‘I’m not signing’
- The Man Who Closed the Asylums: Franco Basaglia and the Revolution in Mental Health Care by John Foot
Verso, 404 pp, £20.00, August 2015, ISBN 978 1 78168 926 4
In Britain, the man who closed the asylums was Enoch Powell. ‘There they stand,’ he announced to two thousand delegates at the 1961 annual conference of the National Association for Mental Health (now known as Mind), ‘isolated, majestic, imperious … the asylums which our forefathers built with such immense solidity to express the notions of their day.’ But the era of high-walled colonies for the mentally ill was past and ‘hospital building is not like pyramid building, the erection of memorials.’ There was no longer any plausible function for most of these vast complexes, and reform should ‘err on the side of ruthlessness’. The mental healthcare of the future would take place in general hospitals, and the number of beds would be halved, with care in the local community preferred wherever possible.
Powell spoke in stirring and martial terms of setting ‘the torch to the funeral pyre’, ‘the defences we have to storm’ and ‘their powers of resistance to our assault’, to an audience of people who had in many cases dedicated their lives to these institutions. His use of the term ‘asylum’ was striking. The 1930 Mental Treatment Act had legally replaced it with ‘mental hospital’ to signal that the Victorian model, in which inmates were ‘put away’ for life in crowded back wards, had been replaced by the treatment of mental disorders as diseases of the brain, using the latest discoveries in medical science. Accordingly, the Act had also substituted the term ‘lunatic’ with ‘patient’. Powell’s rhetoric collapsed such distinctions by presenting the mental hospital as a continuation of the asylum.
That same year, 1961, Franco Basaglia arrived in Gorizia, a grim outpost on Italy’s Balkan periphery overlooked by the watchtowers of communist Yugoslavia, where he’d been appointed director of the municipal asylum. Here the term – manicomio in Italian – was less controversial. Italy had had no equivalent of the 1930 Mental Treatment Act, and the legislation of 1904 that governed such institutions in Italy conceived them more as prisons than hospitals. Their primary purpose was to protect the public from the threat presented by the ‘mad’, a category that could still include epileptics, alcoholics and people with Down’s syndrome. Inmates’ civil rights were removed and medical treatment – primarily electroshock, though antipsychotic drugs were on their way in – was punishment as much as therapy, employed, along with restraints and cages, to maintain order.
The 1904 law concentrated power in the hands of the director, who had full authority over the asylum’s internal policies. At the end of Basaglia’s first day, when the head nurse passed him the list of inmates to be tied up that night, he said simply: ‘I’m not signing.’ The moment has acquired mythic status, joining other famous refusals in the history of psychiatry: Philippe Pinel striking the chains from the mad at Bicêtre asylum in 1793 (a much celebrated event that never actually took place), or John Conolly abolishing the use of restraints on his arrival at Hanwell asylum in London in 1839. As John Foot stresses throughout his exemplary account, myth and reality aren’t easily separated in Basaglia’s story. The early stages especially involved a small team of psychiatrists in a forgotten provincial hospital with few independent witnesses, and the story we have is ‘circular, limited, insular and top-down’. As Basaglia’s work became the core of a movement that spread across Italy and beyond, the story was polished into legend through its retelling in countless magazines, books, television documentaries and films. Basaglia’s refusal elegantly encapsulated the principles of the movement that took his name. The asylum was to be ‘negated’, its legitimacy rejected, and this was to be accomplished from inside the system.
Basaglia’s roots were in Venice, his background bourgeois, his sympathies anti-fascist. As a young man in December 1944 he was arrested and held in harsh prison conditions by the occupying Nazis until their expulsion from the city the following April. He studied medicine in Padua, where he specialised in mental and nervous diseases but read widely in existentialism and phenomenology: Sartre, Husserl, Heidegger, Merleau-Ponty. Few in those days entered psychiatry as a vocation but after 12 years in Padua, Basaglia was tired of university politics and the post at Gorizia offered a way out. As soon as he entered the asylum, he wrote, ‘it took me straight back to the war and the prison.’ It had ‘a terrible smell, the smell of death’. Basaglia looked for evidence of the medical efficacy of the regime, but found none: the institution was apparently run only for the benefit of those who worked there. ‘In the face of this absurd, disgraceful logic of the asylum – we said “no”.’ Together with his wife, Franca Ongaro, who assumed a little acknowledged but crucial role in the movement as a writer and translator, Basaglia assembled a team of collaborators whose views were shaped by an evolving canon that included Primo Levi’s If This Is a Man, Michel Foucault’s Madness and Civilisation, Frantz Fanon’s The Wretched of the Earth and, most significant of all, the work of Erving Goffman, which Ongaro translated for an Italian edition.
