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História, Ciências, Saúde-Manguinhos

Print version ISSN 0104-5970On-line version ISSN 1678-4758

Hist. cienc. saude-Manguinhos vol.26 no.4 Rio de Janeiro Oct./Dec. 2019  Epub Nov 28, 2019

https://doi.org/10.1590/s0104-59702019000400008 

ANÁLISE

Franco Basaglia: biography of a revolutionary

i Researcher, Centro de Estudos Sociais/Universidade de Coimbra. Coimbra – Portugal mauroserapioni@ces.uc.pt


Abstract

1978-2018: 40 years since the passing of the Basaglia law, which decreed the closure of psychiatric hospitals in Italy (where almost hundred thousand were confined), the primary goal of Franco Basaglia in his lifelong struggle against the violence of total institutions and, in particular, mental asylums. This article offers a reflection on the human, intellectual, and professional trajectory of Basaglia, highlighting his criticisms of the backwardness of university clinics, his interest in the therapeutic dimension of care (Binswanger and Minkowski), the influence on his thinking of European philosophy more open to the complexity of the human being (Husserl, Jaspers, Merleau-Ponty, and Sartre), and his encounter with historical (Foucault), sociological (Goffman), and anti-institutional (Fanon) perspectives on mental health.

Key words: asylum; psychiatric reform; mental health; abyssal lines; Italy

Resumo

1978-2018: 40 anos da aprovação da lei 180 (Lei Basaglia), que decretou o encerramento dos hospitais psiquiátricos italianos (com quase cem mil internados), principal alvo da longa e incansável luta de Franco Basaglia, que dedicou a vida inteira ao combate da violência das instituições totais e, em particular, do manicômio. O presente artigo propõe-se a refletir sobre a trajetória humana, intelectual e profissional de Basaglia, realçando suas críticas contra o atraso das clínicas universitárias, seu interesse pela dimensão terapêutica do cuidado (Binswanger e Minkowski), sua aproximação da filosofia europeia mais aberta à complexidade do ser humano (Husserl, Jaspers, Merleau-Ponty e Sartre) e seu encontro com a perspectiva histórica (Foucault), sociológica (Goffman) e anti-institucional (Fanon) da doença mental.

Palavras-Chave: manicômio; reforma psiquiátrica; saúde mental; linhas abissais; Itália

Basaglia’s utopia

Tomorrow morning, at visiting time, when you attempt, without words, to communicate with these men, may you remember and recognize that you have no advantage over them but strength.1

This is the first sentence from a speech given by Franco Basaglia at the first International Congress on Social Psychiatry, held in London in 1964, in which he called for an end to mental asylums and freedom for all those confined in them. By this time, Basaglia had already been working and studying intensively for three years at the asylum in Gorizia, a town in northeastern Italy on the border with the former Yugoslavia. Gorizia was the first care community created inside an Italian asylum, with more than six hundred patients, without the slightest legal support, and without civil society having the maturity to cope with such a radical change.

Basaglia’s words were heard with increasing alarm and bewilderment. The British reformists – who had established the National Health Service in 1948 and who, with the 1959 Mental Health Act, had introduced social and territorial psychiatry, changing the name of the asylums to psychiatric hospitals – were not willing to accept Basaglia’s arguments to go beyond the open-doors system of psychiatric institutions. Basaglia recognized the progress that Britain’s social psychiatry represented as well as the French experiment in a “sector policy,” based on having fewer centralized hospitals and more community care, where patients would receive care and maintain social ties. He showed great interest in Maxwell Jones’s (1968), Ronald Laing’s (Laing, Esterson, 1964), and David Cooper’s (1967) experiences, but wanted to avoid the risk of creating a new form of institutionalization of mental patients – a “simple disguise of the primitive master-servant relationship” (Basaglia, 1981a, p.257). The ultimate goal of Basaglia’s movement was to do away with the whole asylum system, whereas the British model sought merely to transform it, from the inside out, by providing care communities. For this very reason, the radical wing of psychiatry linked to Laing and Cooper had left the NHS to develop alternative therapeutic experiments.

For Basaglia, a care community was just a spruced-up way of maintaining control over patients. If things were really to change, care communities must develop a single purpose: to help highlight the contradictions of the system, catalyzing uprisings and revolts by the oppressed people. In his own words (Basaglia, 1973, p.47), “the patient’s opposition to the doctor, to the organization, and to the hospital authority is just the first step for the strengthening of his fractured ego, so that he may face reality and its contradictions.”2

Education, anti-fascist activism, and academic career

The researcher’s distance from his own investigation is particularly significant in the case of psychiatry ... On the one hand, a science committed to researching the genesis of a disease it recognizes as ‘incomprehensible;’ on the other, a patient who, in his supposed ‘incomprehensibility,’ is oppressed, humiliated, destroyed by the asylum organization (Ongaro Basaglia, 2005, p.128).

Franco Basaglia was born in Venice on March 11, 1924, into the lap of a rich family who recognized the fascist State. He spent a happy childhood and adolescence in the district of San Polo, a typical Venetian neighborhood. In 1943, after graduating in the classics, he enrolled at the University of Padova’s Faculty of Medicine. It was at this time that he came into contact with a group of anti-fascist students and later joined the Resistance (an anti-Fascist military and political movement). Betrayed by a companion, he was arrested and imprisoned for six months in Venice, an experience that marked him profoundly and that he would recall years later, when he was appointed the director of the Gorizia asylum, another confined institution. Indeed, it is suggested by some of his biographers that Basaglia’s hostility and intense reaction to asylum systems (defined by Goffman as “total institutions”) was related to his experience and memory of the months he spent behind bars.

