Practical Overturnings

What can the work of radical anti-psychiatrist Franco Basaglia, documented in John Foot's new book, teach us about contemporary crises in 'mental health'? In his review, Howard Slater revisits  the debate around the closure of asylums and the cut-rate 'care in the community' policies they supposedly triggered, and salvages Basaglia's political reading of social alienation as his true legacy

We are encouraging the politics of desire and for people to become aware of the right to life, the right not to go to the asylum […] the right to all the ways in which people express their political mode of existence.

– Franco Basaglia (1976)

The current run of mental health features and reports, with their pristine language, pretty charts and Twitter feed straplines makes for difficult reading. A different gender, race or age group keeps rising to the top of the depression charts in a kaleidoscopic shifting. This week young women are the subject of increased focus, last week it was middle-aged men. The police moan about being the mental health workers of last resort because, of those deemed mentally ill, it is those who are not in in-patient facilities but on the streets that are three times more likely to kill themselves. A leaked report from last February¹ shows suicides increasing overall, NHS waiting times lengthening, a 10 percent rise in compulsory sectionings under the Mental Health Act and a non-precedent-busting over-representation of non-white peoples in the cells of locked hospital wards. With such pressing urgencies in mind – despairing spikes commonly linked to the welfare robbery intensified by the 2008 bank bailout – it may well be asked what use is it to go back in time and learn from the more or less forgotten work of a radical psychiatrist in ’60s and ’70s Italy?

This is more or less what we’d be doing by reading John Foot’s book on Franco Basaglia, The Man Who Closed the Asylums: Franco Basaglia and the Revolution in Mental Health Care. In so doing we would discover a pretty much concerted movement to not only close the asylums that Félix Guattari referred to as ‘quasi-zoological’ and which others described as akin to concentration camps, but to reflect also on the creation of alternative modes of therapeutic initiative. And perhaps, in a longer lasting historical arc, reflect on madness as a psycho-social alienation that brings us closer to the diffused core of how we are produced and attempt to produce ourselves as subjects. If we want to pursue the latter theme we may well need to consult other books and testimonies as Foot seems to shy away from a closer engagement with some of the political ideas and strategies of not only Basaglia, but of the many other radical psychiatrists and team members who pepper this book – like Franca Ongaro, Giovanni Jervis, Carlo Manuali, Giorgio Antonucci etc.

In writing about the still yet-to-be-translated collective work entitled L’Instituzione Negata (The Institution Denied, 1968) that was issued from the eleven strong équipe working to transform the asylum of Gorizia² in the ’60s, Foot describes Basaglia’s writing as ‘a complicated mix of statements and concepts’ and parts of the book as ‘verging on the incomprehensible’. This is a pity as, neglecting, too, to take seriously the International Network of Alternatives to Psychiatry in which Basaglia was involved as one of many, we are often left, outside of the book, without a clear sense of how these practitioners were reflecting upon the political import of their experiences. Such reflections would not only be useful in gaining a more rounded view of the history of ‘anti-psychiatry’ – being additions to a predominantly English language history – but useful as modes of inspiration to a contemporary psychiatric practice that, outside of isolated and always underfunded projects, has recently been seen as having moved from ‘psychiatric abuse to psychiatric neglect’.³

