Basaglia’s young psychiatrist tells all

Today is the main event – going to Ground Zero of Italy’s mental health revolution, Trieste. For the last few days, we have jumped into Edoardo’s car and not known what to expect. We have been suitably impressed, getting out at places which felt exciting, playful and ‘like home’ – not at all heavy, alien or out-of-our-depth in a strange culture. But that is so often what it feels like visiting a TC you haven’t been to before.

The road to Trieste

...into the city

Today was different though, as we weren’t going into a community – but meeting two senior figures involved in Italian progressive mental health. And the conversation, in a rather elegant and gracious sea-front hotel over afternoon coffee, did not disappoint our high expectations in any way!

We had met one of our hosts already – last Saturday, at the Annual Forum of the Visiting Project (as posted here) – Michaela Vogrig, who is president of the League of Cooperatives for Mental Health Provision, across this whole region of Italy. She is keen on supporting all this work, to develop less repressive mental health services.

The other was a mega rock-star of global mental health: one of Basaglia’s young psychiatrists who he recruited to bring the best of what he had learned in various cities through the 1960s to Trieste: Giovanna del Guidice. Sadly, we couldn’t communicate directly, as my Italian is worse than her English (which is fairly good) – but Edoardo did a great job of interpreting, and it was immediately clear that we were on the same wavelength, even if the words took a while to catch up.

She first asked how much I knew – and when I explained that I was pretty much limited to the recent book written by the Bristol historian, John Foot (‘The Man Who Closed the Asylums’, Verso, London, 2015), she immediately said ‘ah yes, but he didn’t have a lot to say about his Trieste work from 1979. The book goes into great detail and fascinating illumination of his first years in Gorizia (1961), then Perugia and Parma (1965), Regio Amelia (1969), Arezzo (1970), return to Gorizia (1969) – but does not have much to say about his final project in Trieste from 1971 to 1979. Law 180, usually named after him, to all Italy’s mental asylums, was passed in 1979 and came into force in 1980. Sadly, Basaglia himself died that year, at the age of 56, from a malignant brain tumour – unable to see his life’s work put into practice across Italy, and later beyond.

Giovanna’s account began in 1970, when Basaglia was called by the president of the Democratic Christian Party to help in Trieste. Basaglia was on fire – or at least had fire in his belly - he demanded that the institution of the hospital must be destroyed, and not merely changed on the inside. Changing just the inside is what he did ten years earlier in Gorizia, including developing the hospital therapeutic community, but he had decided that it was no longer enough. The ‘total institution’ must go.

To accomplish this, he had given up on accomplishing any meaningful change with the old psychiatrists who were in post – so he recruited a tranche of young ones who were not attached to the old and traditional ways of working.

Giovanna one of them, and she told us how it all happened. At the age of 24 in July 1970, she was a newly qualified doctor, who was not sure what specialty to pursue; she had read Basaglia’s two books, and did want to work in a field that was ‘not constricting’, and particularly wanted to join one that respected human rights – and women’s rights. So, in October 1970 she decided to try and talk to Basaglia about her career choice, and went to Trieste to find him – but he was a busy man, spending his time in many places. He was in Parma at the time. The staff she approached were quite amused that she thought it might be possible to just walk in and talk to him.

Being a determined person, Giovanna took herself to Parma to hunt him down, and there was some confusion when she arrived – again, mutterings like: ‘who is she?’, ‘what is she doing here?’ - and it looked unlikely that it would happen. But – contrary to what everyone expected – he seemed to rather like her unconventional way of tracking him down, and offered her a place on the new team being developed in Trieste. She was one of a group of young psychiatrists who were all very different, and after two years she was in a position to apply, through a process of public competition, for a substantive post. At their first meeting Basaglia had been clear that, to be successful, he would need to be sure that she was a suitable person, and she would need to be sure that it was a job she wanted to do. But all was satisfactory, and she obtained the public post in 1972. Many of her contemporaries were not successful – and either decided that the work was too difficult, or were rejected.

The demands were substantially more than in a traditional job: Basaglia himself was rigorous and demanding, and the hours were much longer than usual. The day would start at 07:30 by attending an ‘interview’ with Basaglia, in which he would ask searching questions to ensure that the young psychiatrists understood traditional psychiatry. His line was that ‘you can’t discuss it or oppose it unless you know exactly what it is’, and the sessions were often difficult and argumentative.

