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00207411.1985.11448987

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International Journal of Mental Health
ISSN: 0020-7411 (Print) 1557-9328 (Online) Journal homepage: http://www.tandfonline.com/loi/mimh20
What Is Psychiatry?
Franco Basaglia
To cite this article: Franco Basaglia (1985) What Is Psychiatry?, International Journal of Mental
Health, 14:1-2, 42-51, DOI: 10.1080/00207411.1985.11448987
To link to this article: http://dx.doi.org/10.1080/00207411.1985.11448987
Published online: 04 Sep 2015.
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Date: 12 November 2017, At: 03:07
Int. 1. Ment. Health, Vol. 14, No. 1-2, pp. 42-51
M. E. Sharpe, Inc., 1985
WHAT IS PSYCHIATRY?
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FRANCO BASAGLIA
No one tries to fend for himself; each awaits the contribution of every
other and the "division" among all to bear fruit. And effectively there is
nothing more fruitful. When I see today's intellectuals, otherwise quite
notable, so jealously guarding their autonomy and so manifestly determined to take their little secrets with them to their graves, I tell myself that
they have gone backward and that, whatever they may think, they are not
on the right path.
-Andre Breton
In 1948 Sartre, in an essay entitled' 'What is literature?" (Situations II.
Paris: Gallimard), wrote: "Ideologies are freedom while they are in the
making, but oppression once they have been made. " This describes the
tendency for ideas to become fixed in preestablished patterns even
though, having acquired their birthright through a repudiation of a
particular reality, they should, as a safeguard against their becoming an
element of oppression themselves, be constantly reverting to reality to
reinvigorate the spirit of renewal that originally informed them. It is
also the leitmotiv of the discussions and essays presented in this collection, which together may be reduced to a single question: What is
psychiatry?
Indeed, this is a very provocative question in itself, although in
posing it here we wish merely to stimulate discussion. It has arisen
from the state of genuine malaise in which we find ourselves, oppressed
by a psychiatric ideology that is closed and permanently defined in its
role of a dogmatic science that has been able merely to define the
otherness and incomprehensibility of the object of its inquiry-which in
actual practice has meant its social stigmatization.
Psychiatric diagnoses have in fact assumed a categorical value in
Franco Basaglia (1924-1980) was the principal founder of Psichiatria Democratica and the Italian psychiatric reform movement.
This article has been translated and reproduced, with permission, from F. Basaglia (Ed.), Che cos' e la psichiatria? Thrin: Einaudi, 1973.
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WHAF IS PSYCHIAFRY?
that they correspond to a labeling, a stigmatization, of the patient;
without a diagnosis it becomes impossible even to approach the problem, let alone act. Face to face with his "partner in dialogue" (the
"mental patient"), the psychiatrist knows well enough how to draw on
his bag of technical knowledge, which will enable him, on the basis of
symptoms, to reconstruct the specter of an illness. But he will clearly
realize that, as soon as he has formulated his diagnosis, the human
being will disappear from view, thereafter permanently codified in a
role that gives sanction to a new social status for him, the patient. A
kind of passivity, assumed by the "scientist" in this regard, enters the
picture, inducing him to decipher the phenomenon in a routine that is
technically perfect and possessed of an existence-totally separate and
distinct from his own person-whose end would seem to be to sort out
what is norm~l from what is not. The scientist himself takes no personal part in this operation; after all, the parameters in terms of which
psychiatry has built up its system place him beyond whatever there is
that is problematic in the situation, i.e., in this dyadic relationship there
exists neither the interviewer (who is "unsituated," neutrally uninvolved) nor the "interviewee" (who, once codified, disappears forthwith from the picture).
The necessity for the scientist's direct participation in the situation
is analyzed by Sartre in his Critique de La raison diaLectique (Gallimard, 1960) when he states:
The position of the unsituated experimenter strives to maintain
analytic Reason as a type of intelligibility; his passivity as a scientist
toward the system reveals to him a passivity of the system toward
himself. The dialectic unveils itself only to an observer situated
within, i.e., to a researcher who lives his own inquiry either as a
possible contribution to the ideology of the epoch in which he is
interested or as the particular praxis of an individual, defined by his
historical and personal adventure within the broader history upon
which that is contingent.