Maybe making such requests of the author is unfair. Maybe this book is not an intellectual biography. Maybe it is enough to have this story told as the narration of a theoretical arc by means of its ‘practical overturnings’.⁴ And so, in this book the narrative ends with that most pragmatic and visible of all modes of politics: the passing of a Law. This Law 180, or ‘Basaglia Law’ as it came to be dubbed, seems often to be related to as both the epitome of ‘anti-psychiatry’ and as its only lasting impact. Putting aside Basaglia’s allied but critical reception of anti-psychiatry (he met and corresponded with R.D. Laing and David Cooper as well as with Maxwell Jones and Félix Guattari), this Law effectively signaled an intention to immediately close asylums, an end to forced treatment, and the recasting (as late as 1978) of those deemed mad into ‘patients’ with ‘citizens’ rights’. Seemingly the culmination of Basaglia’s ‘de-institutional’ drive to close the asylum, Foot does draw our attention to the complexities, contradictions and laggardly implementation of this Law (with Basaglia’s widow, Franca Ongaro, maintaining an activist position for decades after it was passed). In some ways, as Foot mentions, Basaglia became a kind of bogeyman for the Left who (maybe to this day) equate the drive to close asylums with the ensuing disaster of community care; as if the ‘anti-psychiatrists’ willed such a callous outcome and/or were politically naïve in their being motivated by a horror of authoritarian zoos. This misrepresentation is perpetuated by Mike Jay in his recent review of this book for the London Review of Books, when he refers to Enoch Powell as the first ‘anti-psychiatrist’. Powell’s call, in 1961, to close ‘cost-ineffective’ asylums, (which can be seen in the light of the ‘Kennedy Act’ in the USA that did likewise, but more swiftly deposited former ‘inmates’ on the streets) is obviously devoid of the left-libertarian political effects that Basaglia and others were motivated by. So, if drawing such parallels between anti-psychiatry and mental health budget cuts is unfair, they are so in Basaglia’s case because they occlude the level of his commitment to ‘politicizing madness’. Twice arraigned by the State on manslaughter charges following tragedies associated with released patients in his care, and being one of many in the Psichataria Democratica movement, Basaglia practiced a confrontational Marxist-inflected politics that aimed at ‘keeping the contradictions open’ to the degree that the culminations of asylum closure and the passing of Law 180 are not the full story.

John Foot’s book fills in this history and, in so doing, brings into view diffuse culminations and heterogeneous practices that follow a trajectory that Basaglia, adopting a kind of historical materialism of ‘stages’, rhetoricises as follows: ‘The madhouse in the paleocapitalist phase, the therapeutic community in the neocapitalist phase, mental health centres in the advanced capitalized phase.’⁵ This mode of political vocabulary is revelatory in terms of what Foot neglects to discuss of Basaglia’s political views, and is indicative of a militancy of practice in Basaglia and his cohorts at the same time as it seems to hint at a surpassing of any currently achieved ‘stage’. In contrast, the 30^th Anniversary edition of Asylum magazine is filled with articles suggesting a forced march back to a situation prior to Basaglia’s neo-capitalist phase where the bio-medical model that sees mental illnesses as a ‘chemical imbalance’ can come to render even therapeutic care unnecessary. Worse perhaps is the assertion that ‘in mental healthcare, moral judgements are never far away, and all around us now there are echoes of the Victorian division between the deserving and undeserving poor.’⁶ That the Victorian period is one that precedes the building of asylums is an unseemly echo of our returning to times in which the asylums, often small towns in rural settings, were invested with reformist hopes. So, as a troubling contemporary commentary on the past struggles of the Italian psychiatrists, there is evidence to suggest that ‘many user groups find themselves fighting to keep psychiatric wards open and even demanding admission and treatment.’⁷

So, returning to the story as told by Foot, we have the famous case of Basaglia assembling an équipe at Gorizia Asylum and from there unchaining patients, unlocking wards and pulling down fences. Along with his team they introduced general assemblies of patients and staff that were described as ‘disorganized, uncontrolled, and open to anger, passion and unreason.’⁸ They established a patient newsletter and ‘put mental illness in brackets.’ This approach seems to suggest that ‘treatments’ aligned with diagnoses were suspended and that ‘psychiatrization’ or excessive ‘interpretation’ would take a back seat and be superceded by experiments of ‘collective responsibility’ across the hospital as whole. The general assemblies as well as regular community meetings seem to have replaced any application of individualising therapy with a kind of socialised consciousness-raising.⁹ Presumably writing after a visit to Gorizia, Susan Jones and Donata Mebane-Francescato offered that ‘he [Basaglia] then tossed out the use of all psychiatric labels, encouraging people to relate to one another as human beings rather than as disease prototypes’.¹⁰ It is perhaps in this light that Basaglia could offer that ‘our only rule, in here, is linked to our practice, to the lived experience of reality.’¹¹ A ‘lived-experience’ outside the reifying confines of category and the reality-diminishing subservience induced by such abstracting generalisations that, along with the removal of white coats, could encourage the autonomy of those deemed inhuman. This was intended to lead not only to the reversal of ‘tutelary relations’ of patient-doctor, but to a society-wide positing of the politics of marginality that had been ignored by the institutional Left.