In 1961, too, Goffman published Asylums, the fruit of his research at St Elizabeth’s Hospital in Washington DC, a vast mental institution with more than seven thousand patients. His study of ‘inmate culture’ and ‘the inmate world’ drew parallels with prisons, conscript armies and concentration camps. Inmates became, in Goffman’s enduring coinage, ‘institutionalised’: they conformed to the system, avoided attention, and in the process lost their life-skills and ultimately their identities. The asylum was supposed to be a staging post to recovery and a return to normal life but in reality it was the opposite.
In Gorizia, Basaglia and his team unlocked the wards one by one, and patients who failed to notice were gently coaxed out. Nursing staff, themselves institutionalised in poorly paid routines of feeding, cleaning and restraint, were evangelised. Volunteers and local family members were brought in to run creative and social therapy sessions. By 1965 these efforts had flowered into the ‘general meeting’. Every morning doctors, nurses, patients and their families would assemble in a hall filled with makeshift rows of chairs where, in a thick haze of cigarette smoke, the administration of the hospital was thrashed out by means of a clamorous direct democracy.
Foot is alert to the ways in which the archive photos of the general meetings conceal as well as reveal. They capture the buzz of mass participation but don’t register the absence of the many patients who chose to remain on their wards, or the inmates of the ‘C wards’, high-security units which remained under lock and key. (There was much agonising over the existence of the secure wards. They undermined the negation of the asylum, but to abolish them risked a violent incident that would be seized on by opponents of the experiment.) A few white coats attest to the presence of nursing staff, but what the images can’t show is that the nurses’ workload was greatly increased by open wards, 24-hour care, trial systems and newly empowered patients. Many of them remained opposed to the reforms. In Basaglia’s analysis, they had been the footsoldiers of an oppressive regime, and it’s true that they tended to regard the manicomio as part of the prison system and their primary role as protecting the public (around 70 per cent of them were members of a trade union with neo-fascist affiliations). But Basaglia needed them: as Goffman had observed, from the patients’ perspective it was the menial staff rather than the doctors who really ran the asylum; without their support there couldn’t be any reform.
General meetings, with their shouting matches, awkward silences and lengthy airings of patients’ grievances, may have been a grindingly slow and inefficient way of advancing hospital policy. But by refusing the supreme power invested in the asylum director, Basaglia accelerated the process of negation from within: nurses were slowly converted, and patients, feeling that they had regained control of their lives, found more energy for their therapy. Discussions of administrative detail expanded into larger questions: ‘What was madness? Why were they all inside an asylum? Who had put them there?’ Myths aside, Foot sees in the general meetings the seed of something genuinely momentous. There was no more authoritarian structure than the asylum, and its overturning in a forgotten corner of Europe prefigured the takeovers of institutions in 1968.
From 1965 onwards, as news of Basaglia’s experiment spread through the networks of Italian psychiatry and radical politics, staff and patients were joined at Gorizia’s general meetings by a procession of students, journalists and filmmakers. Giovanni Jervis, who joined Basaglia’s team after working with the Turin publishing house Einaudi on Herbert Marcuse’s Eros and Civilisation, set up the project that would emerge in 1968 as L’istituzione negata (‘The Negated Institution’), edited by Franco Basaglia – though it seems that Ongaro’s input was at least as substantial. This collage of interviews, communiqués and transcripts of group meetings captured the transition from an authoritarian regime to a state of flux in which every rule and command had become provisional. Over the next four years it went through five editions, its sales far exceeding what had been considered the market for a book on psychiatry. All profits went to the patients at Gorizia. It was, as Foot puts it, ‘a call to arms, and not just for psychiatrists (and perhaps not for them at all)’.
