Background and task
It can be argued that post-World War II, mental health reform in Western countries started at the turn of the 1950s and 1960s. It found its expression in diverse events, statements and publications such as Enoch Powell's Water Tower speech (in England) in 1961, the Community Mental Health Centre Act (in the USA) in 1963 and Franco Basaglia's directorship of the Provincial Mental Hospital in Gorizia in the northeastern part of Italy in 1961. Seminal texts inspiring some of this reform process were published in 1960 and 1961: ‘Asylums’ by Erving Goffman, ‘The Myth of Mental Illness’ by Thomas Szasz, ‘The Divided Self’ by Ronald D. Laing and ‘Madness and Civilization’ by Michel Foucault. Thus, converging lines of thought and a practical movement were underway early in the 1960s in trying to change what was considered an outdated psychiatric care system.
There has been much international debate on the Italian Mental Health Law 180, which was passed 17 years later in 1978. The international perception of Law 180 has been shaped by diverse frames of reference. There are some current accounts which remind of the genre of eulogy. Nevertheless, these accounts resound of an era in which Italian society was changed profoundly with an outdated, scandalous asylum system dismantled along the way. This went along (with serious regional variation) with the construction of a system of care that was in line with much of the international community mental health care practice and literature. In this editorial, we will offer a few (non-systematic) references to recent publications on Law 180 and the current mental health care system in Italy, and we will discuss the role historiography might play in making sense of regional and international perceptions. We hope to trigger further studies on Law 180 and the Italian mental health reform from a comparative perspective.
Publications in English-language books and journals
Several authors have discussed the Italian reform with a focus on deinstitutionalisation and patient human rights. The radical nature of the Italian reform has been emphasised (Coldefy, Reference Coldefy2012; Morzycka-Markowska et al. Reference Morzycka-Markowska, Drozdowicz and Nasierowski2015a, Reference Morzycka-Markowska, Drozdowicz and Nasierowskib; Castaldelli-Maia & Ventriglio, Reference Castaldelli-Maia and Ventriglio2016). Davidson et al. (Reference Davidson, Mezzina, Rowe and Thompson2010), with an Italian co-author, explicitly describe parallels between the ideas of the Italian mental health reform of the 1960s and 1970s and both (a) the current concept of ‘recovery’ as discussed in the mental health field internationally and (b) the current ‘place and train’ paradigm as applied in, e.g. supported employment and supported education. The authors emphasise that both movements share a firm belief in the right of the individual with severe mental illness to live the life they choose in the community. The authors state that the Italian reform was about ‘changing the community to be better able to accommodate and be responsive to the needs and predilections of its citizens … battling mental illnesses …’ (Davidson et al. Reference Davidson, Mezzina, Rowe and Thompson2010). They say that the reform was centred around four related efforts: (a) two-way streets (people leaving the hospital, and others coming in for all kinds of events); (b) social cooperatives to create employment for people with severe mental illness; (c) joining forces with citizens, welfare services and social movements; and (d) ‘one person at a time’ (implying a genuinely individual approach).
Rosen et al. (Reference Rosen, O'Halloran, Mezzina, McQuistion, Sowers, Ranz and Feldman2012), in a multi-author text with an international perspective, state that there is wide consensus in recognizing that institutional hospitalisation failed to offer adequate therapeutic support or care, that mental health services should, as a rule, be provided in the community, that innovation in community care including housing, work, legislative reform, leadership and funding as well as measures to strengthen the mental health workforce were required. As for Italy, the case of service development in Trieste is used to describe the creation of a system of community services which have replaced the old asylum. The Italian reform is considered a model with community services and good practices deriving from the process of deinstitutionalisation. The authors take their account of international developments as indicating that a model of ‘global community mental health practice of the future’ is evolving. Barbui & Tansella (Reference Barbui and Tansella2008), in an article on the occasion of the 30th birthday of the Italian reform, acknowledge the progress made and highlight concerns: a lack of residential facilities in some regions, the excessive regional heterogeneity in levels of resources, a heavy care burden on families in some regions, shortage of and failure to develop innovative treatment approaches, a lack of research mindedness and of studies to identify the ‘active ingredients’ of the Italian experience. Piccinelli et al. (Reference Piccinelli, Politi and Barale2002) described the implementation of a new and comprehensive system of community services and general hospital psychiatric units. They retained that the quality of care was still a matter of debate. The evidence suggested that drug treatment, psychotherapeutic, psychoeducational and rehabilitative interventions were not readily available, and inpatient admissions tended to be too short and possibly inadequate for most patients with severe illnesses. On the other hand, adverse effects on the incidence of compulsory treatment were not found (Guaiana & Barbui, Reference Guaiana and Barbui2004).
