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.
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| The road to Trieste |
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| ...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…
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| 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.
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