The Man Who Closed the Asylums: Franco Basaglia and the Revolution in Mental Health Care

This is a hugely ambitious book about the movement in Italy, inspired by the legendary psychiatric reformer, Franco Basaglia, involving a whole host of actors and groups from diverse walks of life, that got under way in the 1960s to transform the institutional landscape of Italian mental health care, dominated by repressive and decaying lunatic asylums, or manicomi, and, still more daringly, to transform the society that had brought such deficient institutions into being in the first place.

Basaglia and his associates belonged to a post-war, anti-fascist generation who cared deeply about human rights and were shocked by the violence and squalor that confronted them in these institutions, the utter disregard, not to say the wilful repudiation, of the humanity of its inmates. The 'essence of psychiatry', remarked Giorgio Antonucci who worked with Basaglia at Gorizia, 'lies in an ideology of discrimination' (p. 105). Basaglia interpreted mental illness as a socio-political problem and drew upon Husserl's concept of 'bracketing', the suspension of judgement in the first encounter with reality, in his approach to mental patients, maintaining that it was essential to establish a relationship with the individual patient independently of the label by which that individual had been defined. Along with phenomenology, Basaglia also turned to Gramsci and other Italian Marxists to understand the complex nexus of contradictions (institutional, ideological, ethical, medical, political, social) in which madness was embedded.  The movement of Psichiatria Democratica he inspired took the political engagement of mental health reform to a new limit, linking with, and becoming a rallying point for, wider social protests, so lending the movement an overtly revolutionary, and in the minds of its critics an extremist or 'ideological', character, eventually succeeding in 1978 in bringing about legislation, the notorious Law 180, that led (though the process took some 20 years to complete) to the closing down of all psychiatric hospitals in Italy. 

As a distinguished historian of modern Italy, the author of works on diverse subjects such as Italy's Divided Memory, a study, with considerable relevance to the present work, of the divisive ways in which events have been interpreted, the facts themselves often contested, and also of Pedalare! Pedalare! A History of Italian Cycling, John Foot is admirably qualified to embark on this project. In addition, he is not burdened by any kind of formal background in mental health or history of psychiatry, and so is innocent of the prejudices and preconceptions that those of us on the inside track frequently carry with us, and in a position to make common cause in this respect with the voluntari, the lay persons, who made such a notable contribution to the Italian movement through their enthusiasm and openness of outlook. Foot embarked on his research with a focus that was initially Basagliacentric but soon discovered that the movement as a whole, in its rich and jostling diversity, and not least the processes implicated in the creation of the Law 180, were more complex and multi-valanced than this. Though the movement began around the asylum in Gorizia, 'its scope and reach went far beyond the story of Franco Basaglia and Franca Ongaro' (Basaglia's wife and long-time collaborator). 'By reducing the history of psychiatric reform to the life story of Franco Basaglia, we are doing the history of the movement a great disservice' (p. 393). Within Italy, followers of Basaglia have tended to exaggerate the significance of Basaglia's own contributions and downplayed the achievements of others, such as Mario Tommasini, Giovanni Jervis and Ferruccio Giacanelli (p. 275).

Moreover, as Foot points out, a Basagliacentric account is unfair to Basaglia himself in as much that Basaglia is then made to carry the can for every kind of setback and failing. In actuality, 'the anti-asylum movement in Italy was polycentric, involving a number of actors...cities and institutions. Nobody had the right answer. Everyone made mistakes' (p. 284).  In the creation of Law 180, Basaglia was 'involved in the whole process but he was not the only voice that was heard'. As David Forgacs, another distinguished historian of modern Italy, whose study of Italy's margins deserves to be read alongside John Foot's work, remarks, it is only by a 'play of false memory' that the law continues to be referred to in Italy to this day as the 'legge Basaglia'.(1) In the last years of his life (he died prematurely of a brain tumour in 1980) Basaglia felt himself to be the prisoner of a myth, variously extolled or derided by the press as the man who either freed or abandoned the mad, burdened by hopes and expectations on which he could not possibly deliver. Foot's purpose is in considerable part to tackle and deconstruct this legacy of myth and misrepresentation and to begin to tell the story of a movement that was inspired, but only partly led, by Basaglia himself. In decentring Basaglia's role, and debunking the Basaglia myth, Foot perhaps mimics the gesture of a small museum (now sadly closed) in the grounds of the asylum at Trieste which included a bust of Franco Basaglia that was intentionally covered with a sheet (p. 362).