So, this phase, the therapeutic community phase, was the phase when the asylum as institution was ‘negated’ and psychiatry as a discipline was brought into question (a prior collective work from Gorizia was entitled Che cos’è la Psichiatria? (What is Psychiatry? 1967). This may have been a contradictory polemical claim as locked wards were still maintained at Gorizia, but the work there, often risky and improvisational, practically demonstrated some key themes of the radical Italian psychiatrists. Amongst these Foot highlights an opposition to psychiatric incarceration, a critique of the medical model of mental illness, and a move away from the segregationist modus operandi of all public institutions. At one moment Basaglia calls himself and others at Gorizia ‘non-psychiatrists’ and it is this aspect of devolving roles and anti-specialisation that both marks Basaglia’s continual self-questioning as well as introducing contradictions that would be played out in the radical psychiatry of 1970s Italy.

When he left Gorizia in 1969 Basaglia, again in a language bearing the traces of Marxism, offered that he ‘wanted to negate what I had created with my previous negation.’¹² Though many more were involved in this venture of ‘de-psychiatrization’, it is as well to pick up that Basaglia, initially drawn to and inspired by the therapeutic community at Dingleton run by Maxwell Jones,¹³ soon began to differentiate Gorizia from this venture. He did not want Gorizia to function as a ‘model’ or blueprint, but to ‘negate the negation’; moving beyond ‘segregation’ and the potential insularity of ‘communities’, and beyond drawing parallels between the therapeutic community and the wider power relations in capitalist society. Perhaps this was a more revolutionary solution to the problem of ‘madness’ in that it implied a recognition of and retaliation against the social violence perpetuated against those deemed ‘mad’ and ‘marginal’.¹⁴ As Guattari, in assessing the Italian ‘non-psychiatrists’, put it: ‘Only the sensitization and mobilization of the entire social context could create conditions favourable to real transformation. Certain experiments like that of Trieste offered living proof.’¹⁵

Before picking up on the lasting import of Trieste, we should attend to Basaglia’s ‘advanced capitalist stage’ and the Mental Health Centres that he saw as indicative of this period (at least in Italy). In so doing we will not only find further indications that the rhetorical device of ‘stages’ is best assessed as spirals and curves, as enlit enclaves and persistent pits, but that the struggle to inaugurate Mental Health Centres (Centri di igiene mentale) marked a sustained effort to actually provide real and lasting alternatives to the Italian asylum system. This little known effort which often required intense political maneouvering, and which Foot here brings to light for English readers for the first time, is propelled by other less known figures some of whom had either worked at Gorizia or been inspired by their visits there. One such was Mario Tommasini, an ex-gas meter reader and communist deputy who became director of Parma’s Colorno Asylum and was shocked with what he saw there: ‘I began to understand the real aim of these institutions – to avoid dealing with more serious social problems. Health assistance of this kind was an alibi.’¹⁶ Following an occupation by students of the Colorno Asylum in 1968, Tommasini, describing the occupation as the best forty days of his life, attempted reforms in the institution at the same time as he moved into the wider social world that the Italians referred to as ‘the territory.’ He restored a co-operative farm for use by patients and ex-patients. Meanwhile in the province of Reggio Emilia, Giovanni Jervis set up what was described as ‘the first ordered and coherent networks of Mental Health Centres.’¹⁷ And in Perugia, throughout the early ’70s, there seems to have been the ‘perfect’ balance between rendering the asylum obsolete through non-admission policies, whilst at the same time setting up Mental Health Centres with the support of a left-wing local government. A prime mover in Perugia was Carlo Manuali who, holding the opinion that ‘mental illness is not a problem for doctors’, came to look beyond the Mental Health Centres towards something akin to the Belgian therapeutic town of Geel;¹⁸ a de-segregating move into the wider social territory that, for him, didn’t mean ‘the disappearance of madness, but [rather] a facing up to it.’¹⁹ Such a facing-up would surely imply both a questioning of the, by now, globalised Eurocentric model of psychiatry as well as a rendering visible the many forms that psycho-social alienation can take.

