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Closing the Asylums

Forty years ago this week, Italy began to shut down its psychiatric hospitals. The change was driven by a movement with a radical new vision of mental health.

Franco Basaglia, year unknown. Franca and Franco Basaglia Foundation

On May 13, 1978, Law 180 marked the beginning of the end for Italy’s asylums. A social movement that had begun in 1961 finally reached parliament, securing the support of all parties except the neofascists. The law is often known as the “Basaglia law,” owing to the central role of the radical psychiatrist Franco Basaglia in driving a new approach to mental health.

Basaglia’s revolution began at an asylum in Gorizia, northeastern Italy. Like many others at the time, it was structured around the architecture and paraphernalia of containment. There were cages for unruly patients, straitjackets, portable electroshock machines, and storerooms for personal belongings that were often never collected. But Basaglia created a movement that broke down these walls of repression, in his workplace and beyond.

Introducing a radical democracy in the asylum, Basaglia allowed psychiatric patients to speak for themselves, in the heart of one of the most antidemocratic institutions imaginable. This cultural revolution was a precursor for ’68. People came from around the world to see the patient assemblies. But Basaglia did not want to create what he called a “golden cage,” prettifying the hospital. Rather, he aimed to destroy the whole psychiatric hospital system.

This struggle also had a wider cultural significance. Gorizia’s radical psychiatry movement fed and fed off movements in Italy and around the world. Italy’s institutions were in dire need of reform, from the schools, to the army, the Church, prisons, and the universities. Inspired by Basaglia’s example, doctors, soldiers, prisoners, priests, lecturers, and students all began to “overturn” their own institutions and call for real change.

The First Prison

Franco Basaglia was born in 1924 in Venice. His family were very well off, and lived in an imposing four-story palazzo on the Grand Canal. They were not militant fascists under the regime, but nor were they enemies of Mussolini. Franco Basaglia was different. He was radicalized at school thanks to a charismatic teacher named Agostino Zanon dal Bon. He opposed the regime’s ideas and policies and already as a teenager took part in anti-fascist activities.

On one occasion he broke into his class at night and covered the blackboards with radical slogans. In some ways, his actions betrayed his family. He had lived his whole life under fascism up to that point. The Nazi-occupied Venice of 1943 to 1945 was a grim place. Pitch dark at night and overcrowded, the population lived in fear and food was scarce. Partisan activity was difficult in the city and many anti-fascists joined up with small groups in the mountains. The opposition was vulnerable and easy to infiltrate.

In November 1944, somebody named names, and the entire group was picked up. Basaglia tried to hide on the roof of his family’s palazzo but he was arrested. He then spent five terrifying days in a police station under interrogation before being sent to prison with no sentence. The prison, run by Nazis and Italian fascists was a forbidding place, with daily deportations and an area reserved for Jewish prisoners.

In April 1945 a revolt erupted inside the prison. The prisoners broke out of the institution and spilled into the city. It was the beginning of the liberation of Venice. Basaglia was one of those who liberated themselves that day. If a film is ever made about Basaglia’s life, it would start here — with the breaking down of the prison walls.

Basaglia did not take up a career in politics after the war. He wanted to be an academic. His unorthodox approach, interested in Sartre and new forms of philosophy, did not endear him to his professor, a traditionalist neurologist named Gianbattista Belloni. After many years as an assistant on little or no pay, Basaglia was told he wouldn’t make it as an academic. This was a bitter blow, and Basaglia would not forget it. He later compared the university system to psychiatric care; universities, too, were “total institutions.”

Gorizia

However, another kind of post had just come up, and Belloni urged Basaglia to take it. This job was in Gorizia, a tiny town with a big history. The city had been razed to the ground in World War I and then cut in half by the peace agreements at the end of World War II. Just yards from the Iron Curtain, Gorizia was a town of just 40,000 people with numerous soldiers, barracks, and checkpoints.

It was also a very right-wing, with a powerful Christian Democratic party, a strong neofascist presence, and a tiny left. This was not, perhaps, the obvious place to start a revolution. Basaglia was a sophisticated intellectual from Venice with cultured friends and a young family, while Gorizia was a backwater. But he had little choice. In November 1961 Basaglia took charge of the asylum, with its 500 patients.

