The Destruction of the Mental Hospital
*Editorial note
Until recently, the website for Trieste, Italy’s mental health services hosted a substantial archive of texts and materials of the Psichiatria Democratica (Democratic Psychiatry) movement, including a sizable subsection in English. They suddenly came down sometime a few years ago. I can only guess that the removal had something to do with the threatened loss of funding from the Northern League in 2021. This is a big loss, so we at the Network will be reposting them. Democratic Psychiatry is a movement that emerged at the conjunction of two experiences: fascism and social psychiatry. The group the began the movement were committed antifascists and multiple served prison sentences. They also happened to start their psychiatric careers right as the humanizing/liberalizing movement for social psychiatry was once again taking off and gaining international popularity in the 1950s and 60s. They believed that such reforms were a “guilded cage” and that the real goal of psychiatry was to “destroy the institution” in a continual process of revolution to ensure the most open and free development for patients. Franco Basaglia was one of the central figures of the movement (we also just passed the centennial of his birth!) and this speech represents his entry into public debates around psychiatry. It was delivered at an English Congress of Social Psychiatry. It also perfectly represents the kinds of bold and stark interventions Democratic Psychiatry made. I am sure the psychiatrists there thought of themselves as among the most enlightened and peaceful of all psychiatrists, and Basaglia’s first statement accused them of having nothing but force to prove their superiority to their patients. A few notes: the original text had “Burton” to refer to the author of the book Institutional Neurosis. This must have been the fault of a transcription or a translation, because the author is Russell Barton, so I’ve replaced it throughout. Institutional Neurosis was one of a few highly influential works on the personal and social effects of long-term institutionalization. Today it is overshadowed by the more popular Total Institutions by Erving Goffman. “Slave-lord” refers to the passage in Hegel’s Phenomenology of Spirit and is often translated as “lord-bondsman” instead.
-Sasha
“The Destruction of the Mental Hospital as a Place of Institutionalization: Thoughts Caused by Personal Experience with the Open Door System and Part-Time Service”
Franco Basaglia, Direttore Ospedale Psichiatrico Provinciale di Gorizia
First International Congress of Social Psychiatry. London 1964
In 1925, a manifesto by French artists who signed themselves. "La revolution surrealiste", addressed to the directors of "looneybin" ended thus: "Tomorrow morning, at visiting time, when without any lexicon you try to communicate with these men, you will be able to remember and recognise that, in comparison with them, you are superior in only one way: force".
Forty years later, tied - like the greater part of the European countries - to an antique law still swaying between assistance and safety, pity and fear - in an attempt to reorganize a mental hospital where force did not have to be the only method of approach - one finds himself in front of new prospective problems in certain aspects insuperable if one wishes to arrive - through the definite destruction of "looneybin" - at the construction of a hospital as a place of treatment for the mentally ill.
The psychiatrist of today seems to have discovered, all of the sudden, that the first step towards the cure of the patient is his return to liberty of which, until now, the psychiatrist himself had deprived him. The necessity of a regime, of a system in the complex organisation of the closed space, in which the mental patient has been isolated for centuries, had required the doctor to be merely a keeper, an internal guardian, a moderator of the excesses which the illness might bring about: the value of the system surpassed that of the object of its care.
But today's psychiatrist takes into account that the first steps of liberation in the mental home cause in the patient a sudden release from the prospect of time erased, not only by his illness, but also by the long time spent in the hospital. The patient - from the moment in which he is placed in a new dimension of emotional vacuum (the result of the illness that Barton calls "institutional neurosis", or stated more simply, "institutionalization") - find in the "looneybin" a place constructed for the complete annihilation of his individuality, a place where he can assume a concrete state in his own objectiveness. If mental illness is a loss of individuality and liberty, in the "loony bin" the mental patient can find nothing more than a place where he will be definitely lost, where he will be made the object of by his illness and by those who treat him.
The loss of a scheme, the loss of the future, the state of being in the power of others without being able to direct oneself, and having one's day tuned and organized on an impersonal rhythm, dictated only by organizational demands that - such as they are - cannot take into account the single individual and particular circumstances: this is institutionalization. This is, however, also the rhythm on which society is based. Thus, when the patient - alienated from life, suffering from the loss of relationship with others, and himself - enters the mental home, instead of finding here a place where he can free himself from the burden of others, where he can reconstruct his own personal world, he finds new rules, new structures that make him lose himself still more, and push him more and more towards objectiveness, until he identifies himself with them. This is why men still fear each other, why they do not trust one another and why the consequences of madness, that are for the legislator the centre of his apprehension, overcome the value of the mentally sick patient as a man.
