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00207411.1985.11448986

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International Journal of Mental Health
ISSN: 0020-7411 (Print) 1557-9328 (Online) Journal homepage: http://www.tandfonline.com/loi/mimh20
From Antonio Gramsci to Franco Basaglia: The
Theory and Practice of the Italian Psychiatric
Reform
Richard F. Mollica
To cite this article: Richard F. Mollica (1985) From Antonio Gramsci to Franco Basaglia: The
Theory and Practice of the Italian Psychiatric Reform, International Journal of Mental Health,
14:1-2, 22-41, DOI: 10.1080/00207411.1985.11448986
To link to this article: http://dx.doi.org/10.1080/00207411.1985.11448986
Published online: 04 Sep 2015.
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Date: 12 November 2017, At: 03:09
1m. J. Mem. Health, Vol. 14, No. 1-2, pp. 22-41
M. E. Sharpe, Inc., 1985
FROM ANTONIO GRAMSCI TO FRANCO BASAGLIA:
THE THEORY AND PRACTICE
OF THE ITALIAN PSYCHIATRIC REFORM
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RICHARD F. MOLLICA
Cursory summaries of the intellectual and philosophical context of the
Italian psychiatric reform movement have overemphasized its practical
limitations while understating its conceptual framework. Emphasis on
either theory or practice, not on theory and practice, has kept mental
health policy stuck within Gertrude Stein's witty aphorism "What
history teaches is that history teaches." Modern psychiatric practice
seems particularly prone to chronic repetition of the question "What
did we do this time that failed?"
This paper presents the sociopolitical concepts and psychiatric strategies underlying Western Europe's most radical psychiatric reform
movement, Psichiatria Democratica. Little attention has been given to
the important influence of Italy's major political theorist of this century, Antonio Gramsci, on the Italian reformers and their leader, Franco Basaglia. Understanding Gramsci' s theory and the practices of
Italian psychiatry can help us to evaluate and improve public mental
health services in both Italy and elsewhere.
From Antonio Gramsci to Franco Basaglia
In November 1926, Italy's leading political theorist and revolutionary
thinker, Antonio Gramsci, was arrested by Mussolini, and was subsequently sentenced to 20 years in prison by the fascist state [1]. His
prison confinement ended with his death in 1937. During his confinement Gramsci wrote one of the most important Italian works on political theory since Machiavelli, Quaderni del carcere [Prison notebooksl
[2]. Gramsci' s theory of "hegemony," unsystematically developed in
Dr. Mollica is Assistant Professor of Psychiatry, Harvard Medical School. His
address is Richard F. Mollica, M.D., Psychiatric Epidemiology, Warren 7, Massachusetts General Hospital, Boston, MA 02114.
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FROM GRAMSc/ TO BASAGLlA
his Prison notebooks, is probably the single most significant theoretical
position relevant to the Italian psychiatric reform movement.
Twenty-five years after Gramsci's death, the Italian psychiatrist
Franco Basaglia, his wife, Franca, and their colleagues committed
themselves to creating within Italian society a new morality (with
psychiatric reform as the vehicle) that would nurture the human spirit
by ending social alienation. The political movement they spawned in
Gorizia in the 1960s, which later found expression in their national
organization Psichiatria Democratica (created in 1973), aimed to bring
about psychiatric reform at all levels of the social structure, from
governmental to interpersonal.
Although both Gramsci and Basaglia were influenced by Marxism,
they rejected economic determinism and the Marxist prescriptions for
social change based on a simplistic economic analysis of class struggle.
For both men, cultural transformation was a goal above and beyond the
conventional ends sought by traditional Marxism. Gramsci, for example, in discussing the role of the "Modern Prince" (Le., the Communist Party), states: "The Modern Prince must be and cannot but be the
proclaimer and organizer of an intellectual and moral reform, which
also means creating the terrain for a subsequent development of the
national popular collective will towards the realization of a superior,
total form of modern civilization" [3. Pp. 132-33]. As part of Gramsci's' 'modern civilization, " Basaglia envisioned a society completely
freed from the repressive structures of psychiatric institutions.