After that, the job was to stay on the wards until 17:00, which was not done or expected elsewhere. It was important to be involved with all the day-to-day care, and to be seen to be there, as part of the team, all day and every day. After this, the obligatory 17:00 meeting was a very important open group. It was daily at the beginning of the transformation and moved to Mondays only once much of the activity had moved out of the hospital from about 1975. It was usually attended by more than thirty people and open for all. Widespread recognition of the work attracted international visitors as well as from across Italy. Although patients were fully entitled to attend, that was slow to get going in the first few years. Giovanna describes it as a vital part of her training, although it was often difficult to get a word in edgeways!

The policy of having unlocked doors led to ‘contradictions’ – such as how hospital admissions arrived being bound up and entirely ‘unfree’, being immediately put into a completely different milie; and how patients who were formally detained (by a judicial process) would sometimes wander off and go missing.

Basaglia did not just move the hospital ‘into the territory’ (ie community), but also wanted people from the territory and city to come into the hospital. This included festivals, parties, artists and numerous visitors from far and wide. All the ideas of deinstitutionalisation were based on putting right the wrong that had been done to the patients – including their inability to have property, jobs, voting rights and much besides: they were ‘denied citizens’, as if in jail. Their civil, social and human rights had to be restored.  

The ’work makes you free’ slogan was painted on the wall of the hospital and much photographed. But it was not true for those in the institutions at that time: unpaid labour was part of the dehumanising regime of the ‘total institution’. Because Basaglia recognised patients’ strengths and abilities – he insisted that they must be paid the proper rate for the work they did.

In the early 1970s hospital staff started resigning, and some went to the new ‘group apartments’ – but it was hard to find suitable accommodation for them in an expensive and crowded city. Seven state-run mental health services opened in Trieste, each allowed to include up to eight short-stay beds.

Despite the necessarily slow process of finding homes for the 1200 patients who were still in the hospital in 1971, Basaglia – ever one for a big splash and grand gesture – announced to the president of the province, and to the national and international media, that ‘the hospital is closed’ when there were still 500 people in it, on 1 April 1980. Whatever the exact truth of the matter, it certainly gave a strong message and vision for mental health services the world over.

Giovanna is less optimistic now than they all were in those heady days, and is keen that the drive for anti-institutionalisation is kept alive – as she feels the ‘story of the revolution is in danger’. Considerable efforts are being made, through the ‘International Conference for Mental Health in the World of Franco Basaglia’, of which Giovanna is President. It is active in South America (Argentina and Uruguay) and former Yugoslavian States (Bosnia and Serbia). We thought together that the UK should also be fertile ground – particularly as next year is the Basaglia Centenary, with a special Trieste event on his birthday (11 March), and other events throughout Italy and elsewhere during the year. Some ideas for a UK event started to germinate.

One fear Giovanna has is that all the celebration and razzamatazz could canonise Basaglia in a way that allows the message to become ‘he did great things, but that was then – but the world is different now’, and hence consigned to being a historical curiosity. Therefore, she says, any events that happen need to not focus on the past – but look at what his work and approach means to us now, and what we need to change now. It is not as if the job is finished!

I think this is much wider than just mental health, and I strongly believe that the forces of oppression and dehumanisation are flourishing in many different areas of our lives – but in a context and form unknown and unimagined in 1960. This is indeed what the ‘Relational Practice Movement’ is all about…

Neels, Giovanna, Michaela, Rex and Edoardo

Before parting company, with mutual expressions of much appreciation and thanks, I think we agreed (the translation was a bit patchy here) to see if some young British psychiatrists want to go on a trip there early next year (to help pick up the radical vibrations – or waves – perhaps). All present agreed to this would be a Good Thing, and also to tie a UK Basaglia Centenary event to the Relational Practice Movement’s first anniversary (maybe two days instead of the one planned) in early July. Watch this space!

As with the previous three days, profuse thanks to our Italian friends who made all this possible – Edoardo Mancuso and his organisation, Cooperativa Itaca; Simone Bruschetta and Amelia Frasca from the Programma di visite per le Comunità Terapeutiche Democratiche.

Udine was there 60 years before Basaglia

The artwork gets everywhere...

