institutional psychiatrists and those psychoanalysts who were greatly committed to the advancement of the political concept of psychoanalytic treatment.
The psychoanalytic movement has always taken an interest in many arenas and institutions have often been a special observatory. A specific worry regarding the structural alterations that could modify the cultural identity of psychoanalysis has arisen from this exchange. Even now it is difficult to distinguish between balanced caution in order to preserve identity and conservative stances which are expression of anxieties regarding change.
In Italy, Franco Fornari drew on Bion’s, Jacques’ and Bleger’s partially convergent theories in 70’s, to analyse, in a series of papers, the deep affective functioning of institutions. He made inventive interpretations about the existing socio-political configuration that turned out to be quite useful for understanding the way institutions function. Even though there has been a rich theoretical output on institutions and social issues, psychoanalysts have waited a long time before challenging with the task of applying their psychoanalytic knowledge about the human mind to the management of institutions.
Among the variety of possible approaches, it is important to differentiate the several levels of psychoanalytic contribution to psychiatric teams. Group supervisions is the most suitable area of work to get the mental health professionals close to the varied facets and different levels of competence of the psychoanalyst supervisor.
Francesco Corrao, charismatic founder together with Franco Fornari of the Italian Psychoanalytic Association (Società Psicoanalitica Italiana) introduced Italian psychoanalysts to Bion’s theories on group functioning and promoted the reading of group dynamics in institutions along those theoretical lines.
“Group Supervisions” seem to us as a specific context able to promote: a complex and significant group activity with different aims which are at the same time mutually enriching, a clinical understanding born out of the different observational vertexes expressed by the various mental health professionals taking part to the group, the progressive development of a point of view and a shared language by those participating to the supervision experience, the chance of experiencing in a shared group the emotions felt by patients and their families and to outline a cultural narrative for the psychogenetic reconstruction of the illness of patients, the experimenting and shared elaboration of group dynamics thus a valid training for group dynamics and psychoanalytic reading of mental illness.
Paolo Fonda (Trieste)
Forty years ago: the abolishment of psychiatric hospitals in Italy
In 1978, the Italian Parliament approved the law decreeing the closure of psychiatric hospitals (PH). It was made possible through results obtained from an experiment that had begun a number of years before in Trieste and, in various degrees, in other Italian cities too.
In 1971, the city of Trieste with its 230,000 inhabitants had a PH with more than 1100 patients. The majority of them had been hospitalized for multiple years if not decades. That same year, Prof. Franco Basaglia was given directorship of the PH. He set in motion a radical program to humanize the care and assistance provided. The psychoanalysts involved in Basaglia's project viewed it as a great challenge and stimulus.
The priorities Basaglia established included humanizing the PH, which had to that time been delegated more to reclusion rather than treatment, and to rehabilitate patients by restoring dignity and a semblance of humanity to their lives: replacing gowns with normal clothing, providing barbers and hairdressers, letting them frequent normal places – cinemas, theaters, sport events, day trips, and work environments – rather than confining them to the same ward day in day out. The idea was to open their doors and let them gradually return to the world from which they had been cast out.
Within general society we witnessed the growing need to call into question the prejudices, stereotypes and mechanisms that marginalized or oppressed the ill within the environments they lived or where they would eventually return. Society held a rigid paranoid-schizoid image of the mentally ill: “healthy” population projected all “madness” onto the ill, who were then connotated as “crazy, aggressive, dangerous and incurable” and thus had to be locked up in PHs. This implicitly granted all those on the outside with a certificate of sanity. The stereotype of the mentally ill was entirely negative and dehumanized. It was forced upon and into the mentally ill both by the culture of general society as well as by psychiatric institutions in particular. Their Self, which was already fragile due to their pathologies, was unable to defend itself from these projective identifications and ended up identifying with the image that had been embedded in them by their environment. Only after scraping away at least a part of the decades-long accumulations would we be able to consider more in-depth treatment of mental illness on an individual level.
Tearing down the myth of the dangerousness linked with mental illness was paramount. This was done by highlighting how levels of acted aggressiveness, which cause was once exclusively attributed to mental illness, almost entirely disappeared first with the humanization of the PH and then with its absence. A parallel positive influence was this of the outside social environment that became progressively more and more containing, thanks to years of efforts done not only by psychiatrists, but also by a large part of the cultural world.
After few years we begun to glimpse the big effects of the continuity in therapy, as the hospital was divided into five areas, each taking care of a specific part of the city. The result was that, with successive hospitalizations, each patient was cared for by the same doctors and nurses. At the same time, home visits began to be carried out by the same hospital workers; it became clear it was necessary to extend treatment outward from the hospital area into the outskirts of the territory, and that this would require the creation of external curing facilities.