L’istituzione negata has never been published in English, and in consequence Foot thinks there has been a protracted misunderstanding of Basaglia in the Anglosphere (though he finds no evidence for the persistent rumour that a translation was nixed by R.D. Laing; this may be an extrapolation from Laing’s role in suppressing a British edition of Zone of the Interior, Clancy Sigal’s dirt-dishing roman à clef of his experiences at the centre Laing set up at Kingsley Hall). Although there have been some nuanced treatments of Basaglia’s work (for example, in Peter Sedgwick’s Psycho Politics), the perception of him in British psychiatry was predominantly formed by hostile assessments that emerged in the 1980s as part of the backlash against ‘antipsychiatry’, particularly Martin Roth and Jerome Kroll’s The Reality of Mental Illness (1986).[*] Roth and Kroll wrote about Basaglia in the present tense though he had died six years earlier, and took him to be both a Marxist and of the opinion that psychiatric diagnoses were no more than pseudoscientific labels for social deviancy. Their caricature wasn’t entirely unjust when applied to those on the radical edge of Basaglia’s movement, but there are abundant examples of Basaglia’s rejection of them and of the term ‘antipsychiatry’ itself. ‘I am not an antipsychiatrist,’ he said, ‘because I don’t believe in that type of intellectual.’ He wasn’t interested in dreaming up an alternative system either for psychiatry or for society at large, but in improving the one that existed. He regarded mental illnesses as all too real and prescribed psychiatric drugs to treat them, but preferred to ‘place the diagnosis in brackets’ as a way of undermining the operating logic of the asylum, where the main purpose of diagnosis had become to justify confinement and coercive treatment.
The writings of Laing and David Cooper were early influences on Basaglia, though he didn’t meet Laing until 1969 when he visited Kingsley Hall. What he witnessed there was fundamentally different from what was taking place at Gorizia, operating outside the state healthcare system and never claiming to offer a feasible alternative to it. He received more direct inspiration from Dingleton Hospital in Melrose in the Scottish Borders, which he and his team visited several times in the early 1960s. Scotland had a little-known tradition of ‘open door’ asylums dating back to the 19th century, when some governors had received political support for a policy of unlocking cells and giving patients the freedom to indulge in sports and gardening – in some cases they even boarded with local families. In 1962 the South African-born psychiatrist Maxwell Jones took over the former asylum at Dingleton with the brief to establish an ‘open hospital’. He dispensed with white coats, uniforms and formalities, assigned patients to managerial tasks and set about organising the institution on communitarian lines. Thanks to Basaglia, Dingleton would become better known in Italy than in Britain.
Jones was a link to a tradition that had emerged in the early days of the mental hospital. Originally a neurologist, he was assigned during the Second World War to treat casualties of combat stress in a makeshift hospital at Mill Hill. He found that once he had explained the physiological basis of their condition to the patients, most of them recovered rapidly. There was little point in confining them in regimented wards when they were capable of taking staff roles, and so the hospital regime gave way to a more collegiate atmosphere. There were regular group meetings in which patients were encouraged to share suggestions and grievances; staff led discussion groups, showed films and ran drama workshops. A similar system emerged at Northfield Military Hospital in Birmingham, where the term ‘therapeutic community’ was coined – Basaglia later borrowed it for Gorizia.
After the war Jones developed his methods at Henderson Hospital in London before taking over at Dingleton, by which time he had formulated some basic precepts. The regime should be democratic and communal: patients’ ability to help one another was perhaps the most powerful therapeutic tool available, yet most mental hospitals not only ignored but actively suppressed it. In contrast to the authoritarian regime of the asylum, whereby everything that was not explicitly permitted was prohibited, there should be a presumption of permissiveness. There should also be a group commitment to challenge disordered thinking; peer pressure among patients was a means to ‘reality confrontation’. Jones had grown sceptical of the psychiatric model in which ‘care’ was seen as subsidiary to ‘treatment’. Once obvious biomedical conditions were excluded, he believed it was more productive to treat mental illness as the result of adverse social forces.
