De Luca Condino

Theatre as the kairos of care: Basaglia and his legacy

Saturday January 15th, 2022

Foto (c) Luciano d’Alessandro

The boundary between normality and madness has always been one of the ideal frontiers that every society assigns to itself in order to identify and defend itself. In the transition from concept to practice, each society has imposed different laws to isolate the “different” and prevent them from disturbing the established order. Repression has been the dominant response in all eras with a few golden exceptions. In the opening of our psychology section, Valeria Condino and Emma De Luca outlined an in-depth look at the work of one of the greatest innovators in the treatment of madness, Franco Basaglia, and his legacy forty years on. The World Health Organisation estimates that one out of every four people in the course of their lives is faced with mental distress. In 2019, the year to which the latest Report on Mental Health in Italy, disseminated, promoted and implemented by the Ministry of Health, refers, more than 800 thousand people were assisted for psychiatric problems. The patients who came into contact with the Departments of Mental Health in 2019 amounted to 314,120 units, of which 93% had contact with the services for the first time in their lives, but the resources in the field are not enough to provide them with adequate care and from this we can deduce how little space is dedicated to mental health. In other words, today the sector is again under attack, probably due to a specific political will to change the organisational set-up of everything related to mental health. But in order to evaluate what is happening, it is necessary to question the developments of the last few years and how the reforms in the psychiatric field have allowed the development of mental health services and community medicine, which were so far in the vanguard. But let us proceed step by step. In 1964, at the First International Congress of Social Psychiatry, Franco Basaglia posed a crucial question to democratic societies for the first time: “The destruction of the psychiatric hospital as a place of institutionalisation”. Quoting Antonin Artaud, who said in the asylum: “You may remember this tomorrow morning, at visiting time, when without any vocabulary you will try to converse with these men, towards whom, admit it, you have no superiority other than force”, Franco Basaglia acknowledges that the destruction of the asylum is a necessary and urgent, if not simply obvious, fact. Traditional psychiatric theories, which were established behind the shadow of Cesare Lombroso's principles, were not concerned with the treatment of patients, but with the management of the sick person whose danger had been decreed. The gaze of some artists of the time (photo Luciano D'Alessandro to be inserted) shows that it was mainly the poor who filled the asylums, who were at the bottom, because they were enrolled in the judicial system and could not be reintegrated into work, nor cured. To be ill was to be ghettoised. Asylums in the twentieth century were governed by the rules laid down by the provincial health authorities and managed by psychiatry. They stood on the periphery, respecting an ancient tradition according to which the monstrous, the mentally ill, had to be hidden. Between the 50s and 60s there were about 100,000 people interned; in the transition from agricultural Italy to metropolitan Italy many people were left without a specific place, relegated to the outcasts of society, thanks also to Law 36 of 1904.
In the years following '68 came anti-psychiatry, a movement of contestation that arose within Anglo-Saxon psychiatry and psychoanalysis, but whose origins can be identified in the suggestions coming from Foucault's studies, in particular from Histoire de la folie à l'age classique (1961) which reconstructed the forms of psychiatric repression implemented since the 17th century. From that moment on, Focault's thought began to spread, to be appreciated and 'used' within the community of psychiatrists and psychoanalysts. Among them, Ronald Laing and David Cooper developed a thought of strong opposition to classical psychiatry, which gave rise to alternative experiences such as the management of “Pavilion 21”, started in 1962 in a London psychiatric hospital, or the creation of the “households”, reception centres outside the asylum. English anti-psychiatry rejects traditional science, attributing to it a violent practice on madness - in a broader repressive ideology exercised by society, the family, other institutions - against which a dialectic of liberation must be opposed, in defence of an idea of schizophrenia as a creative and purifying journey, a form of rebellion to be adopted to endure an unbearable situation. For Laing, for Cooper and for other psychiatrists who identify with this movement, Foucault plays a function of anchoring and reinforcing ideas that are still in the process of development. Unlike British anti-psychiatry, Italian anti-psychiatry understands that there is an open contradiction between the denial of institutional power and its management. According to Basaglia, it was necessary to put mental illness “in brackets”, because the definition of the syndrome had