In 1949, war and imprisonment notwithstanding, Basaglia graduated in medicine and devoted the whole of the following decade to the study of psychiatry and philosophy. In 1952, aged 29, he earned a specialization in nervous and mental diseases, then the following year he married Franca Ongaro, who became a long-time collaborator and helped him in his most important life decisions. In 1958, he earned his professorship in psychiatry.

Throughout this time, Basaglia engaged in great intellectual endeavors, producing a succession of writings, scientific publications, and speeches at conferences and congresses on the diverse mental disorders encountered in clinical practice: schizophrenia, obsessive states, hypochondria, somatopsychic depersonalization, depression, paranoid syndrome, anorexia, disturbances related to alcohol abuse, amongst others. However, these were also years when his love of philosophy started to burgeon, with studies of phenomenology and existentialism, and the attempt to reconcile traditional psychopathology with anthropological phenomenological psychiatry.3

Basaglia gradually perceived the backwardness of psychiatry in Italy, where almost hundred thousand people were locked away in asylums in the early 1960s, as compared to other countries (France, UK, Germany, USA), as well as the prevailing rationale in academic studies. The psychiatric clinics at the country’s universities had not reviewed the country’s welfare model; indeed, they had reinforced the trend towards more repressive, restraining practices. Since the late 1800s, two forms of psychiatry had coexisted: the psychiatry of university clinics, where cases of scientific interest were treated, and the psychiatry of the mental asylums, where patients considered dangerous were locked away. The university clinics and asylums were two separate worlds, differentiated in terms of their scientific respectability, therapeutic function, and types of patients (classified by diseases and social classes) (Colucci, Di Vittorio, 2001, p.10). In fact, in the period under investigation, from 1949 to 1961 at the University of Padova,4 Basaglia had not yet come into contact with a mental asylum, where anonymous psychiatrists with no academic ambitions tended to work.

From the outset, Basaglia’s scientific orientation diverged from the organicist approach adopted by the director of the neuropsychiatry clinic in Padova, Prof. Giovanni Battista Belloni, and by other colleagues from the same department, drawing closer to Daseinsanalyse,5 an existential analysis method (literally, the analysis of being) developed by Ludwig Binswanger and Eugène Minkowski, which Basaglia deemed important because it implied “the doctor himself, who cannot remain detached like a mere examiner, having to participate directly” (Basaglia, 1981c, p.3). Based on the work of Karl Jaspers, Basaglia held that “it is not enough to describe the symptom, since such description should awaken the examiner’s experiences, something they have lived: only he may experience fully and intensely the description of this symptom ... and sympathize with the life of the patient himself” (Basaglia, 1981c, p.4).

However, at that time there were still few psychiatrists in Italy who questioned the positivist models inherited from the 1800s, which meant Basaglia continued to work alone in his bid to combine psychopathology and phenomenology, offering a richer, more innovative psychiatry on the therapeutic plane (Binswanger, Minkowski, Strauss, and Freud) and developing his philosophical grounding on reflections more interested in the analysis of the complexity of the human being6 (Husserl, Jaspers, Heidegger, Merleau-Ponty, Sartre) (Giannichedda, 2005). Existentialism was particularly important for the development of Basaglia’s thinking, as was the critical phenomenology of Husserl and Heidegger, which influenced his choices in the field of psychiatry; in other words, the same authors who had inspired Ludwig Binswanger, the psychiatrist he most appreciated. Basaglia was also familiar with the work of Sartre, whom he admired profoundly. For him, Sartre was his master, and he even met him on some occasions in Bologna and Paris. After he reached professional maturity, Sartre’s influence became even more evident, marking some key points of his work, like the conception of the responsibility of technical staff and intellectuals, the centrality of praxis, the criticism of ideology, and the conception of utopia as a quotidian practice.7 During a profound conversation with Sartre about intellectual and practical knowledge, Basaglia raised the subject of utopia in everyday practice (Ongaro Basaglia, 2005, p.46): “In our reality, to seek out a science constructed together with its real or potential users is already utopia ... To try to encounter answers to people’s real needs, for whose care science declares its dedication, also becomes utopian.” Although the French philosopher contested the use of the term, Basaglia, asking his forgiveness, did not back down in his steadfast project to seek utopia as a way to achieve the radical transformation of society. Colucci and Di Vittorio (2001, p.74) make an elucidating comment on this point: “Utopia is before him, every day, it is the very face of the people leaving psychiatric hospital.”

In this sense, and in line with Gramsci’s (1971) reflections, Basaglia criticizes the pessimism of intellectuals concerned solely with writing books and defends imagination, the construction of utopias, and optimism of the will.

The “philosopher Basaglia,” as he was dubbed pejoratively by the director of the Department of Neuropsychiatry, had engaged in research for 12 years at the University of Padova, but it was clear that for him there were no career opportunities there, since academia was overrun by hierarchies and conservative ideas. For this very reason, he decided to rid himself of the “university syndrome” (Basaglia et al., 2008, p.94): “As an assistant at the university, I had learned a great deal of the institutional logic I had experienced directly, and how it could destroy a person and how you could fall ill with the university syndrome.”

Instead, Basaglia decided to apply for the directorship of the Gorizia psychiatric hospital, and in late summer 1961 he set foot for the first time inside a mental asylum.