The subject of this book reaches beyond Basglia and the mental health reform movement into an understanding of the period in which it unfolded, the ‘spirit of 1968', combined with reflections on the problems of telling that history, and along the way unpicking the various misrepresentations, misinterpretations and myths that have accrued over the years. In the long legacy of misrepresentation that Foot uncovers it is, especially, the English-speaking world, and notably the British, who have been the most ardent and consistent contributors (Foot devotes a chapter to 'Basaglia and the British'), starting from a notorious article by Kathleen Jones and Alison Poletti in the British Journal of Psychiatry in 1985 and succeeded by a string of other commentaries and polemics. The British therapeutic community movement, together with the communities established by R. D. Laing and his associates, such as Kingsley Hall, initially had an influence on the Italian movement, but the Italians soon moved beyond them because they were not adequately connected to a practice of collective liberation. Though the reaction in the UK to the creation of Law 180 and its aftermath was not universally negative, even so mostly only 'the negative aspects and arguments have survived the debate, while the other points and discussions have been forgotten or marginalized' (p. 63). Taking their cue from this polemical background, Basaglia and the Italian movement became fair game for mockery and derision in the accounts of some historians of psychiatry, such as Roy Porter who in 1994 referred to Basaglia as 'Enrico Basaglia', labelling him 'a boisterous anti-psychiatrist'.

In the late 1960s and early 1970s anti-psychiatry was fused with the driving ideology of a vast international movement. In many respects it epitomised the anti-authoritarian spirit of 1968, a symbol of a culture of revolt. By the end of the 1970s, however, it had become a term of abuse, associated especially with the denial, or negation, of mental illness. Yet, as Foot demonstrates in tracing the history and genealogy of anti-psychiatry, this is a gross over-simplification. In actuality, the term was associated with a variety of positions among which there were many practitioners who took 'mental illness very seriously indeed and attempted to search for its origins and possible new solutions to it' (p. 39) For Basaglia himself the 'bracketing' of mental illness meant the suspension of the diagnosis and paying attention instead to the suffering hidden behind it. Historians of psychiatry have given equally short shrift to the Italian reforms: Roy Porter dismisses them as resulting in 'chaos' and Andrew Scull assimilates Basaglia into a narrative of the closure of asylums that is, by and large, a story of madness cast out and abandoned. 'By the century's end', Scull writes, 'abandonment of the asylum was visible all across Europe and North America. In Italy, led by the charismatic Franco Bassaglia [sic], the political left led the charge' (p. 59). Yet, as Foot is at pains to show, Basaglia never conceived of the closure of manicomi as a solution, but only as a stage, though obviously a crucial one, in a series of moves towards a different conception, and treatment, of the person with mental illness of and society's responsibilities towards him or her. 'The destruction of the madhouse', Basaglia wrote, 'does not imply that patients will be abandoned, but it creates the conditions under which they can be looked after in a better way in terms of their real problems' (p. 386). The hospital at Trieste, one of the flagships of the movement, was not just closed down, 'its whole raison d'etre was undermined, built as it was on separation, exclusion and silence' (p. 366). Historically, it is a mistake to conflate the closure of asylums with the abandonment of patients since lunatic asylum themselves had come to exemplify a culture of abandonment.(2) In Italy the closure of asylums marked not an end but a beginning in the revolution of mental health care (p. 351), the creation of a new terrain on which the asylum could be overcome (p. 384), where madness would not disappear but could be faced up to (p. 254), and where former patients could find their humanity restored, get their lives back and become people again (p. 245). Felix Guattari described Basaglia's work as 'a war of liberation' (p. 353), where Basaglia was engaged in liberating former mental patients into social life, believing strongly in the therapeutic and liberatory aspects of work, and making plentiful of co-operatives as vehicles for the reintegration of former patients back into society. All along, Basaglia and Ongara stressed the necessity of opening up and maintaining a dialogue between the internal and external worlds, such that 'the external world recognises the psychiatric hospital as its own, and ... a connection is made between an institution which is trying to rehabilitate people and a society which desires rehabilitation' (p. 357). 

The anti-institutional movement with which Basaglia was associated was never just about psychiatry for all along it connected mental health with society, the family, the state and its institutions, and with the psychiatric profession itself (p. 46). This was not about creating a new kind of mental health system, but a new kind of society, a new way of being in life, that would not necessarily eliminate mental illness or severe mental distress, but would foster more productive and hopeful ways of dealing with it, and would to that extent have a definite preventative function. This was all part of the battle against institutions outlined in L'istituzione negata (The Negated Institution), a collective work edited by Basaglia, which was in many ways the 'Bible' of the movement, though unaccountably it has never been translated into English, even though it has appeared in numerous other languages. It was not enough just to destroy these institutions but society itself (which had produced and sustained the manicomio system) needed to be transformed'  'How can we not move from the excluded to the excluder?' Basaglia had asked (p. 180).  Foot also highlights the role of a number of extraordinary films and photobooks in contributing to the anti-psychiatry movement, and in conveying what was at stake in deinstitutionalization, such Matti da Slegare, a documentary about the Colorno asylum; I Giardini di Abele, a TV film about Gorizia addressed to a popular Italian audience that presents the problem of the asylum not as specialized problem but as 'our problem, everybody's problem' (p. 223); and Morire di Classe, 'To Die Because of Your Class: The Asylum Condition', a photobook containing searing images by Carla Cerati and Gianni Berengo Gardin that was widely celebrated as marking a new departure in political campaigning. It bore on its cover a classic Basaglian statement of the institutional reality of the mental patient.