taken on the weight of a labelling that went beyond the real meaning of the illness itself. This putting in brackets, unlike the denial of the mental illness itself, made it possible to approach the patient, to enter into a relationship with him on the basis of an understanding of his current being in the world, part of an interpretative strategy whose objective was a form of treatment. The new operators, mostly coming from the student revolts, often tended to privilege only one pole of this contradiction, denial, without considering that this was already taken within an organisation of power and an ideology of knowledge that had to be taken into account. According to Basaglia, it is not enough to promote a generic liberation of madness without questioning the daily rules of functioning of the institution. For the Italian psychiatrist, as for Foucault, this is one of the reasons for dissenting from English anti-psychiatry, which is based on libertarian, sometimes vague and anti-scientific positions, positions that often fail to have a concrete impact on the particular practices and general policies of psychiatry. The ideas behind Basagli's revolution start from the assumption that the whole of society is needed to deal with “madness” and that, therefore, psychiatry and medicine alone are not enough. Forced marginalisation is no longer considered a therapeutic tool but the possibility of establishing a human relationship with the “mad” is introduced. The principle of freedom was replaced by that of authority through therapeutic communities, i.e. large assemblies within the asylum which, from a place of segregation and objectification, became a place of participation, of recovery of one's subjectivity and, with it, of one's rights and duties, because Basaglia was not interested in sanctifying the madman, but in getting him out of the status of madman and into society in his own right. In 1971, Basaglia won the competition to become director of the psychiatric hospital in Trieste where, unlike in Gorizia, he was given carte blanche to implement changes. The psychiatrist invited him to transform the space, to dismantle the asylum and to support the people who lived there in the process of building and defending spaces for social life. Through this new way of understanding care, he broke several ideologies widespread in the context of mental health, in particular overturning the concept of “entertainment”, where users were often engaged in frustrating recreational activities, with operators who did not consider the users themselves in need of giving meaning to their time. Basaglia, experiencing with great involvement these early phases of the construction of the institution, worked to ensure that this space too would be transformed into a movement useful for encouraging the free expression of the people involved and not into faux-orthopaedic workshops useful for filling the space.
The psychiatric hospital in Trieste had a beautiful, immaculate theatre, rarely used for a few performances involving the best, most diligent, show-stopping inmates. That physical theatre was part of a larger, symbolic theatre, which Basaglia, in an introduction to a book by Peppe dell'Acqua, had called the “theatre of madness”. “The asylum is the theatre of madness where everyone is forced to play a part that is his own. In the asylum there is never an evening in which one plays a subject. All the actors in this strange theatre have a fixed plot, the 'living pictures' of madness, where the parts and the script are always the same. The lines never change. The living pictures are paradoxically characterised by a mortal immobility”. And so the theatre proper, the physical theatre, together with the painting course or the ceramics course, did nothing but reproduce the same immobility, the same closure. At the most, the 'mad' had to be educated, they had to be given something to do, as long as they remained infantile, harmless, and above all hidden from the community. In 1972 Basaglia decided to invite the theatre director Giuliano Scabia to the San Giovanni psychiatric hospital in Trieste, together with the painter and sculptor Vittorio Basaglia, the psychiatrist's cousin. The two were soon joined by other artists, students and volunteers who, in Pavilion P, the first empty pavilion of San Giovanni, began to do something with the mad. Basaglia had told them “come and do what you want”. At the beginning it is not clear what they are going to do, none of them wants to put on a show or do art therapy, the idea is to build something very big, to make the needs and voices of the patients evident and visible, to oppose the attempt of the asylum and the institutions that want them small, harmless and invisible. Among the guests who slowly come to Pavilion P, someone tells the story of Marco, the old horse who carries the dirty linen inside the asylum and who, now deprived of strength, is destined for slaughter. Once again, fragility must be expelled, hidden. But it happens that the inmates, nurses and psychiatrists rebel and set up a committee to ask that Marco the horse be spared and spend his retirement on a farm in Friuli. This gave rise to the idea of building a big blue papier-mâché horse with a belly containing things, requests