Even with this concerted effort at providing a care in the community that was more than just an unfulfilled promise, Foot suggests that these initiatives were hard won and, we could add, increasingly difficult to maintain as the ’70s drew to a close and the reliance on dispensing pacifying drugs and/or imprisonment took over as the main alternatives to the closure of the asylums. It may then be that some of the more militant aspects of anti-psychiatry, particularly the call of those like David Cooper to ‘politicise madness’ as a response to what the Asylum editorial collective refer to as ‘something pathological in the social relations’,²⁰ should not be altogether consigned to matters of historical research, because often a reaction to power imbalances embedded in social relations can be a prime reason in being designated as ‘mad’. So when Manuali is cited as saying, ‘Mental health is connected with the possibility of dominating in terms of knowledge and activity one’s own existential condition and the processes which determine it’,²¹ he is perhaps shadowing Guattari’s notion of the production of subjectivity as, amongst other things, the site of a struggle between psychical and social alienation that afflicts more then just those deemed ‘mad’. Politicisation in this sense, as sensitisation to suffering and as a sharing of psychical precarity, cannot be legislated for. Here maybe lies an ongoing tension or continuing contradiction between tendencies that can be seen as reformist (those that retain the psychiatric role as a professional one) and those ostensibly revolutionary ones that see ‘the essence of psychiatry’, in the words of Giorgio Antonucci, as ‘an ideology of discrimination.’²² Antonucci, included in Foot’s book as a proponent of an Italian style ‘anti-psychiatry’, was connected both to protests at the San Lazzaro Asylum in Reggio Emilia, which saw regular processions of relatives marching on the asylum to check up on the conditions their family members were living in; and to the short lived experimental ward at Cividale that was dubbed a ‘Centre for Human Relations’ by its founder, Edelweiss Cotti. The Cividale Unit had been set up inside a larger hospital and was marked by its refusal to dispense anti-psychotic drugs and its insistence upon ‘continual dialogue and collective discussion’²³ as a means of re-introducing the patients to a social life they had been denied. However, after a three-day occupation in protest at its impending closure, the Unit, surrounded by police, was eventually shut down. Foot notes that Cotti maintained that the reason for the closure of Cividale was ‘his refusal to create a separate psychiatric section for richer patients.’²⁴

Cotti went on to write a book called Contro la Psichiatria (Against Psychiatry, 1970), in which the Gorizian équipe was given short shrift as a reformist venture. However, with only scant information in a short chapter to go on, it is difficult to assess Cividale. With Cotti being cited here as one whose militant position could be described as denying the existence of mental illness as a concept, we could perhaps see how some aspects of ‘anti-psychiatry’ garnered a reputation for being, in Guattari’s phrase, full of ‘demagogic exaggerations’ that perhaps functioned more ideologically than practically. Gaining a guru-like power over the powerless as a by-product of speaking up for those without voice would be something to watch out for and, in the context of mental illness, something that could be acutely damaging. In a sense, the de-institutionalisation and de-psychiatrisation brought about by Basaglia and his allies would function as a way of warding-off this power. This was sustained by another ‘open contradiction’ that flows from the one dividing psychiatry and anti-psychiatry: the one between psychiatric professionals and those ‘para-professionals’ untrained in this form of medicine (in this regard one could also mention, as Laing does, the impact of interaction between patient-peers). Here Foot makes clear how Gorizia (like La Borde and Kinglsey Hall) became a magnet for radical-students, political-activists, film-makers, journalists and counter-culturals. A friend has recounted how reams and reams of film shot at Gorizia have been discovered and preserved, and whilst this is of obvious archival importance it also testifies to the introduction of new means of engaging patients. As part of his drive towards de-psychiatrisation Basaglia seems always to have had an interest in ‘experimentation with new therapeutic dimensions’²⁵ and it is from such an aesthetic realm that non-psychiatric innovations were drawn and came to play an important role in Gorizia as they did across the whole ‘anti-psychiatry’ field. One could simply say that Basaglia and others introduced forms of art-therapy into the mix just as Marie Langer introduced group-therapy to those who attended her clinic located in a working class district of Buenos Aires.²⁶