Not far to go today - just across to the other side of Udine to Parco di Sant’Osvaldo, the old asylum which is now a park for the use of the surrounding community.

It was built in 1904 as a state-of-the-art and progressive hospital for care of the mentally ill, to minimise any sense of oppression - a whole self-sufficient village on the outskirts of the town with its own farm, orchards, vineyards, bakery, kitchens, laundry, a maternity facility with ‘children’s colony’, theatre and cinema, electricity generator and - of course – church and nunnery. A garden city, Berenice Pegoraro, our guide, told us, with health-promoting activities in the fresh air. It was part of the Catholic Church’s influence and domination of all civic life at the time, and the ward staff were all nuns. Its buildings are small and spread out in green and leafy gardens, with the old male wards on the eastern side and female on the west. In the middle were all the facilities; a central building with bar, restaurant and social club remains open – we parked next to it and had our morning coffee there.

Once a staff bar and restaurant, now for everybody in the city

Unfortunately, the early history of being a progressive and bold experiment in more humane mental health provision only lasted about twenty years: the numbers being sent there increased substantially, and it became very overcrowded by the 1920s. Also, this was the beginning of Italy’s fascist years – and the level of general repression and lack of freedom increased the restrictive, heartless, and punitive practices in the hospital. This brought it into line with ‘normal’ psychiatric provision of the time – and its bold experiment, sixty years before Basaglia, was over.

We went into the shell of ward 9, on the female side, and saw the starkly bare corridors, dormitories, and layout. We were shown the ECT room and the seclusion cell, where misbehaving women were locked up for a week; its door had a viewing hole and slot at the bottom for meal trays. All rather grim – and the architecture not far away from my medical student time at Littlemore Hospital in Oxford in 1980, although the programme there was a therapeutic community. Short biographies of many of the women patients are hung up to make it into a type of museum – and pupils from local schools often visit for class projects.

Ward 9

The peak population was in the 1950s – with about 2000 patients and 1000 staff in the ‘total institution’, almost completely isolated from life outside. Many stayed all their lives there, and the commonest form of discharge was by dying: a chapel of rest amongst the central buildings is testament to this. The asylum itself finally died in 1999, twenty years after Law 180 was passed. ‘Territorial Services’ had been set up by this time – and all the patients in the hospital (who were still alive) had been discharged to them! The ‘territorial services’ are the part of care that is mostly provided by the cooperativa – in Udine’s case, Cooperative Itaca. I suppose the closest UK equivalent, though much less coordinated, is probably the third sector MH social care provision, plus maybe the new arrangements for social prescribing.

The whole site now has a slightly sad air, which might be at least partly due to it being a grey drizzly December day, but it clearly now has its new post-asylum life as a public park. Some of the buildings are used by the local services, some have been renovated and rented out, and many are very dilapidated. The offices of the central mental health administration for Udine are there - the city now has five geographically divided mental health services with two in the city and three for the smaller towns and cities in the province. For three months every summer, the whole park hosts a festival of arts and public events for the public to come to – theatre, book fair, music, art and craft exhibitions, discussions, celebration of cuisine, activities for children and much besides. 

The programme for the 2023 park festival

Although many good things continue I had the feeling that the festival itself has seen better days – as in so many places, the public domain is being slowly starved of institutional support and made to rely on individuals’ energy and enthusiasm, and cooperation with external organisations. For example, one of last year’s proposed events – a competition for young rock bands – was not given permission to take place in the park, or to be on the programme, because of deliberate bureaucratic obstruction.

We walked to a far corner of the site to a modern building, which was the reincarnation of Ward 9. Before moving to its current home, in 1995, while a few residents remained in the hospital, it was re-designated as ‘Comunità Nove’.  Although it was still in the old ward, it took on new principles of being OPEN, FREE and COOKING, and was staffed by ‘open-minded nurses and operatori’. There was no formal programme at the beginning, but simple ‘open house’ where those wanting to come would be treated with warmth and friendliness, and given a meal in good company. Over the following years more social functions grew, and in 2001 it moved to its new home.