Isolated, segregated, made more inoffensive by the walls that enclose him, the patient seems to assume a value other than that of a man, something between a docile, shapeless animal and some dangerous beast: this occurs only as long as one considers madness as an irremediable evil against which there is nothing to do except defend oneself.
But the "loony bin" - born as a defense on the part of the sane against the mad, as protection of their structures from the invasion of centers of infection - seems to have been considered, finally, as the place from which the mentally sick must be defended and saved. "The object of Psychiatry - Ey says correctly in one of his recent articles - is no longer the patient who frightens others, but the sick man who is afraid".
The discovery of liberty as an act of rehabilitation for the institutionalized patient brings him, therefore, out of the "loony bin", where he has been segregated for centuries. In reality there are everywhere gratings, keys, bars, gates, and nurses without the slightest theoretical or humane preparation - but the problem is open. The destruction of the "loony bin" is a fact that is, at least, urgently necessary if not plainly obvious.
It is true that the discovery of liberty is the most obvious that Psychiatry could reach. So obvious that no discussion or problems should arise. But, evidently, the obvious is the most difficult thing we have to face, because it places a man face to face with his own basic problem, without screens of refraction. That the restricted, closed, and limited space of "the loony bin" might be harmful to the mentally sick was clearly perceived before now, but the fear of the mad overcame every logical and humanitarian comprehension. So the patient - by now despoiled, possessed by other, a prey their own fears, their own lost plans, their own desolated failures - were not able to give him other than a sick relationship.
The institutionalized person described by Barton in his monograph, is the man petrified by our hospital, the immobile man, without an aim, without a glance at anyone, without expectation without hope, the man for whom there is nothing to move or induce him in the search for himself but the open door, if one does not wish him to continue to identify the physical barrier, the closed door with his own internal barrier, so that the limited and incumbent space of the mental home is gradually identified with his own internal vacuum. For the patient, the loss of liberty, which is at the base of his illness, is inevitably identified with the liberty of which we deprive him: he is the door against which every plan, all his future, is shattered.
Naturally the problem of liberty for the mental sick, or better the problem of the mentally sick man in his hospital, has not arisen suddenly, by the revelation of a hidden or misunderstood reality: Psychiatry - as a branch of medicine - has fortunately found a weapon in psychiatric drugs that have brought a sudden transformation, not so much to the mental illness itself, but to the doctor's method of approach to the patient.
If at first it was possible to ignore the appeal that psychodynamic theories launched, teaching a new method of approach to mental illness and therefore to the patient, after the advent of psychiatric drugs, the necessity of a new outlook on mental homes was imposed, calling into action Psychiatry and the responsibility of the psychiatrist. The fact that the patient, through drugs, appears now free of old schemes, of clamorous syndromes, places him, in our eyes, in a completely human sphere, so that it become impossible to isolate him in the circle of madness, and not to consider him simply as a sick man.
However Barton, in his monograph, acknowledges also in the drugs an institutionalizing power, and one cannot be other than in agreement with him when the drugs are administered in a climate seriously institutionalizing: if, at the same time, the drug is in action, the hospital does not perform the defense of the patient’s liberty from the lack of which he already suffers, the drug - giving him, by its action, a wider limit of consciousness - will increase his conviction of being rejected and relegated to the circle of the "lunatics". Therefore, the particular attitude of the patient in pharmaceutical treatment - indifference, apathy similar in many aspects to the lack of any interest in life, like that in the institutionalized man - can be imputed to the constant institutional power of the hospital, which continues to act on the patient in the sense of further deterioration.
But the obvious discovery of liberty, which the psychiatrist seems to have made, presupposed in him the acknowledgement of his own liberty. The overcoming that is, of an objective relationship with the patient, in whom he can no longer see an isolated object of study or analysis entrusting the patient to himself in the alienated relationship of slave towards lord, but a subject in whom he can acknowledge his own subjectivity and liberty. The doctor - society's delegate to cure the mentally sick - cannot, as the advanced guard of the world of the sane in contact with the alienated, continue to mirror on an executive level the attitude of society. If the society, the administrative organization on which the "loony bin" depends, seems to live in a constant cult of pessimism, the psychiatrist cannot be a disinterested mouthpiece. If fatalism towards the mentally sick could be justified in the absence of a efficacious therapy, then after the advent of the pharmaceutical era it became inexplicable, if not by the imputation of responsibility to the actual psychiatric class.
The part-time services are being started everywhere as an organization outside of the hospital, as the first barrier to avoid entrance into the hospital. But even if this new structure is able to make a first step towards weakening the hospital as institutionalization where the patient is a character still under trial, condemned every moment to be put under an act of accusation, the text of which is never shown because it is drawn up from his whole life in the asylum.
This is not the time to speak - in a country like England in which the first works of emancipation were begun many years ago - of how much has been done and experimented on in a hospital of a hundred patients in which the level of institutionalization was beyond possible supposition.
