Vincenzo Passante Spaccapietra came to the UK from Trieste, home of the Italian democratic psychiatry movement. He was surprised by what he found.
Some people do not fit into our society, they are neglected by unfair social structures and become desperate. What should we, as members of society, do about this? In the UK (and elsewhere) we still assume that psychiatric hospitals are justifiable;
alternative ways of thinking about care are not currently on the menu. We avoid working on different premises, even though hospital admissions far too often lead to the very opposite of safety. The procedural efficiency of the system takes priority to the well-being of the people it is supposed to help.
Staff members are provided with risk management templates that temporarily provide the illusion of controlling suffering. We persuade patients that they are thinking about their life in the wrong way and they must change to fit the requirements of the society that failed them. The most scientific way to repress the symptoms of society’s failure is defined as “best practice” and any other approach is looked at with suspicion.
Far from gradually moving away from the asylum system, psychiatric hospital care has been on the rise in the UK: there has been a 2.4% increase in detentions in 2017/18 compared to the previous year and a recent research article found that rates of detention have at least trebled since the 1980s and doubled since the 1990s. If you are black you are more than four times more likely to be admitted to hospital and seventeen (!) times more likely to be diagnosed with a severe mental disorder than if you are white. There are disparities for other social groups as well.
This is often seen as having nothing to do with society, politics or psychology, but a medical issue that coincidentally seems to affect the brains of social groups that society dislikes. How can all of this be the result of “best practice”? The science behind the system ends up defending dominant social groups from the suffering of those who get left behind and this oppression is presented as an objective necessity for society. Otherwise we would have to accept that there is no magic box where society can safely dispose of the problems it causes.
This mentality, that the more we repress the expression of madness, the more we can cure it and ensure safety, takes shape in different ways. It goes well beyond the mental health sector: it can affect schools, universities, families and every other human organisation. Citizens face an intrinsic hypocrisy – we live an intellectual crisis where many of us want to fight stigma, but we re-enforce it in our habits, policies and procedures. In turn, to protect ourselves, we justify the actions we undertake as necessary or even therapeutic. This ensures the perpetuation of prescriptive rituals, where individuality is denied, and emptiness is endemic, an emptiness that gets inevitably filled by tragedies.
Life is more complex than any safeguarding procedure. Mental health professionals have to apply a simplistic and unidimensional idea of “risk” to complex phenomena that society refuses to address holistically. Dangerousness becomes the only important aspect of self- harm, suicidality, aggressiveness, or even hearing voices, that a psychiatric hospital system cares about. However, it is by no means the most relevant, let alone the only, element to consider in the practice of creating safety.
I qualified as a Psychologist in Trieste, an Italian city that led a national revolution in the 1970s which closed all psychiatric hospitals. The implementation of the new legislation was generally poor, and this led to a range of problems which are yet to be addressed.
Despite this, in the minority of cases where it was implemented as intended (Trieste being the most prominent example), it proved that a different way forward is possible. There is still a small, open door, general hospital psychiatric ward in Trieste for acute psychiatric emergencies: and its existence is still questioned by some of the reformers. The system is almost exclusively focused where it should be, in the community, with the provision of beds in open door community mental health centres, in a relational context where the person is considered much more important than the disorder.
In 2014, given the chronic lack of career opportunities in Italy, I came to work in Britain (not as a Psychologist, in the UK you need a doctorate for that). I crashed into a care system that in Trieste had been defeated by Franco Basaglia and others many decades ago. I quickly realised that hardly anybody knew anything about this situation (Asylum magazine is a virtuous exception). The training I got was the opposite of what I learned in Trieste (a widely internationally recognised setting for training). I realised I would not even have the right to believe, for instance, that doors should be kept open to bring about safety. Years and years of training became suddenly pointless, or even wrong, and I had no opportunity to discuss this with managers, because they knew nothing about any of this.
British mental health care is in a state of emergency. Harmful practices are often defined as "best practice" and taught as the only acceptable view. In Trieste I was taught to avoid seeing complex behaviour through the limiting and stigmatising lens of dangerousness. Here I found myself in a position where my level of competence was evaluated against
skills like remembering to ask patients: “Do you have any thoughts of hurting other people?”; at every contact. This was meant to “ensure safety”. It applied to every patient, regardless of whether there was or was not a concern for their state of mind (this, to be fair, does not happen in every service). Imagine if we applied this mentality to other social groups, if for instance we asked every black person that entered a shop: “Do you have any thought of robbing the shop?” Would that be an acceptable way forward? Would that ensure safety?
This is the type of thinking that in Trieste we call “stigma”; and we commonly attribute to poorly informed individuals who are worried about the supposed dangerousness of mad people. Lack of funding has a role in all of this, but these concerns go well beyond the (important) issue of austerity. Call me mad but sometimes I feel we are living through a large scale “Milgram experiment”, a famous social psychology experiment where subjects were persuaded to administer lethal electric shocks to other people for the sole reason that the experimenter had told them to do so. My perception is that workers persist in carrying
out questionable procedures without objection, for the sole reason that the establishment tells us that it is necessary to follow the rules.
Action must be taken. Whereas in Trieste I had endless debates with my supervisors about questionable aspects of care, here in the UK I find myself confused, caught in the dilemma of leaving the system or staying in. In a small way, by staying in, I have already seen change happen in places where I worked, despite remaining in an intrinsically contradictory position.
For these reasons, a friend and I recently started to host a podcast: “A place of safety?”, in which critical voices are legitimate. We question whether safety measures, like hospital admissions, can be defined as such if they lead to tragedy, or whether an intervention is really “best practice” if it ignores things that could be done better, differently. If we could become less dogmatic about our beliefs, we could find healthy spaces for debate. More democracy must be the first step. Without the right to disagree no change is possible. When I came across Asylum magazine, I realised we had a similar ethos and history. So they were one of the first places I turned to for help. This quickly is turning into establishing a closer working relationship, where we hope to put our resources together to widen this important debate. Any contribution you want to give, we are here to listen.
Our “;A place of safety?”; podcast is available on the main platforms: iTunes, Stitcher, Spotify…
Twitter and Instagram accounts: @apospodcast.
We will keep you updated,
Vincenzo Passante Spaccapietra
This is a Sample Article from Asylum 26.2. Subscribe to Asylum magazine.