Response

We write in response to the short text published in the British Journal of Psychiatry (BJP), on behalf of the Royal College of Psychiatrists, commemorating the centenary of Franco Basaglia’s birth. ^{Reference Schochow, Ernst and Steger1} This contains several inaccuracies about Basaglia’s work and its impact.

Basaglia considered all psychiatric hospitals as anti-therapeutic, not just ‘traditional psychiatric hospitals’. After his appointment as the director of the asylum in Gorizia in 1961 he quickly realised that the psychiatric hospital, as a total institution, was not just a threat to the identity of the patients but it also made their conditions worse and systematically violated their human rights. He opened the doors of the asylum, abolished restraint and declared the need to ‘destroy’ the psychiatric hospital. ^{Reference Basaglia, Toresini and Mezzina2} After having experimented with a therapeutic community approach at first, he planned a reduced role for the hospital, and quickly moved to shutting down the hospital completely and creating a full alternative to the old institution that ‘had to be denied’. ^{Reference Basaglia3} Basaglia did not merely ‘campaign for the promotion of out-patient psychiatric treatment’. Rather, he helped establish a completely new mental health system in the community, mainly through his work in Trieste in the 1970s. While the psychiatric hospital was being closed, community mental health centres were developed that were open all hours and addressed all therapeutic needs in each locality. This included supporting patients’ livelihood through economic subsidies and work cooperatives. ^{Reference Dell’Acqua and Cogliati Dezza4} Basaglia helped establish a new approach for realising patients’ rights as citizens in the community.

Basaglia’s main concern was not to promote a new mental health law, but rather to challenge and eliminate the role of psychiatric hospitals from mental healthcare, culture and legislation. The BJP editorial fails to reflect the enormity of the change that Basaglia and his colleagues achieved in Trieste. Their work was not limited to ‘discharged patients [being] offered accommodation in newly established mental health centres and residential homes’. The newly established 24/7 community mental health centres offered a range of support, with a very small number of beds, not just for those discharged from hospital but for anyone who needed mental healthcare, treatment and support in the community. Patients with complex conditions who had been institutionalised for a long time were offered a variety of housing options in group homes and supported accommodation, as well as supported independent accommodation in the community.

Law N.180 (1978) did not constitute a ‘milestone for anti-psychiatry movement’ for Basaglia. The new legislation marked the culmination of several years of anti-institutional (not anti-psychiatric) work led by Basaglia and was part of a larger mental health reform movement in Italy. This shift to community care was explicit in the law, which had nothing to do with the ‘anti-psychiatry movement’ at the time but marked the beginning of a new form of psychiatric practice in the community.

Basaglia was not an ‘anti-psychiatrist’ even though he had a dialectical relationship with them. He repeatedly rejected being an anti-psychiatrist: ‘I am not part of any anti-psychiatry movement, and I categorically refuse to be an anti-psychiatrist. Anti-psychiatry does not mean anything, it is like psychiatry. Instead, I think of being a psychiatrist, because my role is that of a psychiatrist and through this role, I want to wage my political battle.’ ^{Reference Basaglia5} He also stated, referring to himself and colleagues working with him in Gorizia, ‘we have never been anti psychiatrists, we were simple employees…we worked in the real world within psychiatric institutions to give people suffering an alternative to the violence and repression of the asylum’. ^{Reference Foot6}

Anti-psychiatrists of the time, such as R.D. Laing and David Cooper, were essentially proponents of a form of cultural dissent, engaged in a theoretical discourse, largely disconnected from a more collective practice of psychiatric reform and deinstitutionalisation. According to Basaglia, ‘Laing’s theory and practice tend to focus and concentrate on individual subjective change; instead we tend to concentrate on social transformation, while keeping in mind other levels of the problems… [but] these two aspects, the subjective and the social, are two sides of a single reality’. ^{Reference Basaglia, Ongaro Basaglia, Scheper-Hughes and Lovell7} Basaglia’s work and his achievements survive his death and continue as a practice of collective transformation with far-reaching implications for mental healthcare and public health choices. While anti-psychiatrists such as Thomas Szasz denied the existence of mental illness, Basaglia was more interested in improving mental healthcare. This included challenging the claims and power of institutional psychiatry and its epistemological basis, that of control rather than treatment. ^{Reference Basaglia8}

The World Health Organization (WHO) did not ‘intervene in the reform process’. Fundamental changes in mental healthcare – the development of a comprehensive, community-based mental health system as a complete alternative to the psychiatric hospital in Trieste – came about because of the work of Basaglia and his colleagues. It had little to do with the WHO. However, the WHO commissioned one of the first evaluations of the Trieste services and recognised Trieste as a WHO Collaborating Centre in 1987. According to the WHO, the mental health service network in Trieste is among the best practices globally. ⁹ The Italian law is also considered a model for entrenching human rights in mental health. All this is the result of the work of Basaglia and his colleagues, which, we believe, is not fully acknowledged in the article in the BJP.