Response

This commentary responds to the recent piece ‘Franco Basaglia (1924–1980): the reformer of the Italian psychiatric system – psychiatry in history’, published to mark the centenary of his birth. ^{Reference Schochow and Ernst1} Beyond celebrating his historic achievements, it reflects on how Basaglia’s legacy resonates today and how his principles may continue to shape modern psychiatric practice.

When Franco Basaglia (1924–1980) began working in psychiatric hospitals in the 1960s, he encountered institutions that resembled custodial facilities more than medical settings, where patients were deprived not only of rights and autonomy but also of the therapeutic attention central to medicine. ^{Reference Mezzina and Saraceno2} Rooted in humanism and political engagement, Basaglia saw the asylum as a ‘total institution’, in Erving Goffman’s sense – a place that stripped patients of both liberty and identity – and argued that treating mental illness under such conditions was inherently contradictory. ^{Reference Suibhne3} His radical response involved unlocking wards, abolishing physical restraints, creating therapeutic communities and opening psychiatric hospitals to the broader public. These reforms culminated in Italy’s Law 180 of 1978, which mandated the closure of psychiatric hospitals – the first and only country to legislate such a complete reform – and established a nationwide network of community mental health centres, general hospital psychiatric units and social cooperatives. ^{Reference Badano4} Basaglia’s insistence that psychiatry address not only symptoms, but also autonomy, independence and functional capacity, provides a guiding framework that remains influential today. His approach stemmed from a deep critique of psychiatry’s epistemological roots and its role in social exclusion embodied by the asylum. His project sought not just institutional reform but a redefinition of mental health within a broader human and social context.

Since Basaglia’s time, psychiatry has undergone profound scientific, clinical and organisational transformations. Advances in neurobiology, genetics, neuroimaging and pharmacotherapy have expanded the therapeutic arsenal, while evidence-based psychotherapies, early intervention programmes and integrated care models have improved outcomes and functional recovery for many patients. ^{Reference Scangos, State, Miller, Baker and Williams5} Mental healthcare has also shifted toward person-centred and recovery-oriented approaches, emphasising autonomy, hope, resilience and social inclusion alongside symptom reduction. International frameworks reflect this evolution: the World Health Organization’s (WHO’s) Comprehensive Mental Health Action Plan (2013–2030) ^{Reference Singh6} and the United Nations’ Convention on the Rights of Persons with Disabilities (CRPD) ^{Reference McCusker, Gillespie, Davidson, Vicary and Stone7} advocate for community-based, rights-focused and socially inclusive mental health strategies. Despite these advances, major challenges persist. Involuntary hospitalisation and coercive practices remain widespread, raising ethical and legal concerns. Community services are often underresourced, resulting in fragmented care and continued reliance on hospital-based interventions. Disparities in access to mental healthcare are pronounced, particularly for marginalised populations, and gaps remain in the prevention, early detection and integration of precision medicine into routine practice. Workforce shortages, limited interdisciplinary collaboration and bureaucratic barriers further hinder comprehensive care. In this complex landscape, Basaglia’s principles remain highly relevant, offering a moral and strategic compass for shaping a psychiatry that is scientifically rigorous, ethically grounded and firmly committed to recovery-oriented, humanistic care. However, despite the broadening of therapeutic options, evidence for substantial improvement in long-term outcomes remains limited. Gains in effectiveness and functional recovery have been inconsistent, and the impact of psychosocial interventions continues to depend heavily on social and contextual factors. Basaglia maintained a critical yet constructive stance toward scientific methods. Informed by phenomenology, he sought to integrate humanistic and social perspectives into psychiatry while supporting epidemiological research, including his later collaboration with the National Research Council on the prevention of mental illness.

Basaglia’s ideas converge with modern psychiatry in several important ways. Today’s person-centred care echoes his conviction that patients are citizens first and patients second, while attention to social determinants of mental health resonates with his critique of inequality and social exclusion as drivers of suffering. Similarly, the growing emphasis on rights-based care aligns closely with CRPD’s call for dignity, autonomy and inclusion.

