Asylum magazine was established in 1986, in part inspired by the Italian democratic psychiatry movment.
We invited Vincenzo Passante to report on recent developments.
Until the 70’s, Italy’s public mental health system consisted of large asylums. Patients who lived in these places lost their civil rights, were treated in inhumane conditions and were often there for decades. Things started to change in the 60’s and 70’s, when a group of Psychiatrists, nurses and patients gradually opened up asylums, most notably in Trieste, where an alternative system of care developed within the community which no longer needed psychiatric hospitals.
Inspired by this, and other experiences, a revolution engulfed the entire country and led to “law 180” in Italy, also known informally as “Basaglia law”. Both Franco Basaglia, the director who closed Trieste’s asylum and the figurehead of the Psichiatria Democratica (Democratic Psychiatry) movement, and his wife Franca Ongaro Basaglia had a prominent role in the reform process. After Franco’s death in 1980, Franca continued to fight for its implementation as an activist and, for a period, even as a member of parliament. The reform gradually phased out psychiatric hospitals and outlawed building new ones in the whole country. I refer to people who were part of this movement as Basaglians.
Unlike other anti-psychiatric endeavours, the Basaglians didnt just fight for the destruction of asylums per se, or to defend an individualistic notion of liberty, but they built in practice a system which improved the conditions of those who previously had virtually no voice nor rights and whose needs meant very little to society.
The new system in Trieste was centred around 7 community mental health centres (reduced to four about 15 years ago), open 24/7, plus a small (6 bed) general hospital ward for acute emergencies. In none of these settings were the doors locked nor were patients physically restrained. The system was, and is, sustainably based on negotiation and compromise rather than coercion. In the Asylum era, mad people were excluded based on risk, now the idea was to include people based on need. The ideas was that if someone needed a bed they would be able to stay in a mental health centre. The vast majority of beds were, and still are, in mental health centres, but they were always more than just crisis centres. People in crisis, as well as other people, could meet there for all sorts of activities. These included individual psychotherapy sessions, group therapy or other peer support group activities, but people could also meet there to have a meal together or be supported with their medication.
Trieste’s services received significant international recognition. However, in recent years they have come under attack by the “Lega” led regional government, an arguably far right political party. I feel very strongly about what’s happening there due to my past experence as a service user and later as a Psychology student there. Since moving to the UK I have tried to argue for the relevance of Basaglian ideas in the UK context.
In order to get a clearer picture of the current situation, I went back to Trieste and met with a Psychiatrist and ex director of Trieste’s mental health services, Dr Roberto Mezzina, who has now retired, and a service user and worker in a social co-operative, Arturo Cannarozzo (personal capacity).
To understand what is currently happening, it is important to know that regional politics significantly influence health services in Italy. The Lega led regional government has a major voice in deciding who heads local structures and many feel it is using this power to undermine services, particularly in Trieste.
Opposition to Basaglian ideas has usually come from the political right in Italy. The reforms had broad support across political parties in the 70’s, with the exception of the far right. The emphasis on community and inclusion, as well its challenge to the illness-danger paradigm, never appealed to the far right.
For many years, right and left governments have been in power in the region, and there hasn’t been any attempt to fundamentally undermine services in Trieste. Yet now, despite both local and international condemnation, Lega is pressing ahead with substantial changes. It is hard not to see this as an attack on the Basaglian approach. So far other cities in the region have been relatively spared from the changes, suggesting they are undermiming Trieste’s services because of its historial and symblic significance for the left.
The offensive has been two pronged: 1. Replacing Basaglians with non-Basaglians in management positions 2. Underminining the ability of services to function as they used to.
The first mental health centre that the Basaglians opened in the city, in Barcola, is now led by a psychiatrist from Cagliari, Dr Pierfranco Trincas, who was preferred to a local candidate with an arguably superior curriculum. The psychiatric emergency service that he previously directed in Cagliari functioned on a locked door basis and made the news for its questionable conditions. Locked doors were always a symbol of traditional psychiatry for the Basaglians, as opposed to their “open door” approach.
There are definitely troubling signs. For example, Barcola’s mental health centre has two entrances, one of which leads to the main road through a garden. This gate used to generally be open, and this had a strong symbolic value. Now I am told that it always appears to be locked. The concern is that this may represent a move back to a traditional view of how safety is created, through increased control. In October 2022 Trincas was promoted as head of the city’s mental health department.
In the meantime, another mental health centre had its daily opening hours reduced from 24 to 12. This means it no longer offers beds for people in crisis. People who used to spend the night there, now have to be hosted in other mental health centres or in the general hospital ward. Roberto explained how this has a significant impact on service users. Trieste’s services always invested in personal relationships, and it was always seen as crucial for someone in crisis to be able to get help in familiar places, from people they know. This new arrangement impacts on the relational dimension of ensuring safety in a crisis.
There has been fierce opposition to this move by local service users and family members. Thankfully, there have been some u-turns on previous proposals to cut mental health centres (from 4 to 2), and reduce opening hours, even at Barcola’s mental health centre. This suggests the Basaglians are able to fight back, but the regional government offensive is undoubtedly determined.
In addition, ties with the Basaglian generation have also been cut. For example, Roberto has offered to continue working on the international relations of the system, but there has been no interest in this. The projects he started when he was in charge of services have stopped or been significantly reduced. He had made attempts to integrate the Finnish “Open Dialogue” approach within services and introduce open door placements for forensic patients. On top of this, the Italian Psychiatric Society (Società Italiana di Psichiatria) nominated a new professor of Psychiatry at the university of Trieste who Roberto describes as a “biological Psychiatrist”.
Roberto has tried to enquire about current levels of coercion. For example, how often is the “tso” (mandatory health treatment) used? Numbers were always very low and this was considered a powerful indicator of how effective services were at responding to people’s needs. However, current data does not seem to exist, suggesting it is not seen as relevant.
Despite all of these concerns, Trieste’s services are still unique, and arguably amongst the best in the world. For example, even when tso’s happen, they don’t involve locked doors or restraint. The system always had a huge impact on the community, well beyond itself. When I was a service user there, I was part of a group of young people (with Arturo and others) who regularly met to have lunch, go on walks or even on holiday together. To this day we are still regularly in touch, and have continued to exist outside of the systen from which the group was originally born.
Arturo feels that many professionals still work within a Basaglian framework, but he questions whether people in crisis get the level of help that he got when he was in crisis. Roberto is worried about younger generations being less able to fight for the system in the future. When Basaglians fought to change services in Trieste it was based on a theory of practice and a political understanding of the role of mental health institutions in society. Because many people who currently work in services weren’t part of the orginal Basaglin reforms, there are less aware of why this unique system exists, why it is important and what its theoretical basis is.
When people in the UK ask how the Trieste model works from a procedural perspective they often miss the central importance of its underpinning values and approach. It is symbolised by the movement’s slogan “la libertà è terapeutica” (freedom is therapeutic), and this is what is at stake. Trieste is proof that we can take care of people in despair differently, relying less on proceudures and more on solidarity. Sometimes UK traditionalists assume the only way to deal with people in crisis is either hospital or prison. Trieste gives us all a chance to push back and argue that another way is possible. That is why we need to highlight its achievements and support its survival.
This is a sample article from the Winter 2022 issue of Asylum (29.4). Subscribe to Asylum magazine.