From Gorizia to Trieste

The San Giovanni asylum did not differ greatly — either in its structure or in its methodology — from what the Borda or Moyano neuropsychiatric hospitals are today.

It is in this way that the process of psychiatric deinstitutionalisation begins, as a movement critical of traditional psychiatry, around 1961, when Franco Basaglia — together with a group of young doctors — develops a practice in keeping with the principles of the therapeutic community in the city of Gorizia, an experience that will continue until 1968, the year in which Basaglia asks for the asylum to be opened and comes up against the refusal of the administration; he then resigns with his team, denouncing the fact that the patients of the asylum remained committed because the economic conditions were not there for them to be able to live outside it.

Italy had some 110,000 people committed under a law of 1904, by which patients lost — among other things — their civil rights and found themselves subjected to a regime of oppression characteristic of the institutional structure.

The game becomes dialectical by breaking with the system of hierarchical, pyramidal order, producing a horizontality of roles and, as a consequence, their derigidification; all of this from a socio-political-economic point of view in which marginalisation and social exclusion appear between the community and the inmate of the asylum; where it is observed that the majority class of the asylum is the weakest one, and that the use of technical and scientific knowledge, translated into power, serves to sustain the system.

These gestures are then clothed in a phenomenon that marks the whole of Europe: the French May of 1968, which in Italy has a particular repercussion in the workers’ movements; permeated by the new health policy, these support the variant approaches to madness put into practice up to then and the ideology that goes with them.

Franco Basaglia takes over as director of the San Giovanni asylum, in Trieste, in 1971; the population of inmates was at that time around 1,200 people…

Among the first measures, a programme is presented that outlines “the new structuring of psychiatric assistance according to the principles of prevention, care and aftercare”, and Law 431 is brought into force, which provides, for every 125 inmates, one “primario” physician, one “assistant primario”, one assistant physician, one social worker and one psychologist.

From then on a complex process takes shape that might be called “a space of transition”, peopled with questionings, reformulations and new definitions, whose final objective would be psychiatric deinstitutionalisation.

Of madmen, of slaves, of labels, of roles

Young doctors arrive in Trieste to be trained within this revolutionary experience; they come as fellowship holders, at the same time as students and professionals from different parts of the world and from Italy itself, who occupy the role of volunteers (the concurrentes).

The proposal is to do, moving within a progressive ideology, breaking traditional structures and aiming at clear objectives. From this perspective, the activity that used to be concentrated in the asylum begins to be decentralised. Home visits start to be carried out, in which the life and the history of the patient were discovered: whether he had parents, children, a spouse, whether he had friends; in short, everything that could represent the patient’s world.

One of the results — perhaps the most important — is the humanisation of the role. The old nurses, made chronic by the code of the institution, tell how their own attitude (from within their role) changed markedly once they recognised in this patient no longer merely a label “of the best psychiatric nosography style”, but what lay behind that label: the human being who felt, who thought and who possessed a world full of lived experience.

Out of this simple and complex fact a notable turn takes place in the nurse-patient relationship: distances have been reduced, a verticality declines, hands are joined, affection begins to let itself be glimpsed.

Thus it is not only the role of the patient that changes: the role of the nurse is revalued as well. No longer as it used to be regarded, reduced to the simple task of the doctor’s assistant, in charge of giving out the medication, washing the sick or giving orders to the patients; but from the recognition that it is he who is in permanent contact with the inmate, and that his own experience must be capitalised upon through dialogue, in the daily team meetings (social workers, nurses, doctors and psychologists), where a horizontal dialectic takes place.

The thresholds of marginalisation

The walls of the old asylum begin to give way and it becomes an open community, where the inmates find themselves in the capacity of “guests”. In parallel, intensive work is carried out with the population in order to reformulate the concept of madness and its association with dangerousness.

Theatre performances, exhibitions, recitals or concerts are given by those who are now former inmates and, by a “pendulum” effect, society observes — whether in its own space or on the stage of the asylum — the performances of the members of the art workshops of the former psychiatric hospital. At the same time, politics and the media broadcast denunciations and criticisms of the asylum institution and of its methodology, describing the methods employed as violent and as generating violence.

Facts such as decentralisation itself lead to a closer relationship between the population and the workers of the asylum who, having themselves changed their own way of looking at madness, unfailingly produce changes in those around them. It is in this way that families begin to take charge of the patients, gradually generating, out of the particular, the general process of social reinsertion.