Gorizia: the opening of the first Italian asylum

It is very easy for the dominant psychiatry to define our work as lacking in importance and scientific respectability. A judge may not flatter us, since we are ultimately united by the lack of importance and respectability always attributed to mental patients and all the excluded (Basaglia, 1968, p.9).

The impact of daily life in a psychiatric hospital was painful and even traumatic – a far cry from the sanitized images and representations learned in the classrooms of university laboratories. The reality he encountered was inhumane and intolerable. This first period was marked by profound existential anguish, as he came up against an unforeseen reality marked by the social degradation, marginalization, and misery in which the patients were forced to live. Initially, Basaglia was tempted to give it all up, especially in the absence of the resources and means he needed to deal with the dramatic reality inside the asylum. However, as he drew on his network of relationships and friends, he gradually built up a group of collaborators – psychiatrists, mostly in their youth, whom he had met at the different conferences he had participated in. His first reform initiatives were:

  • to prohibit the use of electroconvulsive therapy at Gorizia hospital and remove the bars from the windows;

  • to remove the straitjackets the more troubled patients were made to wear, preventing them from moving;

  • after this came an important step in the relationship between doctors, nurses, and patients: white coats, the ultimate symbol of power and hierarchy inside the asylum, were no longer worn. They made the doctors faceless in the patients’ eyes, which meant they appeared indifferent, inaccessible, secure in their certainty, their science, their diagnoses. For Basaglia, the white coat was the symbol of total subjugation;

  • Once the straitjackets and white coats had gone, the next step was to overcome the patients’ initial mistrust towards the first meetings and assemblies. First of all, the patients merely showed up, looking warily around, without taking any active part in the proceedings, but as time went on they gained confidence and gradually came out of their shells. The community assemblies held at 10 am in the hospital’s biggest room were for all the patients, doctors, nurses, and social workers. No formal distinction was made between the different members of the community, and they could all sit wherever they wanted. Two or three patients would sit at the head table to run the meeting. Indeed, all aspects of life in the hospital were governed by these meetings, obviously without any obligation to attend, and the right to enter or exit at will.

After these formal barriers had been lifted, the real underlying problem, in Basaglia’s view, remained unsolved: that of the patients’ freedom and opportunity to feel the same as anyone else. In fact, the patients’ gaze and discourse remained different, wary, filled with suspicion and resentment. The most stubborn barriers – resulting not just from the oppressive effect of mental illness, but often from long periods of institutionalization – could not be expected to dissolve immediately. Although patients were no longer the victims of direct violence, they still felt different. Basaglia, now trained in ways to develop empathy with patients, realized with shock just how violent the asylum was, operating as a form of violence against the body, a subject about which Basaglia had thought deeply in his analysis of the writings of Merleau-Ponty (Basaglia, 1981b). In the book L’istituzione Negata (Institution Denied) in which he narrates the experience, significance, and dynamics of life inside the Gorizia care community, Basaglia speaks out about how the dehumanization of the patient resulted more from the violence of the asylum than the disease itself (Basaglia, 1968, p.128):

First contact with the reality in the asylum immediately highlights the forces at play: the patient, rather than appearing as a sick man, is the object of institutional violence that acts on every level ... The level of degradation, objectivization, total annihilation that is seen is not the pure expression of a morbid state, but the product of a destructive action of an institution whose objective was to protect healthy people against madness.

Little by little, what came to be known as the “republic of the liberated madmen” began being created. The patients who had until then been imprisoned for their whole life could now envisage freedom. However, this process took years. The first department to be opened, referred to as a care community, housed just fifty patients. By 1967-1968, all the characteristics of the Basaglian care community had been extended to the whole hospital, namely the assemblies, self-management, the debates, the elimination of hierarchies, and the open departments (Foot, 2014, p.98).

Basaglia was keen to keep transforming Gorizia psychiatric hospital. However, conservative, traditional public opinion and a good portion of the political world remained opposed and resistant to his project, focusing only on the risks and dangers inherent to giving up the old practices of containing patients and completely ignoring the new care approach, which regarded the patient as a human being whose dignity and suffering should be respected (Parmegiani, Zanetti, 2007). For this reason, the outpatient infrastructure that had been planned to receive the patients who left the asylum was never put in place by the Gorizia provincial authorities, responsible for the financial management of the hospital. Furthermore, there was no shortage of scientific arguments from the academic world, who also contested the philosophy and line of action adopted by the new psychiatry. And finally, there was a criminal act committed by a patient after he was discharged from the hospital, which only went to worsen relations with the provincial authorities (Parmegiani, Zanetti, 2007). Bowing to these pressures and barriers, in late 1968 Bsaglia decided to leave Gorizia and take up a six-month fellowship at Maimonides Hospital, in Brooklyn, New York. The disagreements between the Gorizia authorities and the hospital’s management continued after his departure, affecting the hospital’s vice-director, Agostino Pirella, who took over the job in 1969. Eventually, in 1972, the hospital’s then director, Nico Casagrande, announced the resignation of the whole medical team, putting an end to the Gorizia experience.

Basaglia may have left Gorizia, but he had still managed to attract the attention of civil society and the scientific community to a great human and social problem: the continued existence, in psychiatric hospitals in Italy and many other countries, of an unacceptable and extremely disturbing reality. He had managed to show that the asylum effectively stripped patients of their personality and even wrought changes to so-called “normal” people admitted to such institutions after suffering temporary bouts of depression or behavior disorders. He also showed how the asylums were often the destination of alcoholics, people who caused family disputes, people with learning disabilities, and people with hereditary nervous disorders.