Gramsci's concept of hegemony
Gramsci was probably the first Marxist theorist to provide a complete
and radical critique of economic determinism [4]. The conventional
Marxist explanation of a society's social values (or ideologies) held
that:
1 . Ideology belonged to the dominant social class or ruling class.
2. Ideology was economically determined.
3. Ideology was conceived as a "distortion" or misrepresentation
of true class relationships.
Gramsci's concept of hegemony moved away from this economic
reductionism because he saw that it could not explain why individuals
within society often agreed with social values and participated in
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RICHARD F MOLLICA
activities not in their own best interest. Furthermore, he saw that social
attitudes such as racism and institutions such as asylums were not
clearly linked to society's methods of economic production. In developing his concept of hegemony, Gramsci sought a more inclusive explanation that would account for observed patterns of social behavior and
institutional values and practices.
Gramsci defines hegemony as " ... the 'spontaneous' consent given by the great masses of the population to the general direction imposed on social life by the dominant fundamental group. This consent is
historically caused by the prestige (and consequent confidence) which
the dominant group enjoys because of its position and function in the
world of production" [3. P. 12].
G. A. Williams has offered an elaboration of this concept:
By' 'hegemony" Gramsci seems to mean a sociopolitical situation, in
his terminology a "moment" in which the philosophy and practice of
a society fuse or are in equilibrium; an order in which a certain way of
life and thought is dominant, in which one concept of reality is
diffused throughout society in all its institutional and private manifestations, informing with its spirit all taste, morality, customs, religious and political principles, and all social relations, particularly in
their intellectual and moral connotation. (5. P. 587]
Hegemony is much more than a society's social consensus. It is those
historically based practices (sometimes referred to as "articulations"
or "discursive practices") that reveal the meanings and values society
assigns individuals and institutions.
According to Gramsci, hegemony is inclined toward the best interests of the general population. He writes: "Every state is ethical in as
much as one of its most important functions is to raise the great mass of
the population to a particular cultural and moral level" [3. P. 239].
This social drive explains the reformist and liberal tendencies of
modern Western society. Yet, hegemonic practices are often contradictory. The hegemonic group can be in power or dominance only so long
as it can convince other groups of its ability to represent their universal
interests and unite all groups as allies. Corporate self-interest can
prevail only up to a point before it must exert its authority-no longer
through social hegemony, but through police action. The reformist
tendencies of the Western social democracies, according to Gramsci,
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are indeed their legitimate response to desires to alleviate the class
struggle and to improve the society; however, they essentially offer
passive reforms, which frequently give way to the corporate demands
of the ruling class without attempting in any radical way to restructure
society and eliminate the root causes of human misery [6,7].
How does hegemony affect individual consciousness and selfawareness? As implied above, Gramsci did not claim that there was a
one-to-one relationship between the ruling class and society's ruling
ideas. The individual's social context is determined through hegemon ically controlled organizations such as the church, trade unions, and
schools, and society's cultural expressions in the arts, literature, and
the fruits of academia. According to Gramsci, the individual responds
to this social context through his "common sense." Gramsci 's concept
of "common sense" is crucial to understanding the relationship between individual attitudes and the society's hegemonic practices.
Each individual, according to Gramsci, constructs a "philosophy,"
based upon "common sense," that is mainly unconscious. He states:
In acquiring one's conception of the world one always belongs to a
particular grouping which is that of all social elements which share
the same mode of thinking or acting. We are all conformists of some
conformism or other, always man-in-the-mass or collective man. The
question is this: of what historical type is the conformism, the mass
humanity to which one belongs? When one's concept of the world is
not critical and coherent but disjointed and episodic, one belongs
simultaneously to a multiplicity of mass groups. The personality is a
strange composite. It contains Stone Age elements and principles of a
more "advanced science," prejudices from all past phases of history
at the local level and intuitions of a future philosophy which will be
that of a human race united the world over. [3. P. 324]
The" Gramscian man" is not completely unaware of these profound
influences on his life. In fact, his perceptions and evaluations of social
life exhibit contradictions and confusion that reflect the gap between
the dominant interpretation of reality and his subjective experience of
reality. Gramsci did not fully develop the idea of the individual's
unconscious attachment to his society's hegemony. He did not believe
that, left to their own devices, the masses in Western society generally
could overcome their intellectual and moral subordination. Yet he
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thought that, despite the fact that subordinate groups tend to hold
beliefs that reflect the world view of the dominant groups, these subordinate groups were able, under special circumstances, to reassert their
essential interests. Gramsci's view on the means by which oppressed
individuals shift the society's hegemony to a new moral order is central
to a discussion of the Italian psychiatric reform movement.
