TRIESTE: HISTORY
of a change
‘… the important thing is that we have shown that the impossible becomes possible. Ten, fifteen, twenty years ago, it was unthinkable that an asylum could be dismantled. Asylums could become closed, and more closed than before – I do not know -, but, at any account, we have shown that the mad can be assisted in another way, and this evidence is basic. I do not believe that the fact that an action can become general means that one has won. The important point is another one: Now one knows what can be done. This is what I have already said thousands of times. In our weakness, in the minority we represent, we cannot win, because it is the power to always win. We can at most convince. In the moment we convince, we win, that is we give rise to a transformation situation, difficult to recover.’
Franco Basaglia, Brazilian Conferences, 1979
In the annual occasion of the ‘world health day’, April 7th, 2001 was devoted to mental health. In that occasion, Mrs. Gro Harlem Brundtland, general manager of the World Health Organisation, launched a message to all governments, so that they strove, with concrete actions and communication campaigns, to face the stigma, the prejudice, and the social exclusion, which still affected the lives of the people suffering from mental disturbances - over two-hundred millions of men and women, a country four times as large as Italy. The slogan ‘Stop exclusion. Dare to care’ stressed the WHO invitation to close all, still active psychiatric hospitals, both in rich countries and poor ones.
In a booklet, distributed on April 7th, one wrote among the rest:
‘… In Italy, the 1978 reform law started a process to overcome psychiatric hospitals, with the creation of community-centred services, which allowed patients to lead their lives in normal social contexts. The Italian city of Trieste created a significant network of community-based services, protected flats, and cooperatives giving work to psychiatric patients. The Trieste psychiatric hospital was closed and replaced by 24 hours’ working community services. Those centres gave health assistance, psycho-social rehabilitation, social assistance, and, if required, treatments for acute episodes. A certain number of protected flats were created for chronic and most seriously affected patients, giving a friendly, non-medical environment. Eventually, work opportunities allowed many patients to ensure an actual integration in the social environment…’
This opinion – so gratifying for Trieste – represents the culmination of a transformation activity followed during thirty years. The history of this long path has not been written yet, even if a large archive exists. Let us try, in the following paragraphs, to reconstruct, to the highest degree, some sequences, traces of search and memory.
The Overcoming of the Psychiatric Hospital
In August 1971, Franco Basaglia took up the management of the Trieste psychiatric hospital. On accepting the task, he did his best to establish a working group made up by young doctors, sociologists, social assistants, volunteers, and students coming from different cities and regions, both Italian and European. Many were attracted to Trieste from the importance of the speech about psychiatry and total institutions, which was being taken
up in those years in the social and opinion-making movements, the information bodies, and the political debates.
The therapeutic community model, originally developed in Gorizia by Basaglia and his staff in the previous decade, assumed a national resonance after the publication of ‘L’istituzione negata’ (‘The Denied Institution’) (1968). That book, while documenting the efforts to humanise the institution, announced for the first time the fact that psychiatric hospitals could not be reformed: Obedient to rules and laws of public order and social control, they could not meet the assistance and cure targets, even being psychiatric hospitals producers of illness.
Trieste should then follow the path traced by Gorizia to go beyond the asylum - transforming the organisation, not reforming it, but overcoming it through the construction of a network of community, alternative services, replacing the manifold functions – of health, hospitality, protection, and assistance – performed by the hospital.
The challenge was very hard. Despite the several reforming experiences also started in France and England after the Second World War, nobody ever succeeded in actually shifting the axis of cures from the hospital to the community. No knowledge or consolidated practices existed, which the reforming process could be linked to; nor the available juridical and legislative regulations, still based on the opinion of dangerousness of the mentally ill, were in themselves enough to authorise an actual opening up and civilising of the cure functions in psychiatry in a territorial and community sense.
On the ‘deconstruction of the psychiatric hospital’, as an ’urgently necessary event’, Basaglia had written the following in 1964:
‘From when the ill overpass the commitment wall, they enter a new dimension of emotional void (result of the illness that Burton calls institutional neurosis, and that I would simply call institutionalisation); that is, they are admitted to a space that, originally born to make them inoffensive and meanwhile curing them, practically appears as a place paradoxically built for the thorough annihilation of their individualities, as a place for their full objectivation. If mental illness is, in its own origin, a loss of individuality and freedom, in the asylum, the ill only find the place where they will be finally lost, made object of the illness and the repetitive admission. The absence of any projects, the loss of future, constantly being dependent on the others without any personal incentive, seeing their days organised, and dictated by organisational requirements, that – just as such – cannot consider the single individual and the peculiar circumstances of each. This is the institutionalising scheme which the asylum life is articulated’ on.
