Mental-health care: Italy's psychiatric renaissance

Journal name:
Nature
Volume:
524,
Page:
290
Date published:
DOI:
doi:10.1038/524290a
Published online

Andrea Tone admires the history of a radical shift in the treatment of mental illness.

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

John Foot Verso: 2015. ISBN: 9781781689264

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Up to the 1960s, people in Italy's asylums were stripped of their possessions and personhood: victimized by rigid rules, overcrowding and filth, tied to beds or caged and separated from the outside world by towering walls. By the late 1970s, the landscape had been transformed by a reform movement led by 'critical psychiatrist' Franco Basaglia. Historian John Foot explores this extraordinary revolution and its legacy in The Man who Closed the Asylums — first published in Italian as La “Repubblica dei Matti” (The 'Republic of the Mad'; Feltrinelli, 2014).

The movement, Foot shows, came to condemn asylums as morally bankrupt and of limited therapeutic benefit. Spearheaded by radical psychiatrists and joined by journalists, intellectuals, patients, activists and politicians, it laid the foundation for a reform act, Law 180. Passed in 1978 by health commissioners rather than Parliament, the law authorized the de-institutionalization of patients, the establishment of community-based psychiatric services and the closure of asylums. That process finished only in the late 1990s, but it returned 100,000 patients to society. For the first time, a broad coalition united in rejection of asylums to parlay its views into a national political mandate.

The revolution began in Gorizia. An isolated city on the border of what was then Communist Yugoslavia, Gorizia was politically centre-right: mostly Christian Democrats, with some neo-fascist groups. It was an unlikely site to spark a revolution.

Giuseppe Pino/Mondadori Portfolio via Getty

Franco Basaglia in Colorno, Italy, in 1971.

Its asylum, like others in Italy, was “dark and sinister,” a place of “horror”, notes Foot. In 1961, Basaglia became its director, primed for change. After spending six months in prison for anti-fascist politics under Benito Mussolini's Fascist government, Basaglia knew how institutional power could thwart individual liberties. His critique of asylum psychiatry was influenced by philosopher Michel Foucault and sociologist Erving Goffman, as well as psychiatrist Maxwell Jones, whose work turning UK asylums into open therapeutic communities gave Basaglia, and his wife Franca Ongaro, a new paradigm.

In Gorizia, Basaglia assembled a team — the “équipe” — of physicians and reformers including Giovanni Jervis and Ongaro, the latter of whom Foot credits as the principal author of Basaglia's myriad publications. By the mid-1960s, the équipe had opened up the asylum. Freed from shackles, patients rose and slept when they pleased. They socialized at the institution's new bar (equipped with a jukebox), saw films, played sport and gave voice to their experiences in a patient-run magazine, Il Picchio (The Woodpecker). Many took day trips and mixed with locals. Patients and staff met daily to discuss their care and to debate broader questions. Were reforms the goal, or a prelude to closing the asylum? How should tensions between asylum leaders and local authorities — not all of whom embraced having patients in their midst — be resolved?

Despite ideological divisions within and beyond the asylum, Gorizia became famous. Activists demanding freedom and societal change visited to witness “new forms of democracy in action”. The Negated Institution (Einaudi, 1968), a best-selling book by the collective with Basaglia as editor, detailed the transformation and propelled critical psychiatry into the national spotlight.

By then, Basaglia and others had come to believe that patients would be better off in communities with decentralized psychiatric services. He left Gorizia along with some members of his team, and the “Gorizia diaspora”, along with the popularity of The Negated Institution, had a ripple effect. Psychiatric care was restructured in other Italian cities, including Reggio Emilia, Parma and especially Trieste. Basaglia's work there culminated in its asylum's closure in 1980 — the year that Basaglia died of a brain tumour. Trieste became a centre of pilgrimage for critical psychiatrists and a model for reform recognized by the World Health Organization.

The Man Who Closed the Asylums is ambitious and well researched. It is also detailed and long, packed with block quotes and a large cast of characters, as well as a smattering of case studies of asylums and local politics, making it an occasionally choppy read. It is less a biography of Basaglia than a contextualization of the man and the movement in a network of historical actors and the politics and ideology of post-war Italy.

Foot says little about how patients were diagnosed, the spectrum of their disorders and medical interventions, particularly after psychiatric drugs such as the anti-psychotic chlorpromazine reached Italy in the 1950s. Scholars such as Joel Braslow and Andrew Scull have generated a vast literature on these questions, which Foot sidesteps. Also missing is a discussion of what non-asylum psychiatric care, if any, existed in Italy before Law 180.

“Small groups of people in peripheral places can change history.”

Foot's argument would have benefited from more comparative analysis. Before Gorizia, many North American asylums had introduced reforms. In 1956, for instance, the use of anti-psychotics encouraged US public asylums to discharge more people than they admitted. Yet, as Foot avers, no country or movement went as far as Italy in recalibrating the organization and politics of mental-health care. Law 180 (and broader health reforms that soon subsumed it) was unevenly enforced, failed to create a singular model of care and was undercut by political opposition. Yet Foot's impassioned story reminds us that the future is neither immutable nor ordained, and that small groups of people in peripheral places can change history.

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