and needs. But the workshop in Pavilion P is not limited to building the horse, people start to tell stories, often their own stories, to draw them, to interpret them. Songs and operettas are written about Marco cavallo and each of them, and every evening, for two months, they go around the wards hanging large posters and performing travelling theatre: they invent and go around telling what they have invented. This is the first real theatrical action in the Trieste asylum. Not the one performed in the theatre, but this one, created and experienced by everyone, which concerns the reality of the patients, their stories and their present. “Painting, playing football, doing theatre, writing, telling stories, looking after the gardens, cleaning vegetables and floors are actions which in their concreteness can only have to do with people's real lives. Or they are nothing more than entertainment, an obsessive reproduction of the theatre of madness”. What happens in ward P, however, has no meaning if it remains inside the asylum, if it becomes another way in which the institution marks everyday life. And so the big blue papier-mâché horse, with its belly full of letters and wishes from the inmates, crosses the gates of the asylum. It passes through them on the sidelong side, it does not manage to break through, but it does. Patients, doctors, nurses, artists and volunteers perform in Trieste, involving citizens and authorities. They dance, sing, recite the story of Marco cavallo and their own. What takes place in ward P is theatre as an affirmation of one's own existence in front of others, an existence hitherto denied and reduced to the margins. Theatre then becomes a revolution, a political act. As he parades through the streets of Trieste, Marco Cavallo is accompanied by the banner “MARCO CAVALLO LOTTA PER TUTTI GLI ESCLUSI” (MARCO CAVALLO FIGHTS FOR ALL THE EXCLUDED). Scabia's blue horse becomes a symbol for all the oppressed. He was invited all over the world - not only in Italy but also in France, Germany and Spain - to speak for and with prisoners: in prisons and psychiatric hospitals Marco Cavallo spoke of liberation and of another possible reality. In May 1978, Parliament passed Law 180, which sanctioned the closure of asylums. The law also guaranteed, at least in form, rights and dignity for those suffering from mental disorders: the right to care and health while respecting the dignity of the person. Day after day, year after year, step by step, we desperately found a way to bring those who were inside out and those who were outside in. This is what the psychiatrist wrote in 1979, the year following the approval of Law 180, the first law in the world to abolish psychiatric hospitals and to establish a fundamental principle: all people with mental disorders have an equal right to citizenship, a right that psychiatry had denied for centuries. Basaglia's work was not simply a change of course, but a cultural and intellectual revolution which, in addition to proposing a new way of conceiving the relationship with madness, first of all sanctioning the rights of the hospitalised person, was concerned with organising mental health services, setting up territorial mental health centres, residential and semi-residential facilities, psychiatric wards in general hospitals, multi-professional teams, and breaking down the institution of the asylum. In therapeutic communities, doctors, workers and patients have equal dignity and equal rights; relations are no longer vertical, but horizontal, i.e. collaboration between equals is privileged. The patient is not regarded as an outcast, but as a person to be helped, recovered and rehabilitated. Electroconvulsive therapies, restraint beds and straitjackets are definitively banned, and drug therapy is considered only one of the useful methods for granting the possibility of rehabilitation. Two years after the law was passed, the San Giovanni psychiatric hospital in Trieste closed for good, and a network of services and Mental Health Centres (MHCs), open 24 hours a day, took over its functions. However, Trieste's is a model experience, the reality is quite different: the application of the law is in fact left to the local authorities, which implement it in different ways and at different times. When the asylums were closed, few provinces were ready with adequate reception facilities, and many patients found themselves living with families they had not seen for more than twenty years, or more often found themselves living on the streets. It was only 20 years later, between 1994 and 1999, with the “Objective Project”, that the actual abolition of psychiatric hospitals took place. In 2010, a parliamentary commission of enquiry ascertained the conditions of extreme degradation of the OPG judicial psychiatric hospitals (set up in 1975 to replace criminal asylums). After several postponements, it was only in March 2015 that the OPGs were definitively closed. In their place, Rems (Residences for the Execution of Security Measures) were opened. Even the current structures are far removed from the Basaglian experience and the activities of the day centres resemble more the old theatre of the psychiatric hospital in Trieste than Scabia's revolutionary theatre. Users