Reform and revolution
The Italian word riforma translates as both "reform" and "reformation. " This duality of meaning expands our Anglo-American understanding of the concept of reform to encompass a more far-reaching
and fundamental vision of social change. Gramsci theorized that a new
national, collective, popular will could be created only through what he
called a "war of position" [7]. The war of position is political "trench
warfare" that attacks the contradictions inherent in the society's hegemonic practices at all levels-cultural values, institutions, socialorganizations, the educational system, etc. Laclau & Mouffe have described the war of position as a "multi-dimensional conception of
political radicalization." They state:
If the articulations of the social whole are political articulations,
there is no level of society where power and forms of resistance are
not exercised ... [Reform], therefore, does not arise from an absolute break consisting in a seizure of power. It must instead be the
result of a series of partial ruptures through which the ensemble of
relations of forces existing in society will be transformed. [8. P. 20]
Gramsci's reformist strategy was cautious and practical: to seize
every opportunity to reveal the contradictions in society that underlie
all repressive social structures (such as the asylum). Furthermore, he
claimed that reform occurs only in a society in which the necessary
conditions for reform have already been incubated. Otherwise, a "passive revolution" takes place in which the new hegemonic forces are
taken over again by the traditional ruling classes, and no real transformation of the moral structures of the society occurs.
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The role of intellectualsOrganic versus traditional
The counterhegemony must be created, according to Gramsci, by political, intellectual, and moral leadership. Intellectuals have an extremely important role in his program of reform [9]. They are not the
detached elite of the Italian philosopher Benedetto Croce, but active
social agents involved in creating and elucidating new social structures.
Every member of the intelligentsia is to be a dirigente, that is, specialista e politico [3. Pp. 55,56].
Gramsci distinguishes between two classes of intellectuals: organic
and traditional. Traditional intellectuals maintain the values and culture
of the society'S historical structures such as the church, schools, the
medical establishment, etc., and are thus more likely to reinforce the
status quo. In contrast, organic intellectuals are more closely in touch
with the current social and political needs of the various levels of
society, either because of their social origins (frequently working-class)
or their areas of activity (e.g., law or politics).
Gramsci states that it is the function of all intellectuals to provide:
1) a general conception of life, a philosophy which offers to its
adherents an intellectual "dignity" providing a principle of differentiation from the old ideologies which dominated by coercion, and an
element of struggle against them; 2) a scholastic programme, an
educative principle and original pedagogy which interests that fraction of the intellectuals which is the most homogeneous and the most
numerous (the teachers, from primary teachers to university professors), and gives them an activity of their own in the technical field.
[3. P. 103]
Intellectual leaders are important in Gramsci' s scheme only if they
can express the "feeling" of the oppressed or disadvantaged groups
through their intellectual and moral awareness [5]. In other words, it is
the function of the intellectuals to bridge the gap between the felt
experience of the masses and the highest levels of cultural expression.
The organic intellectuals, because of their more immediate association
with popular culture, are in a more advantageous situation to bridge
this gap.
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Italian psychiatry's "war of position"
Gramsci's theoretical framework for reform was an essential influence
on Psichiatria Democratica and the Italian reform movement. AngloAmerican observers have generally failed to appreciate the commitment of Basaglia and his colleagues not only to a total destruction of the
asylum system but also to a radical transformation of the hegemonic
practices of Italian society that had created this repressive social structure. By focusing exclusively on the relative successes and failures of
Italy's radical mental health legislation, Public Law 180 [10], Basaglia's critics have assessed the major goals of the Italian reform movement solely within a legislative framework.