When we walked in, it was clear we had walked into a different universe to the old Ward 9: it was a large room with about twenty multicoloured tables (painted by the residents) in the centre. As well as the atmosphere of bustle and purposeful activity, there was a drum kit, piano and guitar amp at one end, numerous potted plants everywhere and an extraordinary and range of artwork and sculpture – mostly abstract and multicoloured – covering every available wall, space and alcove. A three-metre monochrome Christmas tree was being constructed out of paper shreddings. They call it ‘cheap art’ – mostly made out of recycled rubbish. Katia, the artist behind most of it, has been with the community for many years – and has recently retired, but returned as a part-time volunteer. The aim was to have an ‘art revolution’ as transition from the old Ward 9, and indeed one corridor was like a museum of modern art, including having had its doors symbolically removed and painted with wild and provocative pictures, abstracts, cartoons and patterns. ‘Art is health’ we were told!  Although so much artwork is produced, it cannot be sold – but some is commissioned by external organisations. In one of the activity room proudly sits Basaglia’s original table from Gorizia, around which he and the equipe must have held many of their meetings, discussions and debates. There is also a poster of the community’s ‘identity card’:

 ID Card

NAME	Nine
TYPE OF SERVICE	District mental health day centre managed by Cooperative Sociale Itaca.
WHO ATTENDS	People with experience of hardship who risk social isolation and marginalisation who require personalised rehabilitation programmes; mental health workers; volunteers; friends.
HOW MANY	Approximately 80 people altogether, about 25 per day 7 staff (educatori & operatori) mostly part-time
ORDINARY ACTIVITIES	Cooking, cleaning, growing food, art laboratory, choir, rock band, discussion group, reading group, organisation meeting, sport (with Éventa Nuova Associazione).
EXTRAORDINARY ACTIVITIES	Sport; Artistic, Cultural, Theatrical and Musical events; book presentations and launches; debates; conferences
FOUNDING PRINCIPLES	Hospitality, collaboration, taking care of oneself and others, sharing, discussion, respect, equality in rights and duties, remembering, cultivating hope.
OBJECTIVES	Helping people on a path to feel better Finding their own balance and peace Promoting social inclusion Supporting relationships with others Acquiring and maintaining everyday skills Sharing problems and resources Demonstrating in various ways that change and transformation are possible!

Written by the ‘Current Affairs and Reality’ group of the Comunitá Nove

...and the original in Italian

Art is only one of many activities that the community has on offer. There is also a vegetable garden which produces food for their lunches as well horticultural training for members. Music is also important: there is a choir and a rock band, and numerous other group activities scheduled throughout the week. There are also two important talking meetings every week: community meetings for up to two hours on Monday mornings, and ‘current affairs actualite’ (for planning and decisions) for 2 hours or so every Friday morning. There are many contacts with the local community, including musical and artistic special events on the site, and often at weekend. The community prides itself on working with people’s strengths rather than their disabilities; they do not concentrate on diagnosis, and members are all seen as assets and not illnesses.

When it started, staff were recruited from enthusiastic but untrained individuals who were interested, particularly artists, but now regulations require them to all have professional qualifications as educatori or operatori. There are no clinically qualified staff; all the members of the community need to be engaged with the statutory mental health services. The members stay as long as they need, and usually move on to other services or independent living after several months or many years; some are scheduled to come every day, and others come only to special events – and all points between.

Thanks again for such a unique and special day: to Berenice Pegoraro for the tour and history, to Sandro Carpini who manages the community and to Katia the extraordinary creative force behind the wonderful art. I do hope to visit again – and to show younger contemporaries how things could, and can, be done.

A small but perfectly formed residential TC for adults with longstanding mental health needs

We could see a whole panorama of snow-topped Alps as Edoardo drove us north from Udine. The temperature in the car was 1C when we started, and we thought it might drop below zero with the altitude – but as the day warmed up, it didn’t. In fact our destination, San Daniele del Friuli, was not quite in the mountains. It is a town of 8,000 souls in the province of Friuli Venezia Giulia about 20km north west of Udine, 50km south of the Austrian border and 33km west of Slovenia. Edoardo, our guide, teacher and raconteur of all things Italian gave us a prodigious introduction to the geography, history, culture, literature, architecture and languages of the region as we drove there.  