'At the end of this process of dehumanization, the patient is handed over to a psychiatric hospital    to be cured – he no longer exists – he is absorbed and incorporated into the rules which determine   his existence. He is a closed case. Labelled in an irreversible way – he is never able to cancel   out the signs which have defined him as something less than human, without the possibility of   appeal' (p. 224).

Keeping track of the rich and complicated history of the Italian movement as it unfolded can be confusing, involving as it did different places, innumerable actors, inevitable rivalries and fallings out, controversies and competing accounts. Some of the most interesting descriptions in Foot's account are of people and places, such as Perugia, Parma and Reggio Emilia, that have been somewhat marginal or tangential to the mainstream Basaglian narrative. At Perugia, with its vast Santa Margherita asylum complex, there was a successful attempt 'both to humanize the hospital and create an alternative to it at the same time' (p. 251). More quickly than at Gorizia or at Trieste, the action shifted away from the asylum, taking issues 'linked to mental health out into the streets, cities, towns and villages' of Umbria (p. 249).  Significantly, though, it never sought to, or felt the need to, promote itself, or to create a message for collective consumption, in the same way that other sections of the Italian movement did. Ironically, it may have been a victim of its own success in this respect in that, in stark contrast to Gorizia, it enjoyed the support of the Communist Party-led provincial government in Perugia and so the Perugia team had no need to look beyond their own city to find allies.

The psychiatric revolution in Parma was led by the charismatic Mario Tommasini, a former gas-meter reader with a chequered and rebellious past, who as a member of the Communist Party was appointed assessor with responsibility of the running of the Colorno asylum for the Province of Parma in early 1965. Tommasini had never visited an asylum before and had 'no competence in or knowledge of psychiatry or mental health care or of the asylum system' (p. 258). He was profoundly shocked by what he found at Colorno, not least because among the inmates he recognised 'dozens and dozens of comrades, people who used to live in my neighbourhood and were well known to me', and all of whom recognised him (p. 259). Though the local press questioned the right of a gas-meter reader to criticize eminent psychiatrists, Tommasini was undeterred, devoting himself wholeheartedly to the struggle to close the institution and free its 'prisoners', using the word 'kidnapped' to describe what had happened to them, and saying to himself: 'I won't give up, I will bring those people home ... could I simply abandon them to their fate? And, are they really mad?' (p. 260). Previously, he had thought that various kinds of health institutions were necessary: 'the mad in the madhouse, the abandoned kids in the orphanage, the old people in the old people's home'. Now he had learned 'how to reject these kinds of solutions and look for others'. It is, perhaps, Tommasini, as an outsider with a compelling moral vision and commitment, who more than anyone else epitomised the spirit of the Italian mental health revolution in rethinking the whole project of psychiatry, questioning the segregationist, isolationist and deprecatory premises on which it had been established and maintained. The road ahead was hard, for Tommasini found himself initially at loggerheads with the director and staff at Colorno, who mostly viewed the patients as dangerous, but he succeeded in getting many of the nurses on his side, reducing the numbers of patients in the asylum and in creating a series of 'alternative work-based and therapeutic associations and spaces across the province' (p. 284). The story is complicated in the telling because it has been over-shadowed in some accounts by the story of Basaglia's involvement with Colorno, and the ambivalent relationship between Tommasini and Basaglia (psychiatrist Franco Rotelli called them 'a strange couple'), though in actuality it was largely Basaglia who was over-shadowed by Tommasini, who was making most of the running at Colorno (p. 277).

The legacy of Reggio Emilia, and the history of psychiatric reforms at San Lazzaro asylum, has been caught up in a number of personal conflicts and sectarian accounts, largely centred on disagreements and splits between Basglia and Giovanni Jervis, that have exaggerated the differences between Reggio and other Basaglian places of change. In the late 1960s and early 1970s San Lazzaro became celebrated within radical circles for a series of events known as the calate, or descents, unannounced visits to the asylums of groups of people from the surrounding villages and towns demanding to be allowed to inspect the institution. In subsequent years, however, Jervis became more pragmatic in his approach, more willing to accept the reality of mental illness.