When, in 1979, Basaglia took up a post at the San Giovanni Psychiatric Hospital in Trieste, he continued the work of Gorizia in the direction of both gradually closing the asylum and, as with Perugia and Reggio Emilia, creating alternative spaces throughout the city and its surroundings. Here, at least, as the asylum closed there seems to have been adequate provision made for the thousand or so former patients, some of whom, Basaglia notes in a 1976 interview, put their small savings together and placed themselves in apartments. Foot’s chapter on Trieste shows how, as the asylum emptied, it became widely known as a cultural centre and as a magnet to psychiatric militants throughout Europe. He notes that ex-members of the Socialist Patients’ Collective made their way there to support the effort and it is likely that, amongst other anti-psychiatric notables, David Cooper also visited. So, just as Guattari’s work at La Borde had an ‘art-therapy’ component, it seems the same was occurring at Trieste. The most famous example is the construction in art workshops of a papier-mâche horse called Marco Cavello that, containing the written up dreams and wishes of patients, was regularly wheeled through the streets of Trieste. Foot seems a little cynical about the way this has become, for him, an empty spectacular symbol, but one wonders how much the introduction of such an art-therapeutic accent (including drama therapy) marked a kind of avant-garde approach that the mainstream psychiatry of the day saw as a threat. This can maybe be gleaned from Guattari when he writes in 1977 that ‘it in no way devalorises the invention of psychoanalysis in thus placing it under the aegis of an aesthetic paradigm. Treatment is not a work of art, yet it must proceed from the same sort of creativity.’²⁷

Trieste became so famous in the world of mental health that, as Foot writes, it became recognised by the World Health Organisation. It assured Basaglia of a lasting status as a psychiatric reformer, who, to keep the contradictions open, maybe also had a revolutionary outlook when, cautioning against ‘completion’ and urging an ongoing extra-institutional effort, he offered ‘ideologies are freedom while they are in development, oppression once they are formed’.²⁸ The grinding to a halt of progressive ideologies and the freezing that occurs amidst their purveyors is maybe related to the lack of ‘practical overturnings’ that can be experienced. The ‘political’, when divorced from the politics of the production of subjectivity, seems always to happen at a remove, seems forever distracted by grand themes that outstrip our capacity to feel them. That said, just after WWII it would have been seen as a utopian dream to close the asylums and replace them with community support networks. Perhaps Trieste is the only place this actually happened with any deliberated sense of continuity. Visiting there in 2015, Daniel Goulart, writes of his first impression: ‘In Trieste the services and the social spaces involved in mental health care are conceived as places of socialisation, and not strictly a stage for professionals to make their interventions.’²⁹ Of course Trieste is probably not a bed of roses and Goulart has more critical observations to make, but, in the light of the crisis of mental health care provision throughout so many different countries, it should still be possible to celebrate and take inspiration from the efforts of those Italian équipes and the patients who screamed, debated, wrote, filmed, farmed, suffered and unspectacularly took back some autonomy for themselves.

So, perhaps Basaglia’s lasting impact on the field of psychiatry goes beyond Law 180 and the negation of institutions, and tends towards a fresher field for politics, one that introduces those who have been marginalised from participating in politics. Perhaps having a law named after him was a matter of embarrassment for Basaglia since even by 1971, after Gorizia and the success of L’Instituzione Negata, he cautioned against he himself becoming an institution. By the late ’70s there was still much to do and instead of remaining at Trieste, Basaglia took up a position as the Director of the regional mental health sector in the district of Lazio in Rome. This may be a highly contradictory move, but it was one which it is as well to see in the light of what he said at the 1976 meeting of the International Network in Paris. In a discussion with Félix Guattari and members of Psichataria Democratica, Basaglia stressed how the innovations of Italian Radical Psychiatry were limited to smaller towns and that the urban centres of Rome, Milan, Turin, Naples etc. were relatively untouched. In these terms Basaglia could perhaps do nothing other than move onto Lazio, leading one to wonder what could have occurred in this larger setting were it not for his untimely death. However, whereas Foot comes to eventually settle on Basaglia being motivated by a Maoist politics, we must recall Basaglia’s distaste for ideology tout court and his embrace of the many contradictions of a practice-based approach. In emptying the asylums, Basaglia and others seemed intent on introducing, as he said, ‘a rapport between the marginalized and their social context’ and this Basaglia saw as giving a ‘new impetus to the class struggle.’³⁰ In the slipstream of this ‘socialisation of contradictions’ (as Jervis puts it) what seems to have been posed is neither a normalisation of the mad nor a psychiatrisation of society (two efforts that persist), but a politicisation of modes of alienation that are additional to the one issuing from wage-labour; a politicisation in the direction of desire, in the direction of a struggle on the terrain of the production of subjectivity and its collective modes of existence. Basaglia: ‘It seems important that people know that beyond “health” and “illness” there are human beings and there are contradictions that we cannot master individually.’³¹

Howard Slater <howard.slater AT googlemail.com> is a writer and researcher based in North London

FOOTNOTES