Patients were held for observation after referral from families or doctors, or the police. Many were then diagnosed with specific mental “diseases” (or other afflictions, such as alcoholism) and kept — sometimes for years, sometimes for decades, sometimes until death. The asylums were regulated by two pre-fascist laws, which held patients to be “a danger to themselves and to others, or a public scandal,” and the fascist criminal code of 1930, which gave patients a criminal record, despite the fact that they had committed no crime and been subject to no trial.

Treatments were carried out in Gorizia’s asylum, but they would be difficult to describe as therapeutic. Inmates were subject (without any choice) to electroshock and insulin therapy, lobotomies as well as straightforward torture such as freezing water baths and a localized type of waterboarding where a cloth was placed over their mouths and water poured on top. It was called a hospital, but it didn’t feel like one. Were these people actually “patients” at all?

Many settled down after time into what Erving Goffman in 1961 called the “career” of the “perfect patient” — passive, bowed down, accepting of the system, no longer in control of their bodily functions. Their days went by without any real sign of change. Time went on, but the sentence had no end.

Forms of what was later called “institutionalization” were widespread among both patients and nurses. The asylum was marked by repeated, obsessive behavior; humiliation; hierarchies of power; and torture. Cigarettes were omnipresent and were also used as currency. Doctors came and went as they pleased, carrying out what R. D. Laing would call the “ceremonial of control” of the ward round before dedicating themselves to their private practices.

When a patient died, the church bell was rung, and they were taken away. By any measure, these were a forgotten people e— the living dead. And there were 100,000 of them, in the almost uniform psychiatric hospitals across Italy. These people were powerless — unable to control their own lives or treatment. Wedding rings and clothes were taken away on entry, the patients had nowhere to keep their possessions, and their hair was also shaven. Men and women were rigorously separated.

Basaglia’s first reaction was disgust. It also reminded him of his anti-fascist past. As he wrote in the 1970s:

The first time that I went to prison I was a medical student. I was an active anti-fascist and I was imprisoned as a result. I remember the terrible situations that I found myself in. It was the time of slopping out. There was a terrible smell, the smell of death. I remember that it felt like being in an anatomy theatre where the bodies were dissected. Thirteen years after I graduated, I became the director of an asylum and when I entered the building for the first time, it took me straight back to the war and the prison. It didn’t smell of shit, but there was the symbolic smell of shit. I was convinced that that institution was completely absurd, that its function was only to pay the psychiatrists who worked there.

Things, however, soon began to change.

A Total Institution

Basaglia took the job. But his mind was made up right from the start. He wouldn’t accept how this place worked. From the very beginning he believed that the asylum was like a concentration camp. He saw it as a place of death, and later defined it as a kind of dumping ground for the poor and the “deviant.”

But how could change come? There was no clear plan at the beginning. But according to a colleague, “On his first day as director in Gorizia, when the head nurse passed him the list of people who had been tied up that night, he said, ‘I’m not signing.’” It was a first act of resistance, against his own power and against the logic of the institution he controlled.

One advantage of the fact that Basaglia was in a dead-end job, in the middle of nowhere, was that nobody expected anything of him. This gave him a strange kind of freedom. And it would take years even for most Gorizians, never mind other Italians, to notice what now began to take place.

At first, Basaglia was completely isolated. His only ally was his wife, Franca Ongaro. She had never studied psychiatry and was not qualified to work in a psychiatric hospital, but was central to transforming the asylum. Basaglia and Ongaro wrote together and she was a constant figure in the hospital throughout the 1960s. Studies of Basaglia often relegate her a footnote, or to the role of typist or assistant. But she should be placed right in the center of this story — as one of the leaders and protagonists of a national and global movement for change within (and against) psychiatry.

Family life was dominated by politics and the activity of the asylum. Smoke-filled meetings (Basaglia was an eighty-a-day man!) spilled over into the family flat, in the town center. Often, the kids would be kicked out of their bed to accommodate a guest. Yet, the trappings of family life in the Basaglia household were bourgeois — every evening Franco, Franca, and the two children sat down together for a dinner served by a maid.

Basaglia also needed other allies. The vast majority of the nursing staff was against change, and the other medics were largely (and often violently) conservative. He decided to recruit friends and colleagues to create a group — or an équipe as it became known. This was a laborious process, and the provincial administration did not make things easy. They were suspicious of this young psychiatrist with his unorthodox methods.