The Change of the Internal Organisation
On December 31st, 1971, 1182 people were hospitalised in Trieste, with a yearly turnover of about 1300 patients, more than 90% of which suffered from a forced hospitalisation (Law 36/1904); very few benefited of a voluntary hospitalisation, recently introduced in the Italian legislation (Law 431/1968). Just the use of the voluntary hospitalisation – which, in Trieste, was stressed by the new staff – became a fundamentally important instrument not to deny patients their rights – not only to increase their freedom of movement within and outside the hospital, but also to give the hospitalised a power to exercise in the improvement of cures and assistance.
Already from the first months of 1972, much attention was paid to the organisational change of internal spaces, with the putting in place of a critical attitude towards the rigid,
professional hierarchies regulating the relationships between staff and patients. The transformation was initially conceived as a progressive reduction and restructuring of the hospital spaces into ‘open communities’, with the splitting up into 5 ‘areas’ – and as many staffs –, which five geographical areas of the city and the province would make available.
Besides the management daily meetings, where all working groups confronted each other, meetings and debates with the staff were held every day within each staff. Hospital patients were gathered to debate the changes in progress during periodic meetings, coordinated by Basaglia. The opening of the doors of the wards coincided with the suppression of shock therapies and all physical restraint systems. The subdivision between men and women was also abolished, and the field for the creation of mixed wards was prepared.
While the hospital community life grew lively with several events (parties, bars, inmates’ news), the move of patients to the city – both individual and in small groups – multiplied. People were so slowly reintegrated in the possession of money to access public places, also thanks to the distribution of subsidies (once in a while, or monthly), given by the province administration from the beginning of 1972.
The transformation process beginning rouse resistances in the nurses and alarm in the citizenship:
“… the ideology that the ill were dangerous and had to be closed in an asylum was predominating. The beginning of the work therefore consisted in convincing that things were just not so. We tried day by day to demonstrate that changing the relationships with the inmates changed the meaning of that relationships. Nurses began to convince themselves that their work could be different, and thus become a transformation agent. On the other hand - to convince the population -, it was first of all necessary to take back the mad into the streets, into social life. Through that, we incited the aggressiveness of the city against us. We needed to create a tension situation, to show the change in progress. As time passed by, the city understood what was happening. The important thing in the training of nurses was that the new reality type brought them not to be dependent on the doctors, to be operators who could make decisions by themselves’
Franco Basaglia, Brazilian Conferences, 1979
The Return of Rights to Inmates
In those first years, the staff work concentrated on the reconstruction of the needs and the personal histories of the hospitalised, in the attempt to re-establish their relationships with families and places of origin. As large wards were re-dimensioned, living together groups and flat groups were organised – at the beginning within the hospital, then in the city. The working style was oriented to the systematic involvement and the training of nurses, who had to leave their traditional functions as ‘guardians’ to take up an active and responsible role in the changing process.
Among the different organisation forms of patients – who started to gather between them on several initiatives and activities –, the establishment of the ‘Cooperativa Lavoratori Uniti’ (‘United Workers’ Cooperative’) associating about 60 hospitalised people, assigned to the cleaning of wards, kitchens, and the park, had a special importance in 1972. The assignment of a regular trade union contract to each hospitalised person–worker represented the result of the commitment of the first years against the exploitation of
inmates, usually named ‘ergotherapy’. The stipulation of the contract and the acknowledgement of the cooperative, also supported by a strike of the hospitalised working at the hospital general services, anticipated the paths which in the subsequent years would lead to more and more numerous establishments of social cooperatives.
The acknowledgement of the right to work, along with the breaking of the ward routine with the creation of smaller and autonomous community and living together units, made clear that it was not disability or illness in themselves, but the juridical and administrative statute as ‘inmates’ which hindered the actual establishment of rehabilitation paths. So did a dialogue begin with the province administration, so that the day / night cure and hospitality were acknowledged as a right also for those people who, not even needing hospitalisation, were still forced to be hospitalised as ‘guests’, lacking assistance, living, and social inclusion alternatives.