There is a whole series of papers on various aspects of non-hospital residential services and acute inpatient services at the national level: A national survey of non-hospital residential facilities found 1370 such services in the whole country with mostly 24 h staffing, tenfold variation between regions and very low discharge rates, discharge to independent accommodation was uncommon (de Girolamo et al. Reference de Girolamo, Picardi, Micciolo, Falloon, Fioritti and Morosini2002, Reference de Girolamo, Picardi, Santone, Falloon, Morosini, Fioritti and Micciolo2005). de Girolamo et al. (Reference de Girolamo, Bassi, Neri, Ruggeri, Santone and Picardi2007) described the establishment of a network of care facilities and an excess of private inpatient beds per 10 000 inhabitants over public beds (with one of Europe's lowest overall bed rates of 1.7 acute beds per 10 000 inhabitants), and the authors identified challenges facing the system, namely quality of care issues, effectiveness of system integration, public and private sector balance and coordination of resources and agencies. The process of care in Italian public acute inpatient facilities was variable, and there was limited provision of evidence-based psychosocial interventions; problems in managing the inpatient–community care interface were reported (Gigantesco et al. Reference Gigantesco, Miglio, Santone, de Girolamo, Bracco, Morosini, Norcio and Picardi2007).
Altamura (Reference Altamura2009) highlights both the merits and risks of the Italian reform. He refers to the disease burden of affective and anxiety disorders and the evidence in support of early identification and early treatment interventions among people with at-risk mental states or early psychosis. He points to psychiatry being a biomedical discipline and to the risk of not using the full range of knowledge in delivering care in slim mental health services with a narrow-minded ‘purely socio-psychological’ approach. Together with Goodwin, in an editorial, Altamura similarly discusses how Law 180 in Italy has reshaped psychiatry (Altamura & Goodwin, Reference Altamura and Goodwin2010). The authors consider the law a ‘historical legal landmark’ in focusing on the dignity of the acutely ill patient. However, the authors caution against an excessive weight of political position with a risk of underestimating the challenge for clinical care in community settings and the need for high-quality long-term care. They emphasise that neglecting a biomedical perspective and clinical management issues could contribute to public ignorance and deny adequate treatment. A restricted perspective could lead to a failure in utilizing integrated treatment approaches across all mental disorders. The authors consider the profession of psychiatry to be at a crossroads in both Italy and the UK.
The role of Basaglia
The traditional and the organic intellectual
In a social science perspective, we can consider the run-up of Law 180 (i) a specific phase in the development of institutional mental health care, and (ii) a phase in the development of the psychiatric profession (and related professions). This perspective highlights the relationship of mental health professionals with the general health care system, their professional and administrative tasks, their weight in shaping mental health care practice and their ideas as to how mental health services should operate. A related question is how the psychiatric profession deals with related issues such as poverty (of people or mental health services) and how it defines its wider societal responsibility.
The 1960s saw a discussion of professional roles and the role of professionals during processes of reform or social change. This refers to a broader discussion of the role of professional and scientific elites (Weber, Reference Weber1994) in modern society. Antonio Gramsci, Italian Marxist theoretician of the first half of the 20th century, classified ‘intellectuals either as traditional intellectuals or as organic intellectuals. […] Organic intellectuals […] are more directly related to the economic structure of their society simply because of the fact that every social group that originates in the fulfillment of an essential task of economic production creates its own organic intellectual. Thus, the organic intellectual gives his class homogeneity and awareness of its own function, in the economic field and on the social and political levels’ (Ramos, Reference Ramos1982). In any struggle for social hegemony ‘… these organic intellectuals must reason with the masses and engage in a decisive ‘war of position’ to consolidate the hegemonic status of the class the interests of which they share’ (Ramos, Reference Ramos1982). What is important about this concept is that (a) members of the elite can join in with a reformist movement and that (b) Gramsci gives substantial weight to the cultural sphere of ideas in bringing about societal change.
Clearly, this is the kind of political commitment which Franco Basaglia and his fellow activists gave as they criticised and transformed asylum care in Gorizia, Parma, Trieste, Arezzo, Perugia and elsewhere. They formulated a radical, anti-institutional position and joined forces with other reformist movements, e.g. those on workers’ and women's rights. This occurred at a time when a broad consensus, the ‘compromesso storico’ between Democrazia Cristiana and the Italian Communist Party appeared, for a short time in recent history, to be a majority option for the country.