Basaglia received constant official nagging letters calling him to order — for allowing men and women to mix together, for organizing patient events without explicit permission, for failing to pay his phone bills. He never grew to love Gorizia. His small group of like-minded colleagues kept to themselves. When the town really got to him, he would put a record player on his top floor balcony and blast out the antiwar song Gorizia, ti sei maladetta (Gorizia you are damned) to the high street below.

Bit by bit, the balance of power in the hospital began to change. Like-minded psychiatrists arrived. Walls were knocked down and fences removed, the tying up of patients was discouraged and then phased out altogether, and some were even discharged, as far as possible under the 1904 legislation. Electroshock therapy was reduced (although not phased out entirely). A patient newspaper was set up. A bar was opened in the grounds, as was a hairdresser. Patients got back their clothes, and their dignity. Men and women were allowed to mix together. Many were encouraged to find work, for which they were paid.

Pulling Down Fences

Basaglia argued — more philosophically — that all medical diagnosis should be “placed in brackets.” It was important to build up a relationship with the inmates and to listen to their stories. In one case, Basaglia and his first collaborator inside Gorizia, Antonio Slavich, spent four days and nights listening to the traumatic life story of a patient called Mario Furlan, who had repeatedly tried to commit suicide. Furlan went on to become one of the patient leaders of the movement inside the hospital. Basaglia did not just remove fences, gates, and barriers — as well as locks on doors — but encouraged the patients to take power. The patients themselves pulled down fences

“We put the key in the door,” Basaglia later said, but the patients needed to turn it. In 1965, hospital-wide patient meetings were introduced. Votes were taken and discussions ranged around a variety of issues, from the mundane to the profound.

These events particularly caught the attention of Mario Tommasini, a councilor in distant Parma. Tommasini had a record of rebellion, twice expelled from school and even thrown out of prison after sparking a prisoners’ demonstration. The free-thinking Communist, who had joined the anti-fascist Resistance at age fifteen, strongly identified with Basaglia’s desire to tear down walls. Put in charge of Parma’s own health-services department, he was shocked by asylum conditions there, which he compared to the concentration camps. In 1965 he decided to make an unannounced visit — a 250-mile journey — to Gorizia. There, he witnessed some of the first assemblee firsthand.

After this first visit Tommasini became the first key supporter of the Gorizian experiment. He invited Basaglia to Parma to give a public lecture and published the first book put together by the équipe in 1967 — What is Psychiatry? — with its cover designed by the illustrator Hugo Pratt, a childhood friend of Basaglia’s. Tommasini brought together nurses from Gorizia and Parma for a debate. It was not a meeting of minds. Both were still asylums, governed by the same laws, but in most other ways they were completely different places.

Tommasini also desperately tried to get Basaglia to come to Parma in order to direct (and close down) the Colorno asylum there — but Basaglia was reluctant to do so, and the politics of the move were difficult. Egos and personalities also played a part. Basaglia was a democrat, but he also liked to be in charge. Some even referred to him as authoritarian. Tommasini was also a strong believer in his own way of doing things. They were friends and they often agreed on what should be done, but they found it impossible to work together. The personal was political.

Faced with a hostile asylum director and nurses, and unable to draw on Basaglia’s intervention, Tommasini adopted a different tactic for Colorno. He attacked the hospital from the outside, creating opportunities and spaces for patients in the real world. The hospital itself remained essentially unchanged, but patients were daily taken out of the institution to work or take part in therapeutic activities.

There was more than one way to close an asylum. It took political will, psychiatrists, nurses, patients, a movement of ideas and resources. Tommasini also organized an occupation of part of the asylum in 1969, a spectacular event garnering national attention. The asylum, the students said, was “our Vietnam.”

It was around this time that a group of radical texts began to circulate in Italy — Foucault’s History of Madness (which also provided a critique of reformist approaches to madness and historical context), R.D. Laing’s The Divided Self (which saw what was called schizophrenia as an understandable and even rational reaction to the pressures of modernity) and perhaps above all, Erving Goffman’s Asylums. This Canadian sociologist’s work was central for the movement’s analysis of the asylum. He had immersed himself in the reality of a huge psychiatric hospital in Washington D.C. for more than a year. His analysis was cold, detached, and devastating. Asylums were “total institutions,” which controlled every aspect of inmates’ lives. The asylum patient’s career ended with complete submission to the system.