I would rather try to fix some points in an attempt to form a lever - without the slightest support of a law or a society which says it is not ready and mature enough to take an initiative of this kind.
1) Pressure on the administration, on which the hospital depends, by the involved action of joint responsibility for the situation previously maintained.
2) The awakening of conscience and of joint responsibility on the part of the doctors who have accepted and preserved this situation.
3) The introduction of drugs by means of which, notwithstanding the institutionalized climate, the breaking of the "bond" of the patients was made possible.
4) The attempt at re-education - theoretical and humane - of the nurses (this however is still far from having been reached).
5) The keeping alive - as far as possible - of the ties of the patient with the world outside (family, friends, interests).
6) The opening of the doors, and the beginning of life according to the open door system.
7) The creation of presuppositions of the Day Hospital, soon to be opened, as a part-time service.
To transcribe in figures the result obtained in two years' work in this regard, is to go beyond the aim of this paper, above all because the results are not dissimilar from any other experiment of the kind, practiced in any "loony bin" that wishes to change itself into a hospital, also if, as in our case, the cult of pessimism was and is still hovering around every initiative which can be made only by keeping vivid the joint responsibility of all in the lack of the realization of the necessary means.
I shall limit myself therefore to the examination of some consideration relative to the results contained.
The most important point, after the realization of these first steps towards freedom in the hospital, is the patient's gradual regaining of consciousness of his own right. The mentally ill man is no longer presented as a man resigned and docile to one's wishes (one does not even wish him to be so), a man disposed to accept anything because he is intimidated by force, and by the authority of those who look after him, a man who accepts supinely as natural and logical his own inferiority in comparison with others. But he presents himself as a mad man who, even if made an object of by his illness, no longer accepts being objectivized by the look of the doctor who keeps him at a distance. The allayed aggressiveness, which comes to surface every now and then as an expression of the illness and of institutionalization, which the consequent apathy and disinterest, gives way in many patients, to new aggressiveness arising from their obscure feelings – beyond their particular delusions – of being “unjustly” not considered men solely because they are ill.
It is in this moment that the patient, with an aggressiveness that transcends his actual illness, recovers the possession of his own right to lead a human life. And it is now that the doctor can no longer betray his relationship of equality with the patient; he cannot – after having worked on the feelings of humiliated and wounded humanity that are still lulled in him leave him in the closed space against which his new illusions cannot break out.
It is now that the “open door”, as a definite witness of the doctor’s escape from the world of deception, acts on the patient as a most efficacious demonstration of the fact that the psychiatrist no longer lives in the cult of pessimism although the patient and society continue to believe in him. The patient understands the pregnant significance of this long before society, which still seems a stranger to these problems. The “open-door” (the terror of our legislator), the abolition of the gratings, the opening of the gates, act on him profoundly, giving him the perception of living in a place of cure and guardianship, in a place in which he can gradually re-conquer his relationship with “others”, with the doctor and with his fellows.
An alienated place, for the reasons already stated, the mental hospital seems, however, to risk changing into another place of alienation, if it is organised as a world complete in itself in which all needs are satisfied as in a golden cage: the life of the mental patient is projected towards the exterior, the bonds between the patient and the place of his feelings, of his struggles, of his wounds, cannot be broken. So all the measures that are now adapted (the day hospital and the night hospital) as barriers to avoid entrance into the hospital, may be one of the last steps towards the complete liberation of the rehabilitated patient. In this part-time hospital he can live on two levels: that of the treatment, and that of the re-conquest of a liberty of which he will feel himself master and for which he is responsible. For now, the patient continues to feel this liberty something coming from out side, not as a result of his conquest, so that for a long time, after the abolition of the gratings, within the limits that restrain him materially, he does not go beyond that which he sane have imposed on him: for a long time the pattern of the courtyard remains in his mind, and the open door is to him, for a long time, a closed door. Without realizing it, he now, in his attitude of aggressiveness, completely vindicates his own personal right to personal right to personal freedom as a man and as a patient since, by accepting it as a gift from the doctor, he re-falls into an alien relationship of slave-lord.
Meanwhile the aggressiveness thus arising, (that is the aggressiveness that we psychiatrists need for an authentic relationship with patient) unloads and organises itself into a group constitution of various types: the work-group, the discussion group, community therapy, clubs, and standard and specific group therapy in which the patient is at the side of another patient, each one for himself, and together with the others, stretching towards something in common: health.
So through the destruction of the “loony bin”, and then through the gradual reduction of the open-door hospital as the asylum for mentally ill patients, we will be able to arrive – through the outside service – at a psychiatric service, which will save the liberty of the one who lost it to illness.