John Foot tells the story well, remaining faithful to the dilemmas involved in writing this kind of history, declining to simplify or to talk away the tensions that inhere in the historical record. Inevitably, there were 'excesses' in the Italian experiment, and also a few incidents involving violence on the part of former patients after they had been discharged, some of which were unpredictable, and others more obviously the consequences of lapses of judgement by professional workers, that put the project in question and precipitated counter-reactions, and are reminiscent in this respect of the media influences on community care policies in the United Kingdom.(3) Foot acknowledges that the legacy of the movement remains controversial and divisive, though it might be remarked that this is surely true of the history of psychiatry as a whole. He ponders, at one point, whether term anti-psychiatry can be rescued from the misinterpretations and negative uses in which it has been enveloped (p. 43). And here he might, perhaps, have drawn upon Michel Foucault's fruitful suggestion that the history of modern psychiatry is permeated by antipsychiatry (or more accurately antipsychiatries) 'if by that we understand everything that calls into question the role of the psychiatrist previously given responsibility for producing the truth of illness within the hospital space'.(4)  The issues that Foot is writing about matter enormously, by no means do they lie discarded in some historical back-alley of the 1960s and 1970s. It is the great merit of John Foot's work, and also that of David Forgacs, to encourage us to locate the histories of marginal and socially excluded groups such as the mad and the 'mentally ill' within the contours of larger narratives of nation-making, and there are lessons here for historians of psychiatry more widely.

There are a few oddities, omissions and limitations that deserve mention. Though it was written in English, the book was first published in Italian under the playfully ironic title of La 'Repubblica dei Matti': Franco Basaglia e la psichiatria radicale in Italia, 1961–1978. The main title roughly translates as The 'Republic of the Mad' and whilst Basaglia is announced as the main protagonist in the action, the book is evidently about a larger subject than him. And this reflects, accurately enough, the argument and scope of the book, and the author's intentions. In the English-language edition, however, the play of the Italian title is quite absent. This is a banal and unadorned statement of fact. There are no scare quotes that might permit us to code it as the ironic statement of a legend, for example. It is, at the very least, a distortion, not to say a gross misrepresentation, of the content and argument of the book, and of the author's intentions. It is, of course, exactly this kind of contest over meanings, over the interpretations, the definitions even, of facts themselves, involving numerous agents and agencies, from mental patients to psychiatrists to politicians to publishers, that goes to the heart of what this book is all about. It is as though the author has been silenced, the revisionary Franco Basaglia of Foot's text has been abducted and disappeared, and replaced by the soiled counterfeit currency through which his reputation has long circulated. Ironically, with this title Franco Basaglia is thrown back into the pit of stereotypes and misrepresentations from which it has been the business of the book to retrieve him. The politics of this publication are, perhaps, an ironic demonstration of how resistant to eradication is the power of a legend once entrenched in popular culture.

Though it is obviously the intention of the book to assist in bridging the gap between the history (or histories) of the Italian mental health revolution and an English-language readership, it is not always successful in doing so. Partly this is because only a very small proportion of the phenomenal Italian literature on the topic has been translated into English, but also because John Foot is not as helpful as he might have been in citing English translations (of Luisa Passerini's Autobiography of A Generation, or Dora Garcia's Mad Marginal series, for example) even where they are available. In addition, Foot refers frustratingly to two or three photographs, one of them a group photograph to which he returns several times ('she is sitting between Pirella and the head nurse, surrounded by seven men' (p. 87) ), that are not reproduced in the text, with no explanation given. It is also a limitation of the book that although we are introduced to a host of different thinkers we learn remarkably little about the substance of their thought (this is even true of Franco Basaglia himself).'There were often furious discussions about the idea of mental illness', Foot remarks at one point (p. 302). Well, what were they exactly? Partly, this is a function of the pace and spread of Foot's narrative where he does not permit us to linger long, since there is always another damn destination to be reached. Pedalare! Pedalare! In his conclusion Foot lists a whole string of destinations, including Ferrera, Florence and Genoa, that he has not been to include in his history of the movement so far. Count me in on the next ride, though along the way I will insist on walking from time to time.

Notes

1. David Forgacs,  Italy's Margins: Social Exclusion and Nation Formation since 1861 (Cambridge, 2014), p. 256.Back to (1)
2. See Peter Barham, Closing the Asylum: the Mental Patient in Modern Society (London, 1997).Back to (2)
3. A. Hallam, 'Media influences on mental health policy: long-term effects of the Clunis and Silcock cases', International Review of Psychiatry, (2002), 14, 26–33.Back to (3)
4. Michel Foucault, Psychiatric Power: Lectures at the College de France, 1973–74 (Basingstoke, 2006), p. 342.Back to (4)