‘In those first years, part of the work consisted in talking to relatives, or tutors to be able to change the status of the ill, around the problem of restitution of civil rights and economic, income possibilities. That was the only effort which allowed us to remove people from total psychiatric control. Inmates had to be acknowledged as people endowed with other identities, that did not dry up in their being objects of the institution, and objects of psychiatry. We considered we could not interact with them, if their citizenship statute had not been given back before.’
from an interview to Franco Rotelli, 1978
The Establishment of a Relationship Between Hospital and Territory
Even though the services’ activities continued to have their centre of gravity in the institution, already from 1973, practices were strongly projected towards the outside, in a recovery of the relationships with families, in bringing the inmates to the city, in finding a work and an accommodation for those liable to be discharged. In parallel, the hospital increasingly opened up its entry into the city. Arts groups, parties, and concerts invited the population into the San Giovanni space. It was at that stage that the bases for a knowledge and an alliance between the psychiatric experience, and the citizens and former patients’ associations were cast – groups of young people, women’s and students’ movements, political and trade union organisations, information and opinion bodies, both intellectuals and artists.
A painting-, sculpturing-, theatre-, writing-laboratory was organised in the first empty ward (‘P’), where ‘Marco Cavallo’ was built: A large, light blue horse, in wood and cardboard, a symbol of the wish of freedom of all inmates, which, on the last Sunday of March 1973, was brought around the streets of the city at the head of a procession of operators and patients, artists, and citizens. Stays at holiday resorts and groups’ trips or ‘outings’ to take part in the usual city activities were more and more frequently organised.
The hospital organisation was further transformed between 1973 / 1974, fitting the criterion – already defined in 1972 – to arrange patients in the wards, not according to seriousness (agitated, violent, chaotic, ill, chronic), but according to origin, based on a subdivision of the urban and province area into ‘areas’ that remained the same during the years (corresponding to the present four health districts, and the relevant Mental Health Centres). A working style was thus started, whose target was the discharge and the support to patients in their own domiciles and life contexts; also the assumption of new cases was more and more made dependent on the search for a cooperative relationship
with bodies, institutions, and citizens in the concerned area.
The work outside the hospital – between problems, successes, conflicts – introduced the first and most significant changes in the therapeutic practice, and the institutional, hierarchical, and administrative order, thus becoming a training school in the field for nurses and doctors.
The Birth of the First Community Centres in Identified Areas
At the beginning of 1975, the inmates were 800, 90 of which were detained, 150 volunteer, and 460 guests. The turnover was of about 1700 patients. Many of the discharged had already found accommodation outside - sometimes in families, more often in group flats and independent accommodations, rented by the social security body.
The first community accommodations were activated between 1975 and 1976. These structures were initially geared to the support of patients discharged from the psychiatric hospital, but, almost immediately, they were used for the admission of patients under crisis. They acted as day referral centres, had the effect of consistently reducing the number of new hospitalisations, as well as the frequency and lengths of admissions.
The first Mental Health Centres were therefore established in advance with respect to Law 180, and could develop despite a fragmentary regulation and little firm legal bases. The above-mentioned Law 431/1968 only allowed a difficult validation of the new structures, similarly to the regulation of the ‘Centri di Igiene Mentale’ (‘Mental Hygiene Centres’) the law had introduced. In the meanwhile, the psychiatric hospital organisation was still active, and this was the most delicate and difficult moment in the transformation process, where two organisational and cultural models of assistance lived together, as well as two financial systems, two management styles for nurses. The risk was paralysis. This transitional problematic period would be overcome through the strengthening of the community assistance, the growth and the progressive development of the 24 hours’ open Mental Health Centres.
At the beginning of 1977, the inmates dropped to 132, 51 of whom were involuntary, and 81 volunteer; guests were 433. In the February of the same year, a 24 hours’ available psychiatric intensive care service was established at the emergency ward of ‘Ospedale Maggiore’ (Main Hospital), with the goal of filtering the psychiatric demand, finding the most suitable solutions for the crisis, contrasted with the automatic and routine recourse to the forced hospitalisation. The service would remain active until 1980, when – after the issuing of Law 180 – it was transformed into a ‘Servizio Psichiatrico di Diagnosi e Cura’ (‘Psychiatric Service of Diagnosis and Care’) acting as a psychiatric emergency ward, consultancy at the hospital wards, and channelling to the appropriate community Mental Health Centres.
Towards the end of 1976, on the beginning of the crisis of the province council, that under the lead of Michele Zanetti had supported the reformatory process until that moment, Basaglia decided to publicly announce the closure of the psychiatric hospital as a by then irreversible fact:
‘An important result for us is that community Centres – even if not exorcising the sometimes uncertain level of their practices – increasingly become meeting places for ex-inmates, new users, and other citizens. These subjects, even if not having a common reference point right away, progressively discover the area of their substantial alliance on the emerging of common needs and oppressions. The other important fact is that the so-called ‘management of the