At the same time, significant tensions persist. Psychiatry now rightly emphasises evidence-based rigour, whereas Basaglia was primarily concerned with addressing structural injustice rather than controlled trials; integration of scientific validation with his ethical and humanistic vision remains a challenge. Clinicians also continue to navigate the balance between risk management and respect for autonomy, yet Basaglia insisted that risk is inherent in freedom – a perspective that remains provocative in today’s risk-averse culture. Furthermore, global disparities complicate the application of his reforms: his work unfolded in a high-income European country with relatively strong social services, while in low- and middle-income countries the wholesale abolition of psychiatric hospitals may be neither feasible nor desirable without substantial investments in community infrastructure. Recognising these tensions is essential for any serious effort to bring Basaglia’s ideas into dialogue with contemporary psychiatry, ensuring that his principles inform practice while remaining attuned to scientific, ethical and practical realities. The 2022 WHO World Mental Health Report (https://www.who.int/publications/i/item/9789240049338) underscores the need to shift from institutional to community-based care, reflecting Basaglia’s reform principles. The report emphasises that deinstitutionalisation must be accompanied by the expansion of accessible, community-integrated services, a challenge especially relevant in low- and middle-income countries. Basaglia’s vision was most fully realised in Trieste and the surrounding Friuli Venezia Giulia region, where the closure of the psychiatric hospital led to the creation of a network of 24 h community mental health services. Recognised by the WHO as a collaborating centre for its innovation and sustainability, the Trieste model has inspired reforms in several countries, including Brazil and Argentina.

How might Basaglia’s vision find renewed expression in modern psychiatric practice? Several opportunities stand out. Psychiatric decisions should certainly be guided by diagnostic categories and evidence-based protocols, but they must also reflect an unwavering commitment to respect, autonomy and dignity. This approach prioritises voluntary engagement over coercion and can incorporate the latest psychoeducational programmes, supporting patients as active collaborators in their own care.

Basaglia insisted that mental conditions cannot be understood in isolation from the social world in which they unfold. Modern psychiatry can bring this insight to life not only through partnerships with housing agencies, employment programmes and educational institutions, but also through collaboration with other medical disciplines, including paediatrics. Such integrated care models prevent services from becoming siloed, and ensure that treatment addresses the social, economic and physical determinants of health.

Participatory governance – opening services to patients, families and broader community stakeholders – fosters accountability, responsiveness and shared ownership in the design, delivery and evaluation of care, including research initiatives. Digital psychiatry, from telepsychiatry to artificial intelligence-driven interventions, offers additional opportunities, but Basaglia’s principle of inclusion reminds us that these tools must reduce disparities and remain accessible to marginalised groups.

In a world reshaped by inequality, climate crises, pandemics and forced migration, his focus on social determinants offers a valuable framework for designing responses that address both mental and physical well-being. ^{Reference Kirkbride, Anglin, Colman, Dykxhoorn, Jones and Patalay8} Only in this way can Basaglia’s vision avoid becoming a nostalgic homage, remaining a living framework for a more humane, integrated and rights-centered practice.

Franco Basaglia was a reformer of his time, but his vision reaches far beyond the closure of asylums. He reimagined psychiatry as inseparable from ethics, politics and social justice – a perspective that remains urgently relevant today. Modern psychiatry has advanced in ways he could hardly have imagined: effective treatments, early intervention and digital tools. ^{Reference Colizzi9} Nevertheless, many of the challenges he exposed endure: coercion, exclusion and the chronic neglect of community services. The task now is not to romanticise his reforms or ignore their uneven implementation, but to embed his ethical compass in a psychiatry that is scientifically rigorous, clinically effective and socially just. This work remains unfinished. It is a challenge that psychiatry must embrace to meet the complex needs of the 21st century and honour the humanity of those it serves.