A Household Name

Gorizia’s message reached the general public through the cultural industries. In March 1968, in another moment of perfect timing, a collective book was brought out by the prestigious Einaudi publishing house in Turin. The book was an account of what Basaglia called “the reality of an institution in transformation.” It contained the voices of patients as well as high theory and detailed accounts of debates. Its form, as well as its content, were deeply intertwined with 1968 and its aims.

The Negated Institution: Report from a Psychiatric Hospital was a publishing sensation. It flew off the shelves, and onto the shelves of every budding ‘68er. It was translated into French, German, Portuguese, and Spanish, (but not into English). Students turned up to see Gorizia in droves — and were followed by journalists, photographers, and politicians. Italy’s health minister — the Socialist Luigi Mariotti — passed a reform in 1968 that softened the repressive nature of the asylum system. He was scathing about the hospitals he had seen and compared them to “German concentration camps, Dantesque chambers of hell.” By 1968, Gorizia was influencing national law and policy.

In 1968 the influential documentary filmmaker Sergio Zavoli arrived in Gorizia with his crew. He was known as “God’s Socialist” thanks to his Christian-Socialist approach. Zavoli was very taken with the Gorizian experiment and in January 1969 over 13 million viewers saw his twenty-minute, prime-time documentary on national TV. Basaglia was transported into ordinary families’ living rooms, telling them that “nobody knows what mental illness is.” Even more extraordinary were the words of ordinary patients, interviewed by Zavoli in the hospital grounds. Carla Nardini, who had been deported to Auschwitz and then ended up in Gorizia’s asylum, cried on screen as the camera closed in on her tears.

Another patient denied that he was mad at all and expressed his desire to leave the hospital. The Gorizian revolution was mainstream. The Negated Institution even won a top literary prize, something that caused great embarrassment to the politicized psychiatrists in the hospital. They accepted the money (which they gave to the patients) and not the prize, which caused enormous irritation among the awarding committee. Basaglia’s fear of becoming fashionable was coming true.

Basaglia had become famous, almost overnight. He was ambiguous about this newfound fame, comparing his role on a book tour, held to packed audiences, to a “traveling salesman.” He enjoyed power, and understood that he needed power to get things done, but he was also lucid about what was now expected of him. Basaglia was no magician. He told a group of radical students who had occupied a university that

I think that today, I have become an institution … and I think that the people here today want to know things from me, and discuss specific issues, but they are asking me for something that I cannot deliver.

But Gorizia’s greatest moment of fame was also — ironically — a time of crisis. In September 1968 a long-stay patient named Giovanni Miklus murdered his wife while on day-release. This shocking event was the pretext for an outbreak of hostility towards the Basaglians within Gorizia. Local neofascists called for judicial action, and the Provincial Administration decided that enough was enough.

Basaglia and a fellow doctor, Antonio Slavich, were interrogated by a public prosecutor and although Basaglia was cleared (he was in Germany when the murder had taken place) Slavich was charged with manslaughter. He was not cleared until the trial itself, in 1972.

Basaglia reacted very badly to the Miklus murder. He closed some wards and a fiery debate broke out within the équipe. Personal jealousies and political differences — as well as burnout — were driving the équipe apart. The creative unity of the Gorizian experiment was no more, and it had not done enough to reach out into society. The movement, Basaglia argued, had to move on. He took a break, spending six months in New York and then traveling around Latin America after a huge advance from his publisher for a book that would never appear.

When he came back, he was clear about the future. The movement would go beyond Gorizia. The Gorizians would take control of other asylums, in order to close them down and abolish themselves. Gorizia itself would be abandoned to its fate.

In 1972, the Gorizia revolution came to an abrupt end. The doctors resigned en masse, claiming that all but fifty-one of the patients in the hospital were “better.” They wrote a magnificent revolutionary open letter, citing Frantz Fanon, to the Provincial Council. The psychiatrists claimed that: “Our presence in the psychiatric hospital, as well as being useless, is damaging for those patients … for whom we continue to represent, as psychiatrists, the justification of their internment.” The radical doctors left, and normality returned to Gorizia’s psychiatric hospital. Basaglia’s revolution moved on.