This perspective does little justice to the movement's broader attempt over the past 20 years to create a more humane psychiatric
hegemony. Franca Basaglia has forcefully addressed this issue:
... the cultural change the reform presupposed could not be
legislated into existence: it entailed a change in the scientific assessment that mental illness was incurable, a change in attitude toward
diffe;-ences and disability in any form, and involvement of the public
in reconfronting of a problem that had been simply shunted aside and
hidden in the asylums, a problem for which traditional psychiatry had
no answers. I
How did the Italian reformers conduct their' 'war of position' '? One
way was to reveal how traditional psychiatry's ideas and practices
functioned to keep patients within the asylum. The social contradictions of traditional psychiatry were pointed out and given new definitions in order to bring to light those aspects of the patients' problems
that had been either hidden or ignored. The new definitions are revealed in the following concepts: anti-empiricism, emargination,
chronification, and the deinstutionalization of the staff.
Anti-empiricism
From the beginnings of the movement, the Italian reformers were
extremely critical of positivistically oriented psychiatry [11,12]. They
saw a direct correlation between the horrific conditions of the Italian
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asylums and the so-called "empirical" or "scientific" psychiatry that
was practiced there. Describing the situation, Basaglia wrote:
And so we have, on the one hand, a science ideologically committed
to a quest for the origins of an illness it acknowledges to be "incomprehensible" and, on the other, a patient who, because of his presumed "incomprehensibility," has been oppressed, mortified, and
destroyed by an asylum system that, instead of serving him in its
protective role of therapeutic institution, has, on the contrary, contributed to the gradual and often irreversible disintegration of his
identity. Z
The Italian reformers denied the neutral, apolitical role assumed by
empirical psychiatry. Although they did not deny the existence of
neurologically based illness, they emphasized that any illness had to be
considered within a social, political, and interpersonal context.
Emargination (Emarginazione)
Emargination was the term used to designate the social process by
which mental patients were isolated and segregated from society.
Emargination was considered to stem from the development of the
modern industrial state and the hegemonic and ideological practices of
the social class structure [13]. The Italian reformers believed that
asylums represented the successful management of the displaced poor.
As the capitalist system had expanded in Italy, so had the asylums, as
increasing numbers of citizens were considered economically redundant (i.e., unnecessary and/or unable to enter the work force) and
socially unworthy of rehabilitation. Furthermore, the asylum represented the institutional structure assigned by society to segregate and
punish people who were considered socially deviant.
Psichiatria Democratica also severely criticized social welfare reforms instituted by the Italian state after World War II.3 Psychiatric
patients were recycled through a dependency circuit of welfare benefits
that prevented the patient's emancipation from the asylum. This new
welfare state, according to C. De Leonardis,
is a circuit-system of guarantees and social rights, but at the same
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time it is a network of interdependencies, controls and institutional
dependency. It is ... a response to social needs, but a response
which reproduces and codifies them in the form adapted to the service
of the institution, its criteria of rationality, and its social mandate
within the cycle of reproduction. This is related to the imperative for
socializing social un-reason, the transcendence of the mechanisms of
emargination; yet at the same time it produces and sanctions new
forms of marginality. 4
Chronijication (Chronijicazione)The second disease
The Italian reform movement emphasized "the second disease," the
disease caused by the social exclusion, neglect, and mistreatment of
patients through institutionalization. 5 Although Basaglia and his colleagues did not dispute the important neurological and psychological
processes associated with the etiology and treatment of mental illness,
they rejected its definition in terms of empirically based diagnostic
systems. In fact, they elected never to define the nature of the primary
illness; they treated only the "second disease." As Carrino states, "We
came up with facts to demonstrate that certain forms of behavior
usually attributed to a person's illness actually disappeared if the conditions of hospital life were improved or if the person was able to leave
the hospital and return home."6 Grounded in this orientation, all psychiatric assessments, interventions, and prevention strategies were directed at ameliorating the social and mental disability caused by the
"second disease."
Deinstitutionalization of the staff
The early reformers quickly realized in their experiment that the social
and political values of the asylum were maintained by the hierarchical
relationships between patients and staff. If a true transformation of
asylum care were to to be realized, the primary efforts had to be
directed at changing staff attitudes and behaviors. Staff as well as
patients had to be liberated from the asylum system.