In the midst of this project, in 1975 I found myself managing the first Center for Mental Health (CMH). It had been set up on an experimental basis in a small area with 26,000 inhabitants. It started as an outpatient facility, but with some beds too. Ten of these were occupied by patients who had spent decades in the hospital and were locals but no longer had families to whom they could return. Another eight were dedicated to the temporary hospitalization of acute patients who required more immediate treatment for a few days or weeks. This set-up was a significant achievement, and it proved to have enormous therapeutic potential: it meant the possibility to offer each patient personalized treatment. This included outpatient services, day hospital, night hospital or full board, all assessed on a day-to-day basis and all without moving far from home or disrupting contact with family members and the community. These features led also to a substantial shortening in time needed to overcome psychotic crises.
A more respectful treatment of the patient’s person and a stop to the non-specific amassing of the mentally ill in hospital wards combined with a shift in society’s negative stereotypes – and thus of the image of the self that patients felt mirrored to them – allowed them to experience their illness in a less dramatic manner and to alleviate the sensation of solitude and of general incomprehension. Without the fear of violent and depersonalizing hospitalization, patients could now turn to CMH at the first sign of symptoms, before being pulled into the vortex of the illness in its most acute form. Family members or neighbors were often the first to inform us, making timely home visits and therapy possible, which in many cases allowed for the prevention or the containment of the psychotic crisis to the home.
Because of the political atmosphere of that time, it was sometimes also necessary to fight inside the curing team the indulgence in ideological refusals of the necessity to cure mental illness or of its existence at all. But we succeded in replacing the verified destructive effect of PHs with extensive, individual assistance that was customized for each patients and carried out with respect for their dignity and an understanding of their suffering.
This and numerous other factors allowed us to invert the vicious cycle of the illness, which previously would have led to a progressive aggravation of negative effects. In the first five years of our CMH we witnessed a fall in compulsive hospitalizations from 100 to 10 per year.
After some years working to “humanize” the PH and then to extend the external assitance, it became clear that true reform that was capable of responding to the needs of the mentally ill – and ultimately to the needs of the entire population – must necessarily involve the total abolition of the PH and its replacement with a system of care extended throughout the territory. Ultimately, this understanding brought us to 1978 with the approval of the law in Parliament and, a few years later, to the release of the last hospitalized patients from the PH in Trieste.
Without a doubt, there was a combination of factors that led to the success of Basaglia’s experiment in ten years time, what is a relatively short time for such a radical transformation of the mental health care in a city.
The revolutionary wave of the years following 1968 and its overwhelming momentum led to profound changes in Italian society. It brought attention to the values and rights of the individual that had previously been heavily oppressed by authoritarianism and “total” institutions. The climate of those years spurned widespread social debate, leading to the closure of other segregating institutions, such as those managing abandoned or handicapped children, the blind, the epileptic, etc. Schools where children with learning, physical or mental impairments were segregated from others were also closed. But above all, it was the incredible social sensitivity of and the overwhelming push for innovation by so many young psychiatrists and psychologists (and students) converging at that time in Trieste who made it possible to overcome seemingly insurmountable difficulties. This all led to a greater spread of information and a broader involvement and debate with the population in general (district public meetings, meetings with families, neighbors and work colleagues, publications in mass media outlets, and the sensitizing of culture, of political figures and of unions).
The concordance and synergy between hospital workers and local administrators played a fundamental role. The fact that this new form of assistance proved not only more adequate but less expensive also played to its favor.
It was also of great importance that at that time the use of psychotropic drugs had been well-established and significantly improved, without which none of this would have been possible.
Conclusion. Trieste has not had a PH in last 40 years and nobody in the city regrets it. The great fears that in the 1970s alarmed the city have come and gone. The 5 CMHs are the cornerstones of mental health assistance. A Psychiatric Service with six beds in the General Hospital for acute hospitalizations helps during the night or holidays. There is a system of apartments all over the districts with varying degrees of nursing assistance that hosts those who with no family to return to. A Cooperative offers work opportunities suited to participants. It goes without saying that no patients have been “exported” or “hidden” outside the province or in other institutions. So, there are also no private psychiatric clinics. In fact, chronic patients who had previously been sent to facilities in other provinces and those who had been sent to the Judicial PH were brought back.
In this context, once the fundamental living conditions for the mentally ill had been normalized, psychoanalysis could have started to play a significant role. But the residual prejudices of the leading psychiatric team, rooted in the old ideology of the 1968, still doesn’t allow it. Nevertheless this is true in part, as at the same time and thereafter there was a great increase – that continues today – in requests for psychanalytic and psychotherapeutic treatment. But this has occurred entirely on a private level, while public psychiatric services have remained limited to acting primarily in cases of “great psychiatry” and taking carte of the most marginalized and disadvantaged classes.
That being said, we can confidently say that the experiment carried out in Trieste in the 1970s was a success. It continues to bear witness to the possibility of and a need for psychiatric assistance that does not involve a PH. I personally believe this to be the most relevant fact in the history of 20th century psychiatry.
Read the Guardian Review: The Man Who Closed the Asylums: Franco Basaglia and the Revolution in Mental Health Care by John Foot