By adopting novel therapeutic activities, Basaglia was struggling against what was defined as a “dual psychiatry:” on the one hand, the asylums, for the poor, low-income blue-collar workers, manual laborers, and the underclasses in general; on the other, in domestic settings or private clinics, the better off and those who, thanks to their financial means, were able to be treated and then often to return to work and society. This was a clear demonstration that both rich and poor could be treated, provided they were not locked up against their will in environments that tipped them over the edge forever (Parmegiani, Zanetti, 2007, p.57-58).

The care community certainly improved the lives of patients, doctors, and nurses. It made “non-people into real people again, with a history, an identity and a voice, and it freed doctors and nurses from purely repressive activity” (Foot, 2014, p.96).

Despite the political and cultural hostility faced in Gorizia, the experience of the care community spread its influence across Italy and came to be recognized and appreciated in many parts of the world. In Italy, by the late 1960s, care communities based on Basaglia’s approach were already in place in psychiatric hospitals in Perugia, Pordenone, Parma, Nocera, Arezzo, Reggio Emilia, and Varese. The 1968 book Istituzione Negata, which retold the experience of Basaglia’s group at Gorizia, had a huge impact on public opinion and became a reference text for the anti-asylum movement.

Seeds of the anti-institutional movement

Psychiatry seems only now to have discovered that the first step towards curing a patient is to restore him the freedom that he himself has thus far been deprived of (Basaglia, 1968, p.130).

With the assistance of phenomenology, Basaglia discovered that the positivist perspective on mental illness made it impossible to encounter the patient. This meant that all scientific certainties had to be left to one side in order to understand, together with the patient, the moments in which he/she constructed his/her experience. Breaking away from the psychiatry learned at university and seeking out other sciences capable of embracing a global perspective on human problems was the author’s first epoché – his first philosophical exercise in suspending or “bracketing” the science of psychiatry. However, the reality he encountered at Gorizia meant that even phenomenology fell short. The clash with reality was shocking, and prompted Basaglia to begin a process of humanization of the asylum. The experiments based on the care community, marked by principles of ethics and democracy, revealed a complex and contradictory reality. The discovery that the patients were also socially excluded, that in the asylum most of them were poor, and that behind the façade of neutrality of specialist interventions resided a psychiatry with a decidedly political nature demonstrated that science, in its positivist and phenomenological versions alike (Basaglia, 1968, p.119), constituted a powerful tool for not addressing the patients’ reality: “The contribution of phenomenological thinking has not, despite its desperate search for the subjectivity of man, managed to remove the patient from the terrain of objectification into which he has been cast.” Even so, Basaglia did not give up phenomenology and the search for a definitive truth; he turned his phenomenological epoché back to therapeutic practice when he affirmed that in order to comprehend the mental patient, it was necessary to put the mental illness and the nosographic labels devised by psychiatry between brackets (Basaglia, 1968). This statement sparked a lengthy controversy, and was mistakenly interpreted by some as a denial of the existence of mental illness. In response to this type of argument, Basaglia (2000, p.98-99) stated, in the talks he gave in Brazil, that “if I thought madness was just a product of society, I would still be within the logic of positivism ... I think madness and all diseases are expressions of the contradictions of our body, and when I speak of the body, I speak of the organic and the social body.”

“Bracketing” disease8 means, in Amarante’s (1994, p.65) view, “the denouncement and epistemological rupture that refers to the ‘duo’ of mental illness, meaning what is not inherent to the condition of being ill, but to being institutionalized.” For Colucci and Di Vittorio (2001, p.87), bracketing mental illness “is not just a statement of principle, but also a work plan from which, in a few years, came the turning point in Italian anti-institutional psychiatry, which took on a radical practical, civil, and political commitment.” For Basaglia, the brackets that suspended judgement on mental illness would only be completed when the asylum was abolished and the question of psychiatry became a social problem. Only then could the matter of what madness was be discussed once again.

The anti-institutional turn and the development of alternative psychiatry (which in Italy was called democratic psychiatry) was facilitated, as Colucci and Di Vittorio (2001) point out, by two important factors: the novel and original experience of the care community at Gorizia psychiatric hospital and the conjugation of the historical (Michel Foucault) and sociological (Erving Goffman) perspectives on mental illness, which enabled the asylum and the truth about mental illness to be suspended and critically bracketed. In this sense, the group who worked at Gorizia were strengthened not just in their theoretical reflections, but also in their therapeutic practice by Foucault’s analysis of the genealogy of psychiatry and Goffman’s analysis of the microsociology of the psychiatric hospital. In 1961, in Histoire de la Folie à l’âgé Classique, Foucault (1972) reconstructed the lunatic asylum historically and philosophically, stressing the origin of the knowledge-power system of psychiatry and developing a theoretical and methodological basis for the study of deviation in general and madness in particular. In the same year, in his book Asylums, Goffman (1968) identified the perverse mechanisms of what he called “total institutions,” highlighting the exclusions and gradual limitations undergone by people officially recognized as “mental patients.” In 1961, Basaglia began the transformation of the Gorizia asylum, whose results led to the encounter of the three scientists who had developed, each in their own field, a criticism of mental illness (Colucci, Di Vittorio, 2001).