To this end, the early experiments in Gorizia culminated in a massive
reassignment of the staff in Trieste to new roles that emphasized active
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staff participation in all community activities necessary for the patients' reintegration into society. For example, staff were shifted, along
with their formerly institutionalized patients, into the community. In
this noninstitutionalized environment, staff assisted patients in organizing their personal lives, working, and joining social and political
groups [14].
*
*
*
Central to the psychiatric reform, therefore, was an actual confrontation of the psychiatric staff and psychiatric patients with society.
Society had to be brought into collision with the problems it had tried to
lock away in the asylum and, through this collision, create new social
structures. The movement's therapeutic techniques [15,16]-e.g.,
elimination oflocked wards, "demedicalization" of treatment, elimination of psychotherapy, unionization of patients, and the "guest"
concept (in which patients gave up their patient status to become
"guests" at the institution) -were designed as a way out of the narrow
definitions of mental illness by empirical medicine, which served,
along with other social practices, to prevent the mentally ill from fully
reentering society. Not only the psychiatric leadership (national and
local) but all institutional staff were expected to foster the shift of
patients from asylum to community. All reform-including Public Law
180-had as its goal the social reintegration' of the mentally ill.
The Italian focus on the social rehabilitation of the asylum patient is
often difficult for Americans to appreciate fully since the American
reform through the community mental health center movement had
already firmly rejected the asylum system in the late 1950s and had
expanded its national mandate to ensure universal access of all American citizens to high-quality outpatient services [17]. Whereas American reformers emphasized the community and its equity of access to
comprehensive mental health care, Italian reformers emphasized the
asylum patients and their access to full social participation.
Through the 20 years of reform, the Italian psychiatric establishment expanded its size, influence, and prestige dramatically. (This fact
surprises observers who misinterpret the Italian reform as an antipsychiatry movement.) The Basaglias, G. Jervis, A. Pirella, and Psichiatria Democratica's other national leaders clearly accepted the social
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responsibility expressed in Gramsci' s concept of the" organic intellectual." Changing cultural attitudes through the establishment of a psychiatric elite was attempted in all Italian regions experimenting with
the reform (e.g., Arezzo, Perugia, Trieste, etc.).
A letter by Sergio Piro, in 1971, describing his experiences as the
new medical director (1959-69) of the psychiatric hospital Materdomini, in Upper Nocero, Salerno, is a fascinating illustration of the
challenges and frustrations confronting an early provincial reformer
[18]. Piro, in spite of his many innovative therapeutic changes, was
eventually fired by the hospital administrators, with the support of the
local academic and political community. His dismissal received some
national attention, including a review in 1971 by the Gramsci Institute
(Rome). The review concluded that" ... the repressive action in
Materdomini in 1969 was not an isolated occurrence in a local situation, but the expression of an organized collusion of powers involving
economic, political, administrative, juridical, and medical forces (including the Ministry of Health)." Furthermore, this review criticized
the psychiatric reformers at Materdomini for engaging in "spontaneous" actions that revealed their inability to identify and educate those
real political forces in the community capable of organizing a sustained
transformation of the asylum.
Yet, what would have been a correct political analysis by Piro and his
colleagues at Materdomini? This question is still unanswered, and has
now become the subject of a national debate.
Uneven implementation
and threatened disintegration
As Cassano and co-workers, 7 Paparo & Bacigalupi, 8 and Bennett9 have
revealed in their limited epidemiological analyses, the implementation
of the Italian reform has been uneven, and varies considerably among
the different regions, from the successful experience in Trieste (which
will be recognized as one of the great international experiments in
deinstitutionalization) to the abysmal failure at Materdomini and in
most of the South.
How is an experience of this type to be judged? Unfortunately, the
empirical evidence assessing the major social policy programs in men-
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tal health in Europe and the United States is limited.
Braun and co-workers [19] have demonstrated the scarcity of welldesigned epidemiologic research in the United States upon which
American deinstitutionalization programs can be defended. The work
of Mollica & Redlich serves as one of the few attempts to assess
empirically the relative equity of access achieved by the American
community mental health center movement [17,20]. There is also a
dearth of European studies.