From Gorizia, the Basaglians spread out across Italy — taking over hospitals and psychiatric services in Arezzo, Ferrara, Pordenone, Udine, Venice. Parallel movements were already in charge in places like Perugia and near Naples. In some places Basaglia was outflanked on the left by Italian anti-psychiatrists who denied the very existence of mental illness, but still found work high up in the world of psychiatric hospitals. Many asylums remained entirely unreformed, as Gorizia had been in 1961 and Colorno in 1965.

In the early 1970s Basaglia moved to a bigger city and a larger asylum, in Trieste, like Gorizia close to the Iron Curtain. Here he found another almost unchanged asylum — with familiar features such as cages, bars, and locked wards. Basaglia moved quickly, and this time had political support. Everything was easier, now, and Trieste’s asylum opened up to the city, just as the city moved towards the asylum.

In the 1970s, the Trieste asylum became a magnet for radical psychiatrists. It was here that new mental-health services were first created. Basaglia’s liberation strategy was increasingly flamboyant. Patients were taken up in a chartered plane and flown over Venice — something that was denied to them by law. Ornette Coleman played a concert in the asylum grounds. A blue papier-mâché horse was designed inside the hospital and wheeled out into the streets in the city, followed by artists, patients, and activists. Artists and others created works dedicated to the cause of reform.

The asylum in Trieste became a site of pilgrimage for psychiatrists and volunteers. In 1977 Basaglia held a press conference where he announced that the asylum in Trieste was, to all intents and purposes, no longer working as a psychiatric hospital. Across Italy, reformers and politicians began to push for change to the outdated laws governing mental health.

After the Asylum

The law introduced in 1978 was a compromise. As Basaglia was well-aware, this was a victory, but only a partial one. The next twenty years saw alternative services created right across Italy — day-care centers, emergency wards, halfway houses, cooperatives. The vast majority of the 100,000 patients reentered normal life. Some, quite simply, could not exist outside the asylum. This group was given a technical name — “residuals.” The strategy for their future was never explicitly spelled out, but in reality, the only thing to do was to wait for them to die.

This process of closure (and of opening up to society) was contradictory. There were suicides and murders. Families often had to take up the slack after hospitals were closed. Regional differences were huge and the funding and quality of new services varied greatly across the country. Trieste, however, is still a model for psychiatric services post-asylum.

Franco Basaglia died in 1980, from a brain tumor. His funeral began by gondola and ended in the family plot on the St Michele island in Venice. He was just fifty-six years old. He never had the chance to implement the law that took his name. Mario Tommasini continued to fight for the rights and liberation of mental=health patients, as well as others such as orphans and the disabled. His legacy remains, despite savage cuts, in places like the Fattoria di Vigheffio — a farm once owned by the Provincial government which now contains housing for ex-patients, a cooperative-run bar, and a beautiful garden. In 2008, Parma’s local council issued an apology to “all the people who were interned in the psychiatric hospital.” Arezzo even has a monument to the “victims of the psychiatric hospital.”

Italy today has no asylums. It is no paradise, but that system is gone, and it was abolished not for reasons of cost, but for moral and political reasons. Today, the former asylums perform a variety of functions. Some are empty and abandoned. Others are “museums of the mind.” Many still have links to health and mental-health services. Some are schools, some are universities, some have become housing. Trieste’s ex-asylum is now a stunning rose garden.

The “great internment” described by Foucault gave way, in the 1970s, to a “great liberation.” Society absorbed most of the 100,000 inmates. This process was forced on the system from a movement that acted from inside the institutions themselves, in a way that was unique in the Western world. Italy’s asylums were closed down by the people who worked in them. In doing so, these people abolished their own jobs — forever. Nobody, today, is employed in the posts that Basaglia and his colleagues held in the 1960s and 1970s — as directors of psychiatric hospitals. Nobody, today, is the director of a psychiatric hospital in Italy. Thee movement acted against its own self-interest — in a way that was the opposite of clientelism, patronage, and nepotism. It was a negation of itself.

Today, Basaglia remains a household name in Italy (and not just there). He is still a hugely controversial figure, who divides opinion. His legacy is also felt in many other countries, from the UK to Brazil to the Netherlands to Germany. One of the slogans of the movement was “Freedom is therapeutic.” But was “freedom” enough? Whatever the answer, it was an extraordinary journey.