We arrived at the pretty little town of San Daniele and, after a quick look in its ‘Sistine Chapel of the North’, then went through a door off a gracious arcade and up a colourful mural-covered flight of stairs to be greeted with warmth and hospitality by Valeria, who leads the ‘Group Apartment’ there. I often maintain that you can ‘smell’ a TC as soon as you walk in – but not through your nose, but by the whole sensory and social experience that hits you in the first few seconds. And this place, simply called ‘Group Apartment Via Garibaldi’, had it in abundance. We sat and talked about it for an hour or so, before being given lunch by, with and from the residents. Salmon with a pepper/tomato/caper sauce, salad and bread; followed by home-made tiramisu. Just lovely. Edouardo admits that, although he has worked in many different services, this is his favourite – and he thinks it is probably the best in Friuli.

When I asked what was ‘the magic ingredient’ I got two different answers, one for my left brain and one for the right. Edoardo provided the one in the rational universe – about good communication with the local statutory MH services, and a tightly defined contract with the service provider, ‘Cooperativa Itaca’ – a large third sector organisation with many projects across the area. But I preferred Valeria’s instant response, possibly slightly flustered by the question, of ‘passion’. Exactly! Almost indefinable, but life-affirming and enough to give you a reason to jump out of bed every morning and fight for what you believe in.

Here's a few facts about the service – which, although called a ‘group apartment’ should certainly be thought of as a TC as far as I could judge:

·         A ‘small outpost’ of Udine’s services
·         Two apartments on adjacent floors in city centre, has balconies but no garden.
·         Previously council-owned but transferred to MH service
·         Funded by the local MH service
·         8 beds maximum (equivalent of 1 bed per 1000 population)
·         12 staff – educatori and operatori.
·         Useful concept for staff is as ‘pedagogists’ – more social and less didactic type of training
·         None are clinically qualified (doctor, nurse, psychologist, psychotherapist)
·         Residents chosen and referred by local MH service, and receive continuing care from them
·         Difficult culture change process (to being open and relational)

·         Long-term sustainability threatened by
o   Gradually diminishing resources, year-by-year
o   Staff stress and burnout
o   MH economy being increasingly opened to for-profit enterprises

So, many thanks to Valeria, Umberto and all the residents for their hospitality – and congratulations to them and the other staff for maintaining something so special in adverse circumstances.

No trip to Italy is ever complete without the food and wine, and Edoardo was, once more, an extraordinarily knowledgeable guide. We went to atmospheric and sometimes tiny restaurants, trattorie, and pizzerie that tourists would never know about – and I doubt many locals would.

We sampled wines which were only available in the towns and villages in which they were made. Never ostentatious or expensive – just homely, local and wonderful. And thanks again, Edoardo – for a thoroughly excellent and thoroughly Italian experience of a day!

The Italian Job - VP, ISO, and world domination

ITA's new flashy planes- A330neo - certainly make the two hour hope to Rome a bit easier. With films and good music - as well as all the info like distance, time, speed, altitude, heading, latitude & longitude - it can keep a slightly geeky person occupied until it's nearly time to land. No salty snacks though - only sweet...

Simone and Amelia just escaped from Sicily before Etna's flare-up grounded a few flights from Catania - and showed us the pictures his daughter had sent of the fire-spewing volcanao, from her bedroom just after they left. They arrived at Fumicino about half an hour before us, so - once we had found each other at different terminals at a huge airport, with the help of whatsapp pics -  we all travelled to the hotel together. We could have been in an Agatha Christie novel - and the lift was a complete work of art, that could have come straight down to us fron the 1930s to take us to Piano 4. Shame it didn't have a lift man in a unform to press the buttons for us, and rumour of a ghost with a murder to investigate.

Arriving at about 2200, followed by about half an hour's confusion about who had already had rooms paid for (Simone, Amelia and myself) and who had paid for themself (Neels) made it a bit late to go searching for somewhere to eat. Perhaps it was actually more Fawlty Towers than Murder on the Orient Express. The confused man (Manuel?) at the hotel reception recommended somewhere near Termini train station which at first appeared to be a building site, until we realised it was a sandwich bar without any sandwiches left. So we wandered back towards the hotel and were seduced into a restaurant with pavement tent and lots of Christmas lights by their tourist hustler. But it was just fine, and we didn't go to bed with empty tummies - and the hotel was almost next door. 