Italian researchers are currently finding it very difficult to transfer these modest Anglo-American and European epidemiologic approaches to an Italian cultural milieu that is inexperienced in epidemiologic research and is generally hostile to empirical methods. Any
critique of the Italian reform, therefore, must be developed from whatever empirical analyses exist, no matter how incomplete,IO and from
comparisons of the experiences of patients, professionals, family members, and all 'the other people and the institutions involved.
Unquestionably, the Italian reform movement has changed the practice of psychiatry in Italy. Yet despite its sweeping influence, there are
signs of a threatened disintegration and demoralization of the public
system. Similar trends have been noted in the United States and in
England [20].
The major policy issues affecting the future of the Italian reform are:
(1) political and fiscal instability;
(2) the shift of mental health professionals from the public to the
private sector (trasformismo);
(3) social reintegration versus clinical care; and
(4) the hopelessness and incompetence associated with dealing with
chronic mental illness.
Political and fiscal instability
Franca Basaglia has described the chaotic and inadequate implementation of Public'
Law 180. She believes that this reflects the ambivalence
. I
of the Italian political system toward supporting the rehabilitation of
the mentally ill rather than a failure of the intention of the legislation
itself. She writes:
... from the moment the law was passed, the greatest obstacles
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RICHARD F. MOLLICA
to its implementation were created by those who should have been
applying it: the government, which was in no hurry to provide the
suitable tools (the national health plan, which had been in the works
for years; guidelines and points of coordination that were totally
nonexistent); the Italian regional administrations, which neglected to
establish any guidelines for care in local facilities; local administrators, who, whether unable to act or outright unwilling to do so, let
time slide by in the expectation or hope of repeal or amendment; and
even the care-givers themselves ... II
Paparo & Bacigalupi have empirically demonstrated the inadequate
establishment of community facilities following passage of Public Law
180. 12 For example, in 1979 (the only year for which data are available)
the number of halfway houses in Italy was 348, with only 1,927 persons
resident in these alternative accommodations; in the South, there were
only 13 apartments for the mentally ill, with only 181 residents.
Sedgwick [21], Mauri and De Leonardis, 13 and others have noted
the tendency within the modern welfare state to extend services to the
poor and infirm. But today, conservative political ideology and major
fiscal constraints have crippled the welfare system; more is expected
for less. In the United States, psychiatrists are leaving the public system
as it becomes increasingly resource-poor while the number of patients
is greatly expanding. The American public psychiatrist's role is being
restricted to the use of psychotropic medication for patients who,
because of their major social handicaps, need more than drugs [20]. In
many Italian cities, the situation is similar.
Increasingly, the Italian system (and that of other countries as well)
has challenged the mental health professional and the patient to legitimize the distribution of limited social resources to those (i.e., the
mentally ill) deemed economically redundant. The moral qu'estion
asked by society is: Is it socially proper to extend fiscal resources to
those within society who will probably never be able to enter the work
force regardless of the intensity of rehabilitation efforts?
The Italian reformers, in their emphasis on the "second disease,"
never established minimum clinical standards by which they could
protect patients from the erosive effects of conservatism. They did not
foresee that even minimum clinical care could be questioned in an era
of fiscal conservatism. In fact, left-wing ideologues and fiscal conservatives on the right found themselves aligned on the issue of disman-
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tling the asylum. What the Italian reformers did not anticipate was that,
once the asylum was dismantled, politicans would refuse to finance a
community system because it would be much more expensive than the
former custodial care.
Cassano and his colleagues l4 have demonstrated Psichiatria Democratica's failure to recruit patients' families and communities as advocates for new resources. Basaglia's goal of social confrontation was
achieved between patients and society; but the patients became the
victims not only of politicians but even of their potential supportersmembers of their own families. Their families resented the shift of
clinical and financial responsibility from professionals and the state to
themselves.
The shift of professionals
from the public to the private sector
Gramsci's concept of trasformismo is useful in discussing the shift of
mental health professionals from the public to the private sector. This
concept holds that unless a major transformation of corporate interests
occurs, people will revert back to former standards of political power.