Basaglia remained quite radical in his criticism of the neutrality of science and any specialist approach,9 including psychiatry (whether scientific or technical). Psychiatry and science, Basaglia (1968, p.125) maintained, embraced the violence that was still used against patients under the “hypocritical veil of necessity and therapy.” In this sense, he took the side of the oppressed (Basaglia, 1968, p.124-125): “The rejection of the inhumane conditions in which the mental patient finds himself; the refusal of the level of objectification in which he is left, cannot but be found to be intimately linked to a questioning of the role of the psychiatrist, the science to which he is affiliated, and the society he represents.”

In this radical criticism of the science and profession of psychiatry, it is important to record another decisive encounter with a great intellectual and psychiatrist, Frantz Fanon (1966), whose book The Wretched of the Earth was also published in 1961, in France. Born in Martinique in 1925, and so almost the same age as Basaglia, Fanon had a strong influence on him, so much so that in L’Istituzione Negata Basaglia comments on Fanon’s letter of resignation (published in Toward the African Revolution, Paris, 1954) from the directorship of the Blida-Joinville psychiatric hospital in Algeria, in 1956:

The most his action could achieve was the technical perfectionism and reformism of an institution that offered social rehabilitation and cure in a reality that Fanon defined as systematized inhumanity. The therapeutic act was an act of mute acceptance of the system and Fanon could choose only revolution as the place outside the institutions where he could act (Basaglia, 1968, p.378).

Fanon rebelled against the dual condemnation that affected the patients held in mental asylums, as mental patients and as colonized people, with a dual expropriation of rights. He ended up leaving the psychiatric hospital and joined the National Liberation Front of Algeria. For Basaglia (Colucci, Di Vittorio, 2001, p.200), Fanon became “the model for an anti-institutional career of psychiatry, meaning its self-destruction as a subject of knowledge and its reconstruction as witness to the excluded, oppressed, and colonized state of the mental patient.”

Trieste: destruction of the psychiatric hospital

What matters is that we have demonstrated that the impossible can become possible. Ten, fifteen, twenty years ago it was unthinkable for an asylum to be destroyed (Basaglia, 2000, p.142).

In 1970, after concluding his fellowship at Maimonides Hospital in Brooklyn, Basaglia took up the directorship of the Colorno psychiatric hospital in the province of Parma, where he ended up staying for just ten months. Despite the support and praise he received from the health director – the communist and erstwhile anti-fascist activist Mario Tommasini –, Basaglia was unable to put his plan into action, since the provincial government proved unsympathetic to his proposed changes. In fact, although many people did return to a normal existence, going back to live in their homes and working in agricultural cooperatives, Basaglia and Tommasini continued to face a number of hurdles: “the intellectual sloth, the fears, the prejudice of a political class, also on the left wing, that is unable to realize the value of change, and which fears novelty” (Pivetta, 2014, p.229).

In 1971, Basaglia was invited to run the San Giovanni psychiatric hospital by the Triste provincial commissioner, Michele Zanetti, a young politician who guaranteed full support for the plans to restructure psychiatric care in the province. There were some 1200 patients in the hospital, eight hundred committed involuntarily. Upon his arrival, Basaglia put together a team of young doctors whom he himself helped to train, and submitted his action plan. First of all, as he had done at Gorizia, he planned to make life less oppressive for the patients, assuring respect for their basic human rights. The hospital departments were opened up, violent treatments were prohibited, and rigid gendered divisions of space were eliminated. The patients were divided into five zones of about two hundred each, according to their regions of origin, in order to break down the isolation of the asylum from the city and restore ties with the land, reactivating the patients’ memories of places where they had lived and restoring a sense of connection with the past. Local outpatient services were organized in such a way as to assure prompt intervention, nighttime care, and rehabilitation activities. Meanwhile, work started on the renovation of the hospital, which was in a dilapidated state.

Basaglia’s experience at Gorizia had taught him that setting up a care community, abolishing the physical containment of patients, and even questioning the role of the psychiatrist as a professional was not enough to dismantle the asylum system. Gorizia had shown him that it was not enough to simply humanize the asylum or to change its internal organizational dynamics. At Trieste, he had to work towards the permanent closure of the institution. That meant setting up a network of outpatient services to cut off the flow of new admissions and to meet the needs of the people discharged from the hospital. In other words, a care community had to be built in the territory where the diseases were produced and proliferated. At this time, a large and growing team of professionals was formed and an interesting creative and symbolic strategy was promoted that made use of street theater and other artistic performances. The asylum became a lively space. Many young doctors were attracted to Trieste and even many artists and volunteers from Italy and other countries. As in Gorizia, departmental meetings and assemblies were held to discuss the problems of the day, new treatment programs, and issues that came up over time.

The regimented order of the asylum was upset: parties, dances, painting workshops, the first trips, a bar. In summer 1973, the first seaside vacation was organized for fifty patients accompanied by doctors and nurses. On February 25, 1973, a procession of over four hundred patients, headed by a great blue horse made of wood and papier-machê, set off out of the hospital walls and around the streets of Trieste, becoming a symbol of the liberation of those human beings with mental illnesses and the oppression of an antiquated psychiatry rooted in incarceration. The horse, which went by the name of Marco Cavallo, had been made inside the hospital by patients, artists, doctors, and nurses under the guidance of the painter and sculptor Vittorio Basaglia, Franco Basaglia’s cousin. Marco Cavallo was a theater prop, a collective work inspired by a horse that had actually lived for many years at the asylum, carrying the laundry. Forgacs (cited in Foot, 2014, p.272-73) reports this powerfully symbolic artistic happening in the following terms: “In symbolism, it could be interpreted as a Trojan horse turned backwards: dragged outside a walled compound not in to invade or conquer a city, but to free the prisoners.”