In the midst of all this I had an other-worldy experience in a small grocery shop with a very large neon sign above the door advertising the fact thet they sold condoms - although they also had everything else a corner shop should have too, and I didn't even see the condoms. After accidentally offering the shopkeeper Canadian dollars for a couple of bottles of fizzy water. It was clear he thought I was out of touch with reality and quite probably mad. I then offered him a UK debit card which would not work which ever of the various methods he used on his terminal. He was now convinced that I was also a criminal, as well as mad. I slunk off, muttering under my breath. Neels tells me that this is a perfect educational experience for me - as it is very like what it can feel to be 'a person with lived experience'...

Given the usual experience of Italian starting times, we had breakfast and bowled up about 15 minutes late - and were completely surprised to find that the first talk had begun! What has happend in Italy? Have they had a revolution since Covid?

We sat at the back (audience about 60) but were soon called to the front, to have Amelia's introductory talk translated for us by the brillant blue-haired Andre. (Brilliant hair AND brilliant chap!)  Even more reassuring, Amelia was saying things that we completely agreed with - for example about how the whole world is irredeemably screwed-up and there's no point in hiding... I said it all again with a different spin - and had some very interesting discussion afterwards about how Basaglia politicised mental health and TCs, and in the UK, Laing was never seriously politicised - and the British TC approach had become ever more bureaucratic and and politically moribund since. But at least we're going to do some different and politicise the Relational Practice Movement!

The tech was as problematic as ever in a conference - with a projector that turned off when ever Simone tried to say anything, then later howled at 150 decibels whenever he touched a microphone. It seemed to have something against him. I was luckier - a very sharp and efficient venue technician sorted out my HDMI compatibility in no time flat, so I could play the RPM video without a hitch. Sadly she was nowhere to be found when the system later declared war on Simone. Another bit of interesting tech was Google live translate - so the words appear on your phone screen in English a couple of seconds after they had been spoken in Italian. Although it now seems much more confident that when I was last using it here before covid, and you could get the general gist of things, it never made perfect sense - it did a few good howlers, so Simone was promoted to 'Prime Minister', Neels was 'Bedlam' ('later Dr Bedlam'), and nobody was said to be having sex. True, I suppose, at the time - but how did it know?

The afternoon was the regular jamboree of shaking hands, giving certificates, clapping, smiling and generally celebrating all the hard work and demanding training that everybody in the Visiting Project had accomplished in the past year. Well done, all - it was a truly joyous occasion.

Afterwards, we had arranged to meet Giuseppe Salamina - a senior government public health doctor who we met at the last CMH gathering at Coed Hills. He is very interested in promoting progressive and relational approaches through his work with high-level EU health networks (boo, hisss - won't include us then!). We talked and fantasised about everything we could do together if it wasn't for Brexit, in a pavement cafe over a drink, and he then took us to meet his long-time friend and colleague Umberta Telfener - who lives in a beautiful flat overlooking the Colisseum, glowing with orange lights and projections of Roman Emperors. She is President of a European Family Therapy Association, and was very much in tune with our ideas about things needing a strong push in the direction of relational practice. However, after a little more of her red wine and chili cheese, she got slightly colder feet when we revealed the utter and unrealistic grandiosity of our plans h- to push RP into every corner of public life, in the UK and beyond. After a very congenial hour or so, we wandered back - with Giuseppe saying 'No, go for it!'. We arrive almost in time (Italian Time) for the jolly and convivial conference dinner, with about thirty of us taking over a small restaurant for the evening. And so to bed.

Sunday was an important occasion for the Visiting Project - to propose and vote on whether the project should start the process of accreditation through ISO. Without this, the member services are not recognised by the Italian health service - but it does mean increased costs, bureaucracy and general move in a direction favouring private sector enterprises. But after what seemed to be exhaustive discussion (not to say argy-bargy) which was almost compleletey incomprehensible to us and Google translate, the vote was carried unanimously. The next phase of the post-Basaglia politicisation of therapeutic communities starts here.

After a quick taxi to the Pope's place and Piazza Navona, it was to meet Edoardo at Termini station for the 1655 train to Udine - arriving at 2305. Very fast and smooth - but a long way to somewhere nearly ten degrees colder, just shy of the Alps and Slovenia. Now we're in a clean and friendly AirB&B for the next four nights - in a district with mostly offices, cafes, and posh champagne shops. 

Tomorrow is another day, and another story.