Radical De-institutionalization History in Italy

In my journey through my training centers becoming a psychiatrist, I was accidentally graced that my medical school and subsequent residency centers had medical libraries with superb historical collections. There are a number of other medical school libraries who have similar collections. At Michigan and then at Duke, I found myself spending empty hours reading histories of medicine and then psychiatry in the rarefied collections rooms. These left an indelible mark in my reading appetites that have lasted my entire professional life.

The past five decades of exposure and experience have faced me with the enormous shifts in practice models, the wrenching changes in mental health service delivery since the 1950’s, and continuing dilemmas posed by seductive national solutions that brought with them worsening problems. The overall shift in western mental health care has swung from outpatient care for the well-off seen by private practitioners, the subsequent mental health center movement for the general populace from the 1960’s through the 1980’s, and the even larger but mostly unseen segment of public inpatient psychiatric hospital care that dwarfed all other portions of the mental health care pie. This last “market” underwent the most severe changes of all. By the latter 1960’s the movement to close state psychiatric hospitals was underway fueled by the new sociologic analyses of authors like Erving Goffman and the emergence national awareness of the wretched, medieval conditions of state hospitals and wretched treatment of patients. Commitment laws came to be humanized with respect for patients’ rights to legal representation after the 1974 Supreme Court Wyatt vs. Stickney decision. De-institutionalization, the discharging of inpatients from state hospitals proceeded through the 1990’s, eventually emptying states’ psychiatric hospitals of roughly 4/5 of their beds, closing old hospitals in wholesale fashion.

Many figures played major roles in this profoundly important movement. R. D. Laing in the UK tried treating schizophrenic patients in more open, experimental settings. Typical of those times, whether in state hospitals or a number of private free-standing hospitals, patient governments were formed. Patients were encouraged and helped to make many personal and treatment decisions for themselves. The “therapeutic community” movement arose out of, and in parallel, grew from this non-authoritarian, more democratic hospital life. Hospitals were opened up to the community. Echoing rehabilitation practices of nearly a century before, patients were permitted to work and earn money. Social activities were begun with the return of art, dance, crafts, and musical pursuits.

One very influential source of the de-institutionalization movement in psychiatric hospital care came from Italy in the 1960’s. This piece of psychiatric history is little known in the USA.

The Italian psychiatrist who pioneered many of the components of radical change in public psychiatric hospitals was Dr. Franco Basaglia. His story is nothing short of fascinating. As is so often the case in the culture of Italian figures no matter what their field of endeavor, his crusade began to take shape in his younger years being exposed to different mass political movements and periods of social upheaval in Italy. He was born into the fascist periods of Italy before and through World War II. He absorbed radical social concepts from the communist and socialist movements of post-war Italy. These concepts guided him to become the effective psychiatric reformer that led to his national fame and regard. This kind of personal development would be viewed as heretical, treasonous and would prevent any achievement in this conservative America. But in Italy, Basaglia’s social-intellectual development made perfect sense.

Basaglia did all the things we think of radical in a wretched state hospital. He empowered patients, tore down fences, did away with tortuous physical treatment, had patients go into the community and so on. He did all this in a true backwater town on the northern border away from any and all big cities and centers of thought and social change. He worked for several years in isolation and obscurity. Then through a fascinating chain of fortuitous events, his efforts began to be noticed and the powerful beacons of the press and celebrity status quickly enveloped him, his work and his staff.

His efforts came quickly to be acclaimed and trumpeted nationally and internationally. His influence in Italy was far beyond that of any of America’s famous reformers such as Dorothea Dix, Nelly Bly, Erving Goffman, Laing and all the others. Italy responded with the national social change that has only been equaled in the Scandinavian countries, not France, nor the UK and especially not in the United States.

With a few years, a reform law was passed in Italy named after Basaglia. It set the national goal of the closure of ALL the public state psychiatric hospitals!

This was indeed fully accomplished, a feat that is beyond astounding in the annals of national social change. For several decades now in Italy, there have been no mass hospitalizations of the chronically mentally ill. There do not seem to be hundreds of thousands of “CMI” (chronically mentally ill) persons everywhere on the streets of Italy. Somehow Italy with all its frequent political crises, changes in governments, scandals, raucous politics and all the other tumult that seems par for the national life of Italy, has done what other western societies cannot care pretty well for the nation’s mentally ill.

I would refer the reader who might be interested in the history of Dr. Franco Basaglia and the “reformation” of Italy’s national mental health de-institutionalization and revolution to the writings of Prof. John Foot of the University of Bristol in England. His book, The Man Who Closed the Asylums: Franco Basaglia and the Revolution in Mental Health Care  is well worth the read. An online article published in VERSO, “Closing the Asylums,” gives readers a worthy overview into Dr. Basaglia, the times and his accomplishments.

Realizing what Basaglia accomplished forty years ago leaves this student of psychiatry, its history, and observer of our current national crises, sad for where we have been trapped by our own hobbling prejudices, resistance to social change and pattern of quickie formulas that led to the all too familiar conundrum of “unintended consequences,” and bigger and more complex messes with each year in mental health care delivery.

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Contrarian Thoughts on the State Mental Hospital System: We Still Need Them

The state hospital system in this country began as an attempt in various of the early 13 colonies and later the early states as humane, for the most part, attempts to house the mentally ill. Williamsburg VA, now the site of Eastern Virginia State Hospital and a  similar facility established by the Quakers in Philadelphia were two of the earliest efforts. There was no effective treatment until the advent of ECT (electroconvulsive therapy in the 1940’s and 1050’s with its own then shortcomings and crude, barbaric techniques till refined later, and the advent of psychiatric medications starting with Thorazine, Valium Elavil etc., in the 1950’s.

By this time even the best efforts of Clifford Beers a man who had recurrent psychotic mental illness and wrote in the early 1900’s the first widely read autobiographical account of his onw psychosis which was a national sensation as it described basically for the first time for the public, the pain of being mentally ill, and Dorothea Dix the great crusader for the mentally ill the lattter half of the 1800’s, fell short of preventing the average state hospital from turning into a facility for containment, incarcertion, etc., of the mentally ill. The famous book ASYLUM was published in the fifties and cranked up the debate over “institutionalization” and debasing treatment of the patients in the average state hospital. This fueled, the movement to get patients out of state hospitals, then beginning to be thought of as cruel institutions and less as places of possible treatment or early rehabilitation. This book came on the national scene at the “right” time, caught the attention of the public, politicians, advocates and helped to state the partial dismantling of state hospitals nearly every where. Bed numbers were reduced from averages of a few thousand beds per hospital, as many state hospitals were indeed massive. Smaller was thought to be better and bed numbers through the second half of the 20th century over time came down to the hundreds. And this does not include the dozens of institutions that were outright closed, because of revelations of abuse, mistreatment, no treatment, subhuman conditions, and “warehousing.” The Comprehensive Mental Health Center Act of 1963 was enacted as one of the last major pieces of legislation of the JFK Presidency. Smaller treatment-oriented facilities were to be built all over the country by the hundreds, often to be linked up with major medical centers. One of the earliest community psychiatric hospitals so built was Marshall I. Pickens Hospital in Greenville SC next to Greenville Memorial Hospital. They both still exist today; GMH is the major teaching hospital because of its size and faculty, of the University of South Carolina at Columbia. The opening of Marshall Pickens Hospital was graced by the presence of no less than Hubert Humphrey in the early years of Lyndon Johnson’s administration after the assassination of President Kennedy.

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