The concept of epoché
In a profession (e.g. psychiatry), tension may arise between wider context factors shaping professional acts and the specific technical work that the public expects of any profession. There is clear evidence that Basaglia was aware of this tension, and he clearly said so. As Weiß (Reference Weiß2013) writes about Godina (Reference Godina2012, p. 50 et seq.) ‘… the process of epoché and phenomenological reduction from Edmund Husserl … tries to strictly distinguish between levels of consciousness – between opinions, speculations, prejudices, paradigms or discourses on the one side and reality or the phenomenon as it appears by itself on the other. Husserl's process of epoché, of conscious pausing, excluding, abstaining from and questioning of all (fore)knowledge – and of phenomenological reduction – …’ was a key concept in Basaglia's thinking. It can be likened to putting themes (such as psychiatric diagnosis or treatment interventions) in brackets (for a while). As Foot (Reference Foot2015b) points out, technical professional issues such as diagnosis, differential diagnosis, psychopathology and specific therapeutic interventions were set aside by Italian reformers at the time.
In a journal article, Foot (Reference Foot2014) writes on the life and work of Franco Basaglia in the historic struggle for deinstitutionalisation. His account does not touch on issues such as diagnosis or medical interventions but is very thorough in describing the intellectual, cultural, regional and political networks which characterised the movement. He provides all the flavour of a reform movement rooted in a broader post-World War II, post-Fascist reform movement with clear links to wider political forces, other societal reform movements and the broader sphere of culture including theatre and art photography (Foot, Reference Foot2015a). In a book on ‘the man who closed the asylums’, Foot (Reference Foot2015b) describes Basaglia's contribution to the Italian reform. He gives a detailed account of the reform movement that changed Italian mental health care in the 1960s and 1970s. The author describes the desolate living conditions in Italian mental hospitals at the time, and he provides the context of Italian politics in the early 1960s and 1970s when the reform took off in Gorizia. In his conclusion, the author quotes Franco Basaglia as saying that ‘I think we made a serious error … when we thought that we needed to criticize the asylum in order that the real face of illness could emerge and for this reason we said that we needed to put the diagnosis in brackets’ (Foot, Reference Foot2015b, p. 394).
It is probably for the science of history to reconstruct the flow of events and to understand what happened at the time. Clearly, those most at the hub of the movement realised that what they were doing was somehow tied to a certain ‘window of opportunity’ in a specific country and at a specific time. Perhaps, the tradition and genius of thinkers such as Gramsci and Basaglia helped to ‘grasp’ the opportunity to transform Italian psychiatry. However, the process is bound to have come at a cost. Basaglia knew (and stated) that there were many more technical, professional issues waiting to be tackled.
Outlook: a suggestion
It is true that what Law 180 helped achieve was accomplished in other countries, too. The care system developed in Italy is not unique in many respects. The Italian reform sticks out in its radical rhetoric and practice and in carrying the process right through to the mental hospital closure in relatively little time (although actual closure did take many years). Mental health reform processes elsewhere had strengths such as, for instance, a long tradition of high-quality evaluation in mental health reform in the UK or of high-quality assertive outreach as in Australia. We suggest that an international perspective on a specific national or regional development (such as the Italian one) can be helpful. Additionally, a historiographic perspective can help understand events that have unfolded in recent history. We need serious studies from the History of Medicine on the Italian psychiatry reform of 40 years ago. Such wide-ranging social and health care change is unlikely to have come about without collateral damage and loss that needs to be part of the inquiry. In the process of changing mental health care, there are many tasks for the profession that must develop the full range of technical components required in diagnosing and treating people with mental disorders. We would argue that Basaglia's brilliance (and his phenomenological training) is reflected in his suggestion to use Edmund Husserl's methodologic approach to knowledge (epoché) and that this helped avoid excessive ideological narrowing. The full width of professional discourse may have been weakened but was not lost.
Psychiatrists (or some psychiatrists) may, at a certain point in time, decide to just fight with and for the rights of the poor (in or outside of institutions) many of whom are mentally ill. In such cases, the terrain they are moving in is the wider sociopolitical arena where they are part of a wider movement. In doing so, some Italian psychiatrists in the 1960s and 70s might have had Gramsci's concept of ‘organic intellectual’ in mind. However, the professional and technical terrain will always be there to be covered. Psychiatrists would, hopefully, not forget their profession in the process.
Acknowledgement
Comments and suggestions on an earlier draft by Stefan Priebe are gratefully acknowledged.