In summer 1974, the hospital grounds were opened to society and the neighboring area, and concerts were organized in which well-known musicians performed, including the jazz musician Ornette Coleman and the actor and winner of the Nobel Prize for Literature Dario Fo. In 1975, vacation camps started being arranged for groups of sixty patients in the Dolomites. In August of the same year, Basaglia, David Cooper (an anti-psychiatry pioneer), and a group of one hundred patients took a flight from Trieste to Venice (flying over the Adriatic), a journey of great symbolic significance, courtesy of the Italian airline Alitalia. In Basaglia’s words, “it was one of the many ways to get out of the asylum” (Parmegiani, Zanetti, 2007, p.122).

An intense relationship was forged between the hospital and the city: doctors, nurses, patients, and volunteers managed to involve the city in their struggles, while the city was invited into the asylum. This was an original strategy put into practice at Trieste.

In 1975 came the opening of the first three (of five) community mental health clinics in the territory,10 where patients were offered care day and night. This was the first concrete psychiatric care ever offered outside the asylum. Deinstitutionalization, Basaglia stressed, could not end with dehospitalizing patients, which would simply transfer the mental health burden onto the lap of the territory and the families unless a network of alternative services was set up.

The Trieste experiment gradually started to garner its first international recognition. It was recommended as a health care model by the World Health Organization (WHO), a “pilot zone” in the ambit of psychiatry and mental health research, a recognition that lasted for some twenty years. In line with this, the WHO promoted important programs for the training of social workers and health workers based on the experiments of Basaglia and his team in Trieste. With this international recognition, a steady and rising flow of professionals and scholars from Europe, Latin America, and Australia went to visit it to find out about the new care approach.

Another important step was the legal recognition of the United Workers’ Cooperative, in 1974, which granted patients entry to the labor market and their inclusion in the city as producers and not just consumers. The first group was of around sixty people, who signed a standard union contract and received a regular wage, an important strategy for restoring the patients’ dignity, insofar as they could now receive financial compensation for their work in occupational therapy interventions. Basaglia strongly believed in the therapeutic and liberating effects of work. The social co-ops were later used across every region of Italy to enable patients with mental health problems to reintegrate into society. Later, other co-ops emerged thanks to the efforts of Franco Rotelli and Giuseppe Dell’Acqua, Basaglia’s successors at Trieste.

What Basaglia aimed for at Trieste was not to “deny the institution” (as had been the title of the book about the experience at Gorizia), but to eliminate it once and for all. On this point, Foot (2014, p.266), picking up on the theme of utopia – a key issue for Basaglia – states that “the Gorizian utopia was to become a concrete reality in Trieste.” Basaglia was not interested in setting up care communities like the ones formed in the UK by Maxwell Jones, which he had visited and appraised. Now, his work was focused on the territory outside the psychiatric hospital, the city of Trieste and its province, to enable a real alternative to the mental asylum.

On September 24, 1977, the provincial commissioner and Basaglia held a press conference where they announced the closure of the psychiatric hospital by the end of the year. At the time, 130 patients still lived there, of whom just 51 against their will, plus 430 who came and went, as guests (Pivetta, 2014, p.379). They also announced that the institution would continue to be dismantled, based on: alternative, decentralized activities; small groups of patients going to live in apartments together; and the promotion and support of mental health work and clinics. One persistent problem was housing, considering the great number of discharges and the limited supply on the market, which was also indicative of the population’s mistrust towards former asylum residents, even if the rental contracts were guaranteed by the hospital’s doctors.

In May 1978, the Italian parliament finally passed a new law (law 180, called the Basaglia law) that regulated obligatory and voluntary medical appointments in order to put an end to psychiatric hospitals. Six months later, law 180 was incorporated into the law for the reform of the National Health Service (law 833). In 1980, nine years after Basaglia’s arrival, Trieste psychiatric hospital shut its doors forever. Basaglia recognized the importance of law 180 and demonstrated particular satisfaction at the fact that it no longer mentioned the danger posed by mental patients and that it decreed the definitive closure of all psychiatric hospitals, which had been the ultimate goal of his whole struggle. Nonetheless, he had some reservations. Although the law was a great step forward, it was only a first step, since it still adopted the standard medical response to specific disorders. In other words, Basaglia’s concern was that mental illness would be medicalized, and thus the complexity of its social and individual implications would be overlooked, covering up the contradictions and responsibilities of society itself. For Basaglia, not everything could be medicalized, as this would impoverish the complexity of demands and reduce all social problems (poverty, marginalization, loss of rights and citizenship) to a response to health.

For the author, medicalization was a great effort of rationalization that could easily stifle the contradictions arising from the collapse of the total institution and help to conceal the (silent, inconspicuous) social control exerted by medicine, thus leaving it less exposed to the criticisms of experts (Colucci, Di Vittorio, 2001).