Basaglia adopted many of Jones’s strategies, notably the general meeting, but parted company with him in one significant respect. Most of Dingleton’s patients were, like those at Gorizia, from poor and socially deprived backgrounds which had left them with stunted emotional lives – most psychiatrists diagnosed psychopathy in such cases, but Jones saw ‘anomalies of growth’ that could best be corrected by immersion in an alternative society in which patients could experience a healthy family environment. Basaglia, however, regarded the asylum itself as the problem. As a logical extension of the authoritarian society that had built it, it was irredeemable, and even an improved version – a ‘golden cage’ – was a trap.
Foot conducts a close reading of one of the slogans that became associated with the movement, ‘Manicomio = Lager’ (asylum = concentration camp), which first appeared on a poster by the Arte Povera artist Piero Gilardi in 1969. It articulated the refusal at the heart of the project in the starkest possible terms and captured Goffman’s analysis of the asylum as a ‘total institution’. It drew attention to the Italian asylum’s roots as an organ of the fascist state and the status of patients as ‘non-persons’ under the 1904 law. At the same time it left open the question of whether the equivalence was metaphorical or literal. For some in the movement – such as the Bologna psychiatrist Edelweiss Cotti, who regarded mental illness as an ‘invention’ – asylums were no different from concentration camps: both were repositories for those no longer conceived as human. As such it was ethically indefensible for a doctor to work in them (although that didn’t stop Cotti ending up in charge of the vast asylum at Imola). Basaglia’s hero, Primo Levi, was obliged to confess he found the analogy ‘a little uncomfortable’: although asylums were ‘probably ugly places’ they were clearly intended ‘to defend the mentally ill, not kill them’. For Basaglia it was no more than a metaphor, though a searching one. Psychiatrists, he wrote in L’istituzione negata, were ‘immersed in a reality in which they are in part complicit and in part victims’, obliged ‘to declare themselves as protectors of an order which they want to destroy’.
In 1969 Basaglia left Gorizia, under pressure both from an overworked and fractious team and from a provincial administration that had never been fully committed to his reforms and was stifling further progress. In 1971 he became director of the large San Giovanni asylum in Trieste, with the intention – for which he had political support – of moving towards its closure. An army of volunteers, activists, artists and filmmakers arrived in the city. The asylum was opened up and its grounds became a forum for public artworks and street theatre, open-air debates and performances by the likes of Ornette Coleman and Dario Fo. In March 1973 this mass mobilisation generated the climactic tableau of the Basaglia myth. Amid carnivalesque scenes ‘Marco Cavallo’, a sky-blue papier-mâché horse constructed by patients, doctors, nurses and artists, was wheeled in triumph out of the hospital and through the streets as a symbol of shared liberation. By 1974 the number of residential hospital patients had been halved and a citywide network of apartments and residential complexes, health centres, art studios and working co-operatives was emerging.
In the second half of the book Foot widens the frame to consider asylum reform elsewhere in Italy, both by the diaspora from Gorizia and by others unconnected with it. The most striking example of the latter was Carlo Manuali in Perugia, who was supported (unlike Basaglia) by a powerful local Communist Party led by his close friend Ilvano Rasimelli. Both had been so shocked by the conditions inside the vast and outmoded city asylum in 1965 that they resolved to shut it down. They opened the doors and cut the nurses’ hours; patients emptied into the city streets and back to their home villages, where neighbourhood mental health centres were set up. The transition was accomplished without street parades, anti-psychiatry protests or any form of what the doctor and activist Francesco Scotti called ‘iconic communication’. Instead, Manuali and Rasimelli were simply providing a ‘service for the people – carrying out forms of psychiatry which became invisible … precisely because they permeated into the local context and its needs’.