To start from the needs of the patient, that is the subject: to hear what the human being needs in order to function socially, in order to be able to recover his own worth in society and to reconstitute his dignity (those values he lost on entering the psychiatric hospital), and thus to be amalgamated once again into the social fabric.

In the old asylum, patients carried out cleaning, kitchen and laundry tasks, for which they received no payment; this assignment was turned into stable work, with set hours and the corresponding wage. A system of “health” allowance is then created in which each patient has, on the economic level, the possibility of entering the productive apparatus through his role as a consumer, and of generating a social exchange out of that possibility. A cooperative is also set up in which former inmates come together and in which different trades are practised that make it possible — beyond the economic benefit — to recover an identity within the social structure.

From patients to users

The semantics already give an account of the horizontality of the relationship: the term patient ceases to be used in favour of “utente”, which means user, derived from the Latin uto, to use; a term employed to designate the person who uses a service, and not the one who waits to be taken care of.

For the users, as the process of reinsertion continues, a network of “group flats” is created (from around 1975 onwards), in order to solve the problem of housing; and almost simultaneously mental health centres are set up (seven up to today), each of which covers a given area of the province.

Given that Trieste has 300,000 inhabitants, each health centre would work with a population of around 40,000 people.

The centres are ordinary houses, located in central and outlying neighbourhoods; each has seven or eight beds for emergency admissions, a staff that rotates permanently twenty-four hours a day, and a “trattoria” attached to the centre, where around sixty people have lunch and dinner every day.

The team is made up of 4 doctors, 25 nurses, 2 social workers and a rotating group of volunteers.

Every day a team meeting is held in which ways of working, activities and so on are discussed, and every week a general meeting attended by the various workers of each of the services.

The essential part of the activity unfolds outside the centres, maintaining the decentralised structure of care.

In 1978, the bill for Law 180 is presented to the Italian parliament, repealing the old law of 1904. This law establishes:

Today

Franco Basaglia dies in 1980, “paradoxically” of a brain tumour. Franco Rotelli takes over the direction and carries the movement on to this day; permanent questioning and criticism of the roles being performed is encouraged there, which makes possible their non-rigidity and their non-stereotypy (which would be, precisely, the characteristic of the role within the institution).

How does a working day function today, from the arrival of a user?

The user may present at the psychiatric emergency department of the general hospital; after having been treated immediately, he is directed to the mental health centre that corresponds to him, according to where he lives. There, in dialogue with the workers, the degree of severity is determined and, from that, the length of his admission (let us recall that these are emergency admissions). From that moment on, the form of care is prescribed and the team begins to intervene in an interdisciplinary way.

Home visits are carried out (whether or not the patient has a family), the social workers eventually arrange the possibility of an allowance (if the user is not in a condition to work) and, in the case of work, they will endeavour to place him through the cooperative, as well as to find him housing. In parallel, work is done at the centre with the user: his feelings and his history are learned, his own needs are listened to, always with a view to consolidating the task of reinsertion and reintegration into society.

Epilogue

An Eastern tale tells the story of a man who lived in the grip of a serpent. One day when our man was asleep, the serpent, slipping in through his half-open mouth, went and lodged itself in his stomach and, from there, began to dictate its will to this unfortunate man, who thus became its slave. The man found himself at the mercy of the serpent: he was no longer master of his own acts, until one fine day he felt free again — the serpent had gone. But he suddenly realised that he did not know what to do with his freedom.

All the time the absolute domination of the serpent lasted, the account goes on, the man had grown used to submitting his will, his desires and his impulses entirely to the will, the desires and the impulses of the serpent; he had thereby lost the very will to desire, to want and to act autonomously. In the place of freedom he found only emptiness: the departure of the serpent made him lose the new essence he had acquired during his captivity. He had only to learn to reconquer, little by little, the earlier and human content of his life.

The analogy between this fable and the institutional condition of the mentally ill person is striking: it seems to illustrate, in the form of a parable, the incorporation by the mentally ill person of an enemy that destroys him with the same arbitrariness and the same violence that the serpent of the fable exerts in order to subjugate and destroy the man. But our encounter with the mentally ill person has shown us, in addition, that in this society “we are all slaves of the serpent”, and that if we do not attempt to destroy it or to vomit it up, the moment will come when we shall never again be able to recover the human meaning of our life.