Basaglia had reflected on medicalization11 during his 1969 stay at a New York community mental health center (an institution created by President Kennedy in 1962), where he saw that the new institution, the care community, was creating, through prevention, “a new category of patients (emotional patients) between the marginalized and the maladjusted” (Basaglia, 1982, p.100). Prevention, he stressed, only expanded the field of disease, rather than reducing it, and thus “incorporates into the category of mental illness, through new specialists (social workers and social organizations), phenomena related to social factors” (Basaglia, 1982, p.101). The new organizations, thanks to their multidisciplinary omnipresence, created a far sparser network of social and technical control, where the dividing line between norm and deviation was less clear-cut and “broadened the range of people who could fall into the web of psychiatric services” (Giannichedda, 2005, p.XXXVII).

On this issue, Basaglia showed great foresight, prophetically anticipating by around 25 years the debate and critical analysis of medicalization (Conrad, 2007), biomedicalization (Clark et al., 2003), and pharmaceuticalization (Williams, Martin, Gabe, 2011); namely, the gradual expansion of the science of medicine to areas from which it was previously excluded.

The final challenges

If the basic concept of psychiatry was that the madman is dangerous, just as one plus one equals two, we have demonstrated that the madman is dangerous, just as any other person who acts in society has the same chance of being dangerous. Practice has changed the result of one plus one. We have put the optimism of will in the place of the pessimism of reason (Basaglia, 2000, p.151).

In late 1979, worn down by so many years at the forefront of the defense of his ideas and his anti-asylum practice, Basaglia left Trieste and took up an invitation extended by the government of Lazio (the region that includes Rome) to take over the coordination of its mental health services. He was interested in the idea of working in a big city, host to one of the country’s largest psychiatric hospitals, with over five thousand patients, where there was no community mental health service network. This region also had over half of the country’s total number of hospital beds in private clinics, which meant its psychiatric care was strongly conditioned to attend to private and market interests. But he did not give up, and took up the challenge, studying the situation and presenting his proposal, after getting the green light from the Lazio regional government. The first project had to do with the deinstitutionalization of the big psychiatric hospital in Rome. The second was designed to reassess the role of the private psychiatric clinics and reduce their dominance in the region. The third, undoubtedly the most challenging and ambitious, was to identify and address the routes that led to marginalization, urban poverty, and deviation, looking not just at projects and interventions within the scope and logic of psychiatry, but ones that were open to society and the challenges of the multidimensionality of mental health.

These were difficult years. There were attacks against law 180, passed just a few months earlier. Conservative and right-wing parties launched broad speculative and slanderous campaigns against Basaglia and the supposed effects of the law, especially the reiterated claim that the patients who were discharged from the asylum and returned to their families were effectively abandoned.

In 1979, Basaglia visited Brazil twice in response to invitations to share his experiences and speak about what he had done in Italy to deinstitutionalize psychiatry. The 14 talks he gave in Brazil went down in history: on June 18, 20, 21, and 22 in São Paulo; on June 26, 27, 28, and 29 in Rio de Janeiro; and on July 7 and November 17, 19, and 21 in Belo Horizonte. His audiences consisted not just of health professionals (psychiatrists, nurses, social workers, psychologists, therapists etc.) but also of trade unionists, politicians, teachers, students, and members of the general public (Basaglia, 1979, 2000). Aside from his talks, Basaglia also visited asylums and gave interviews to the press, speaking out against violence in these institutions. For Nicácio, Amarante, and Barros (2000), the talks he gave influenced the plans for the Brazilian psychiatric reform, opening up new horizons and introducing a clear break in the way psychiatric institutions were thought about. His interviews to the press against violence towards psychiatric patients had a great impact and boosted the work of the anti-asylum lobby, as well as trade unions and civil society movements (Goulart, 2007). From this time one, a strong movement of professionals, students, and researchers from Brazil took shape in a bid to find out about the experiences in mental health in Trieste, Imola, and Parma (Nicácio, Amarante, Barros, 2000).

In Rome, in 1979, Basaglia was only able to plan his work and begin a few interventions, since the circumstances were far more challenging and complex than they had been in Gorizia, Parma, and Trieste. The following year, he started to feel ill. On May 15, 1980, after finishing a talk in the lecture hall of Freie Universität, Berlin, he was overcome by a severe headache – the first symptom of a brain tumor already at a very advanced stage. He died just a few months later, on August 30, 1980, in his home in Venice.

In their biography of Basaglia, Parmegiani and Zanetti (2007, p.133) write that “fate reserved a disconcerting conclusion of mocking irony.” When he had been arrested as an anti-fascist in 1943, his father had managed to get him out of prison six months later, preventing his deportation to the Nazi death camps, “thanks to the kind diagnosis of a medical friend who claimed the young Franco suffered from a brain tumor.”

The construction of a post-abyssal practice and theory for psychiatry

When we say no to the asylum, we are saying no to the misery of the world and join forces with all the people around the world who fight for emancipation (Basaglia, 2000, p.28).

All Basaglia’s work reflects his great concern not to adhere rigidly to the science and language of psychiatry, giving voice to every member of the crews of the ships (as a metaphor for asylums) that, for almost two centuries, had sailed the tranquil sea of psychiatry and were now sinking in a storm (Basaglia et al., 2008). Basaglia engaged in a hard-fought political struggle to give the patients held in psychiatric institutions back their voice and to recognize their knowledge – their “subjected knowledge” (Foucault, 1998, p.16), insofar as it was oppressed, dominated, humiliated, disqualified because it was not conceptual and not elaborate, naive, and peripheral.