The Italian reform was responsible for increasing the number of
psychiatric professionals (psychiatrists, psychologists, nurses, and social workers) in the public service by over 300 % (from 6,203 in 1979 to
16,780 in 1980).15 This marked increase was due primarily to the
creation of new professional positions. But in spite of the initial enthusiasm and idealism with regard to public psychiatry exhibited by the
new practitioners, many are now shifting to private practice. Similar
trends are noticeable in the United States. The inadequate implementation of public programs, the difficulties of the clinical cases, and the
stress of working in resource-poor environments have all played a role
in the demoralization of psychiatric staff.
Anxiety concerning their future well-being, both professional and
personal, over the long term has probably contributed more than any
other factor to the desire of public psychiatrists to enter private
practice. No doubt the greater power, pay, and prestige of private practice tempt even the most devoted public psychiatrist, who
can see little future for himself, or his patients, in the public system.
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Social reintegration
versus clinical care
The Italian reformers considered the major moral purpose of psychiatric practice to be assisting all the mentally handicapped to regain full
access to society. Unfortunately, Psichiatria Democratica was unable
(and ideologically unmotivated) to advance a clinical system capable of
treating both the primary illness and the second disease. Considerable
evidence has now emerged in countries other than Italy to suggest that
chronic mental illness is not just a product of institutionalization
[22,23], and thus the concept of "chronification" is in need of revision.
The commitment of the Italian reformers to exclusively sociopolitical strategies did not include a multifactorial clinical approach that
could successfully integrate biological treatments with social strategies. (Of course, this integration is a frontier to be explored.) The
failure of the Italian reform movement to elucidate clinical treatment
goals and to devise techniques capable of monitoring treatment outcome has frustrated patients, practitioners, and families.
Dealing with the hopelessness
and incompetence associated
with chronic mental illness
The Italian reformers appreciated the anxiety and tension that existed
on the psychiatric wards of the asylum [24]. On the one hand, they
wanted to defuse the violent atmosphere within the asylum by treating
the second disease; on the other hand, they wanted to transfer the
anxiety and fear generated by the mentally ill back onto the community.
Again, these reformers believed that new social relationships would
develop if society were forced to confront the psychotic individual.
Unfortunately, neither families, the community, nor even psychiatric
practitioners themselves have discovered how to handle long-term care
of the psychotic patient. Many of these patients, once "deinstitutionalized, " continue to evoke feelings of fear, hostility, hopelessness, and
incompetence in those around them. They often deliver "narcissistic
blows" to their therapists by refusing to satisfy the therapists' wish to
be helpful and caring. They can be explicitly rejecting of the therapists'
goodwill and treatment.
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FROM GRAMSCl TO BASAGLIA
The Anglo-American literature since publication of Hollingshead &
Redlich's classic study Social class and mental illness [25] is replete
with empirical descriptions of how psychiatric practitioners have a
tendency to avoid the so-called "undesirable" patient [26]. A recent
study [27] reveals that in spite of the massive expenditures on the
American community mental health center movement, special groups
of public patients continue to receive treatment that is different from
that of other public or private patients, treatment that quite possibly
yields a poorer outcome.
Although the Italian reformers realized all of the above, and knew
that the dyadic relationship was inadequate to deal with the difficulties
of treating the psychotic patient, they did not develop strategies and
clinical methods capable of making such patients "desirable" and
satisfying to their clinicians, their families, and the community. Unfortunately, they seemed not to suspect, until recently, that there is an
inevitable tendency (not politically motivated) among even the most
idealist practitioners to gravitate away from treatment of the psychotic
patient. And inadequate resources only intensify the practitioner's desire to avoid contact with the most infirm.
Reflections on the Italian
reform movement and the
future of public psychiatry
The energy and commitment of the Italian reform movement is consonant with Gramsci's revolutionary world view, as described by T.
Nairn:
Its specific Italianate resonance is rarely grasped: a world of objective
difficulties so huge, that only superhuman amplification of the subforces can push things forward. "Politics" is the concentraItion at fever pitch of both the leonine and vulpine traits of human
, nature, and their sapient manipulation to get the maximum leverage
in each historical situation. [28. P. 172]
j~ctive
The brilliant and innovative changes introduced by the Italian reform movement over the past 20 years are now being threatened.