can freely enter and leave the day centres, but are often involved in monotonous and infantilising “therapeutic workshops”. The social and health workers (nurses, psychologists, psychiatrists, social workers), who are mostly poorly paid and precarious, mostly ignore the true meaning of the Trieste experience. Basaglia saw people with mental disorders as citizens with needs and requirements rooted in the community and, for this reason, imagined territorial services capable of meeting these needs. He certainly did not imagine outpatient clinics paralysed by waiting lists, a proliferation of private facilities, and a focus on the diagnosis rather than on the person. In 2011, Peppe dell'Acqua wrote: “I believe that Marco Cavallo should travel around the whole peninsula stopping in front of closed Psychiatric Diagnosis and Treatment Services, in front of places where people die of psychiatry, in front of empty, dirty and meaningless Mental Health Centres, in front of private clinics, deprived of meaning, which deprive people of a future”. In June 2021, the Basaglia experience suffered another hard blow following the outcome of the competition for the direction of the CSM of Barcola, in Trieste, opened by Basaglia and still today, after more than forty years, the flagship of public health as far as mental health is concerned. The oral test of the competition overturned a ranking that had seen Mario Colucci, a Basaglia-trained psychiatrist, as the winner, in favour of Pierfranco Trincas, an elderly psychiatrist and director of the psychiatric hospital in Cagliari, a facility known for its restraint methods, allegations of ill-treatment and, not least, a patient who died after seven days of restraint. The competition commission was chaired by Emi Bondi, a psychiatrist far removed from Basaglian ideas and director of the SPDC in Bergamo, where in 2019 a young girl died, burnt alive during a fire while tied to her bed in a locked room. The dispute over this competition reflects the conflict between the idea of mental health as the care of the need and fragility of free citizens in full possession of their rights and to whom dignity is acknowledged, and the idea of a psychiatry that still tries to hide, conceal, sedate. But perhaps it reflects an even broader contrast between an idea of public health, territorial, aimed at promoting the well-being of people and not only at containing emergencies, and an idea of public health that is increasingly precarious, less and less financed, that contracts out and distances itself from people. If it is true, therefore, that the boundaries between the healthy and the sick, between the outside and the inside have certainly become less rigid following the approval of Law 180, the Basaglian experience is under attack now more than ever and, probably, apart from a few realities, has never really been implemented. The theatre, inside the Italian CSMs, has gone back to being the theatre of madness, where people are exclusively psychiatric patients with a rigid script to follow. However, in contrast to a model that is regressing, there are virtuous experiences, in Italy and abroad, which not only seem to be more in line with the Basaglian experience but are themselves a laboratory of research and experimentation. These include the experience of Passpepartout, a social cooperative set up in the Santa Maria della Pietà psychiatric hospital in Rome, which was the first to set up work projects for patients discharged under Law 180. The cooperative still manages some of the workshops in the day centres of the Asl Roma1. From this intra-institutional project, however, several extra-institutional realities were born, which continue to collaborate with the institution, in this case the Asl. The Boudu-Passepartout, which produces and distributes films, and the NonTantoPrecisi, a theatre company made up of several people from different backgrounds and according to whom, as they themselves describe it, “doing theatre means constructing every day, with the expressive and creative work of each person, the common theatre, understood also as the construction of a community, as the possibility of sharing”. (Valeria Condino and Emma de Luca will return to these themes in the next issue with a special report on the "Nontantoprecisi" company. Follow us on our social channels and on the website for the next updates)
1 Italian psychiatrist, neurologist and lecturer, innovator in the field of mental health, reformer of the psychiatric discipline in Italy, founder of Psichiatria Democratica and inspirer of Law 180/1978 (named after him), which introduced a revision of the regulations governing psychiatric hospitals in Italy and promoted changes in the treatment of patients with psychiatric problems in the community. 2 Non ho l’arme che uccide il leone, AlphaeBeta edizioni 3 A psychiatrist, in 1971 he began working with Basaglia in the Trieste psychiatric hospital and participated in its closure. He contributed to the planning and experimentation of the first Mental Health Centres, and directed the Trieste Mental Health Department (DSM). 4 “Quando la follia e il teatro divennero una cosa seria”, Peppe dell’Acqua, article on the online magazine “Doppiozero” 5 Marco Cavallo, Alphaebeta edizioni