The dramatic reality Basaglia encountered in Italy’s asylums reminds us of those people who live on the other side of the abyssal lines, essentially non-existent, to borrow the colonial metaphor proposed by Boaventura de Sousa Santos (2007). In fact, for Santos (2007, p.10), “modern western thinking continues to operate along abyssal lines that separate the human world from the subhuman world, so much so that principles of humanity are not questioned in inhumane practices.” In the area of psychiatry, abyssal thinking produced millions of people deprived of their own existence, ignored, gagged, marginalized, shut away, or simply abandoned inside asylums without this undermining the liberal, Christian, socialist foundations that sustained the rapid economic growth in the post-war years and the development of the welfare state. Basaglia spoke out very eloquently about the denial of human dignity reserved for people with mental suffering, just as Frantz Fanon had done. He did not limit himself to fighting against “global social injustice” in psychiatric hospitals, but launched a fierce criticism of psychiatry as a science, triggering, to use the words of Santos (2007, p.11), “a fight for global cognitive justice:” “After Pinel, if we examine the history of psychiatry, we see the emergence of great names of psychiatrists; but for mental patients there are only denominations and labels: hysteria, schizophrenia, mania, asthenia etc. The history of psychiatry is the history of psychiatrists, not the history of patients” (Basaglia, 2000, p.4).

Basaglia directed his criticism against the same social psychiatry that, with its technical perfectionism, had managed to “make the social inferiority of the excluded acceptable, and had managed, in a more subtle and refined way, to also define a biological diversity that ratified the moral and social inferiority of different people” (Basaglia, 1968, p.116). Both systems, Basaglia stressed, tend to reduce the conflict between excluded and excluders, scientifically confirming the inferiority of the excluded.

For Basaglia, only after turning one’s back on one’s role as a psychiatrist and giving up one’s position of authority and privileges is it possible for knowledge to emerge – the critical voice and dissidence of the confined. The only way to find the patient, he held, is to approach him unarmed, free of artifice, with no defenses, producing a vacuum of all knowledge, old and new, traditional or revamped. Rejecting the social mandate of the psychiatrist, Basaglia (1968, p.117) argues, means “rejecting the act of therapy when it only tends to mitigate the relationship between the excluded and the excluders.”

In the case of Italy, it was an experiment in deinstitutionalization that brought back the knowledge of the confined patients and the strength to fight against the general discourse of medical and psychiatric science.

ACKNOWLEDGEMENTS

My thanks to Charles Dalcanale Tesser, from the Federal University of Santa Catarina, for his reading of the text and helpful suggestions, and also to Fundação Portuguesa para a Ciência e Tecnologia (FCT) for the financial support – CEECIND/00885/2017/CP1402/CT0002.

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NOTES

1 This sentence appears in the manifesto La Révolution Surréaliste, signed on 1925 by French artists and addressed to the directors of lunatic asylums (Basaglia, 1981a, p.249).

2 This and other citations of texts in other languages appear as free translations.

3 Franco Basaglia was trained in anthropological phenomenological psychiatry, developed by Binswanger and Minkowski and inspired by the thinking of the philosophers Edmund Husserl and Martin Heidegger. This philosophy rejected positivist thinking, then in vogue, and considered human existence and, thus, psychic malaise as a relational structure.

4 In 1958, Basaglia was awarded a professorship in psychiatry.

5Daseinsanalyse, also known as existential-phenomenological analysis, was developed in the wake of the two world wars. Ludwig Binswanger, the father of Dasein, called his research orientation phenomenological anthropology. From this perspective, the dualistic world view of the natural sciences adopted by psychiatry and psychotherapy is the target of strong criticism, and a new understanding of human existence and its disturbances is sought.

6 During his Gorizia years (1961-1968), Basaglia tried to reach outside the field of psychiatry and its classifications of psychiatric disturbances, adopting a more general perspective on human problems. It was an attempt, as Ongaro Basaglia (1981) points out, to include medicine in a thinking that considered man in his totality, including the patient’s and the therapist’s subjectivity.

7 In Crimini di Pace (Basaglia, Ongaro Basaglia, 1975), Basaglia states that he is not interested in building an abstract utopia, which would just be a reflection of the prevailing ideology. He is interested in studying and experimenting in possible forms of utopias that could be achieved in the workplace.

8 Bracketing the disease did not mean denying that the disease causes pain and suffering. It was a criticism of psychiatric knowledge, which concentrated exclusively on the disease, ignoring completely the person and his social context. Essentially, bracketing the disease meant identifying the institution’s own responsibility in the destruction of the patient.

9 In L’istituzione negata, Basaglia (1968) argues against the putative neutrality of science and presents a cutting social criticism of technical and scientific knowledge about the role of specialists and the relationship between knowledge and power. What he strongly contests is the professional role of the psychiatrist who agrees to be the “overseer of this system and therefore absolves the delegation implicit in his role, ... thus contributing, both theoretically and practically, to the maintenance of the socioeconomic system of which it is the expression” (Ongaro Basaglia, 1981, p.XXXIX).

10 The gradual demise of psychiatric hospitals was only possible as daytime and nighttime mental health clinics were established in the territory and the deinstitutionalization process was accelerated, thanks to the promotion of alternative decentralized social activities, the creation of supported housing, and efforts to support employment.

11 For Conrad (2007), medicalization is the extension and invasion of medical categories into areas that are not strictly medical. It presupposes a tendency to pathologize phenomena that were not previously considered to be diseases.

Received: February 26, 2018; Accepted: August 6, 2018

Translated by Rebecca Atkinson.

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