Similar forces are challenging the American community mental health
37
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RICHARD F MOLLICA
center movement and the British deinstitutionalization programs
[20,29].
A comprehensive Gramsci1n analysis of the current state of the
Italian revolution would highlight the positive cultural (Le., hegemonic) changes that have occurred as well as the numerous contradictions generated by the movement itself. Perhaps the Italian reform's
single greatest failure has been its inability to mobilize the mentally
impaired as a political force. Unfortunately, no society has ever produced any evidence that the mentally ill can successfully advocate for
their own social acceptance. And the corporate self-interest of mental
health professionals and the traditional sociopolitical forces leading to
emargination almost guarantee that no community of such professionals or politicians will emerge that will have the legitimate power to
sustain a reformed mental health services system.
What about the families of the mentally ill [30]? In both the United
States (e.g., the Alliance for the Mentally Ill) and in Italy (e.g.,
DIAPSIGRA), the families of mental patients have, for the first time,
organized against the psychiatric reform in both countries. Surprisingly, these reform movements have revealed that the family probably
represents the only social structure capable of exercising a new and
sustained hegemony toward the mentally ill. Perhaps the family is the
only social agency that has enough interest in the patient's well-being to
militate for social change. However, what families will truly support
and for how long is still unclear.
Recently, American mental health policy has refocused its public
policy mandate on caring for the so-called "chronic patient." This
emphasis in the United States, similar to the current preoccupation of
Italian psychiatry with Public Law 180, establishes political definitions
that render difficult the identification of the actual forces in the community that could truly improve the social well-being of the mentally
disabled. For example, American treatment of the chronic patient is
almost exclusively services-based; neither the patients' families nor the
average citizen has been educated or enlisted in support for the care of
the mentally ill. The average citizen, in fact, most likely finds the
widely circulated concept of the "chronic patient" both confusing and
threatening.
Perhaps the most important contribution of Italian psychiatry derived from the theory of hegemony is that the old order cannot be
38
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FROM GRAMSCI TO BASAGLIA
reformed just by pointing out its evils, any more than a new order can
be created simply through ideology. Italian psychiatry's war of position
was not just a moral, theoretical challenge to a repressive asylum
system: it confronted that system, with new ideas and practices. Its
failures reveal new contradictions and opportunities for new strategies;
its successes need to be recognized and sustained.
Finally, what should be done about the social devaluation of psychiatric reform emerging in Europe and the United States? Recently, a
wave of cynicism has limited American reform. It denies the community mental health center movement's remarkable achievements by focusing exclusively on its very real limitations. This same tendency has
begun to appear in Italian psychiatric circles. Many dedicated Italian
psychiatric practitioners are questioning their ability to sustain their
efforts within the public service. But if they retreat, disillusioned and
weary, to the politics of tanto peggio, tanto meglio (the worse, the
better, or "let the system fall apart"), this will ensure the failure of a
new and more humanistic psychiatric social order.
Notes
1. See p. 9 in this volume.
2. See p. 44 in this volume.
3. C. De Leonardis & D. Mauri (1980) Istituzione psichiatrica: Politica sociale e
nuove forme di controllo e legittimazione. Unpublished manuscript, Departments of
Sociology, University of Salerno and University of Milan, respectively.
4. C. De Leonardis (1980) Social health systems in the crisis of the welfare state.
Unpublished manuscript, Department of Sociology, University of Salerno.
5. See the Gervis article, p. 52 in this volume.
6. See Carrino's article, p. III in this volume.
7. See the article by Cassano, Mauri, & Petracca, p. 174 in this volume.
8. See the article by Paparo & Bacigalupi, p. 93 in this volume.
9. See Bennett's article, p. 70 in this volume.
10. See the articles here by Cassano, Mauri, & Petracca, Paparo & Bacigalupi, and
Bennett.
11. 'See p. 11 in this volume.
12.) See Paparo & Bacigalupi, op. cit.
13. -See De Leonardis & Mauri and De Leonardis, op. cit.
14. Cassano, Mauri, & Petracca, op. cit.
15. Paparo & Bacigalupi, op. cit.
39
RICHARD F. MOLLICA
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