Perugia was little noticed at the time partly because it was, as Foot puts it, ‘a poor fit with Basaglian narratives’. The story shows that Basaglia wasn’t the only psychiatrist who believed the asylums could and should be closed; it undermines the idea that the Communist Party was an intractable roadblock to reform; and it demonstrates that popular mobilisation was not a necessary component of success. It is also an example of the irreducibly regional nature of Italian politics in general and healthcare in particular. Foot’s chapters on Perugia, Parma, Reggio Emilia and Arezzo show that the eventual closure of the asylums, enshrined in what is still universally known as the Basaglia Law, was the product of a larger confluence of interests than the name implies. Law 180 was passed in May 1978 in the space of twenty days: there was an urgent need to head off a referendum that threatened to repeal the 1904 law but put nothing in its place, leaving the asylums in a legal vacuum. Law 180 was bitterly opposed by Marco Pannella and his Radical Party, who had organised the referendum campaign and collected 700,000 signatures, but it passed comfortably with the joint support of the Communist Party and the Christian Democrats.
Technically the law no longer stands, as it was integrated almost immediately into wider health reforms. But it was a watershed: it restored mental patients’ civil rights and after it was passed, no new asylums were built. The law made Italy the first nation to end all residential hospital admissions, though the rest of its provisions were mostly technical and moderate, owing as much to the psychiatrist who proposed it, the Christian Democrat Bruno Orsini, as to Basaglia. It gave considerable scope to regional administrations, so that in cities like Trieste and Perugia it did little more than add a legal imprimatur to a policy that was already well advanced, while in others, particularly in the south, it was barely implemented. Many of its provisions were applicable only in places where community healthcare was already developed; elsewhere its requirements were avoided, for example by reclassifying asylums so that the ban on admissions no longer applied. The attempts to reverse the law began even before it was on the statute books. After Basaglia’s sudden death from a brain tumour in 1980 Franca Ongaro stepped out from her husband’s shadow and over two terms as a senator for the independent left dedicated herself to pushing through the measures needed to build a post-asylum world.
In outline the Basaglia law offered the same solution as Enoch Powell’s: mental healthcare would be absorbed into Italy’s general hospital system; acute cases would be residential and the rest would be devolved to local authorities who would be able to offer, as Powell envisaged, ‘an almost unlimited range of gradation’ of services, provided wherever possible outside hospitals. But this was a starting point from which many different paths could be taken. For some within the Basaglian movement the road ahead required nothing less than a revolution through which market economics would, like diagnoses of mental illness, be placed in brackets and subjugated to the reformation of society. Others, such as Basaglia’s one-time right-hand man Giovanni Jervis, came to see this project as fundamentally incoherent: ‘You can’t make a revolution with psychiatry,’ as he put it in 1975. In the early days of the movement, reality had been temporarily suspended. A vanguard of highly qualified staff had been prepared to offer their services for nothing. But once the revolutionary moment had passed, the fact had to be faced that community care could be good or it could be cheap, but it couldn’t be both. New policies and budgets would be needed for housing and welfare, day centres and co-operatives, along with administrative structures robust enough to avoid clientism and capture by local political parties.
Jervis had moved from Gorizia to Reggio Emilia, where the asylum was politically too well defended to be closed and his attempts to bypass it with community alternatives had led to bruising compromises with a Communist-led administration and its public-sector interests. By the time the Basaglia Law was passed he believed the revolution had already hit the buffers. ‘“Advanced” therapeutic experiments are very few in number,’ he wrote, ‘and in all probability have produced nothing very new in comparison with the best British experiments of 15 or twenty years ago.’ Yet today, at least in the movement’s stronghold of Trieste, the Basaglian revolution lives on. The site of the old asylum remains dedicated to theatre and community radio stations, and four day-centres across the city combine the functions of dispensary, drop-in centre, café and medical outreach. Acute mental healthcare takes place in the general hospital, in a centre that according to Foot feels ‘closer to a hotel than a hospital ward’: comfortable, unlocked, with no white coats to distinguish doctors from patients.
If a distinctively Basaglian mental healthcare can be discerned only in glimpses today, that is perhaps how Basaglia would have wished it. Even at Gorizia he was insisting that his work should not be taken as a blueprint, or presented as a psychiatric ‘shop window’ ‘where you can see new products to consume’. By 1971 in Trieste, he feared he had ‘become an institution’. To carry on celebrating the glory days of Gorizia and Trieste disconnects those founding moments from their legacy. Foot restores a critical distance that makes it possible to present Basaglia’s achievements as part of a wider story. In Italy, it took more than one man to close the asylums.