This distance of the scientist from his own domain of inquiry is
particularly significant in the case of psychiatry. One need only look at
the actual gap between the rigorous technical level of scientific treatises
(with the enormous edifice of classifications, subclassifications, specifications, and nosographic Byzantinism) and the reality to which these
treatises refer: the mental patient, as we see him in our psychiatric
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FRANCO BASAGLIA
asylums after years of hospitalization. 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.
If this is the reality that confronts us, there can be no way for us to
avoid the questions: What is psychiatry? And what is its field of inquiry? Is it concerned with the mental patient or, limiting its contribution
to a purely ideological elaboration, is it interested solely in the syndromes with which it has invested the patient? And if it does acknowledge the mental patient as the object of its inquiry, what can be its
justification in terms of the results of that inquiry, i.e., our patients
who are institutionalized? We may then ask, in sum, whether the
insignificant facts (in our case, the patients who are vegetating in
asy lums) that often bring down whole theoretical edifices have not been
too long in conflict with the theory to which psychiatry appeals, and
whether theory should not clear the way for the facts to speak out. This
is the question being asked by a group of mental patients, doctors,
attendants, psychologists, and administrators who are all involved in
institutional psychiatry. It is a question that arises out of a real unease
experienced at every level as soon as the validity and, indeed, the
arbitrariness of the authoritarian-hierarchical relationship on which the
whole of asylum life is traditionally based becomes the subject of
debate.
If we but examine the overall significance of this type of organizational structure and the purposes of the various roles performed in it,
the conclusion cannot be avoided-if we just think of the present therapeutic opportunities available to the patient-that the set of phenomena
with which we are dealing has something paradoxical about it. The
hospital as a system seems to exist for itself, to be its own reason for
being, in the sense that the intense activity within it seems to serve only
to keep it going, otherwise aiming at nothing that might justify its
function. If, then, we probe a bit more deeply so as to distinguish the
various levels interacting within the system, we shall find that the first
general impression, namely, that there are no clearly defined real roles,
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WHAT IS PSYCHIATRY?
is correct. What immediately meets the eye is that the patient does not
exist (notwithstanding the fact that he is ultimately why the institution
as a whole exists in the first place), but is buried in a passive role that
both codifies him and cancels him out at one and the same time. And it
is impossible to ascertain what precise roles the psychiatrist and the
hospital attendant actually play. Their presence cannot be fully justified, apart from the role of authority and power-which are part of a
chain of impositions, extending from one level to another and ending
with a sick aggressivity demanding to be restrained-with which they
are generally invested. Thus, we come to understand how, as soon as
their role goes beyond the custodial level, they are always forced to
endow themselves with an authority that sets them apart and, at the
same time, conceals from their own eyes the nothing they are, but are
unable to acknowledge being.
If in fact the purpose of the institution is not expressly the person of
the' 'patient, " the entire organization becomes divested of any meaning, though its meaning could be reacquired forthwith if the patient
were just conceded a role. From this perspective, the first indispensable step is to narrow the distance separating the patient from all the
other roles; this will serve as a symbolic acknowledgment of his intrinsic worth as a person, and on this basis a real relationship can be
established with him, entailing a reciprocity that has previously been
denied him.
But this reciprocity will call into question the authoritarian roles of
the hospital attendant and the physician, who, challenged by a patient
who forces them to shed their privileged roles, must then embark upon
a quest for a real function to replace the fictitious, often even sham,
function that the authority and prestige of their hierarchical positions
conferred upon them. If a reciprocity of roles is inclined to negate any
hierarchy, -then to establish such a relationship with the patient is
tantamount to undermining the very principle of hierarchy and authority according to which the hospital as an institution has been organized,
to replace it with a structure in which each of the poles of reality gives
meaning to the other. Thus, as the patient is liberated through the action
of the psychiatrist and hospital staff, so are the psychiatrist and the staff
liberated through the patient-he alone can invest them with a role they
have as yet not possessed.
Hence, our reality is the inmate in the mental hospital for whom
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FRANCO BASAGLlA
psychiatry has so far found nothing but negative solutions, perceiving
everything that is incomprehensible and psychopathological in him as a
sociobiological monstrosity to be removed and banished. But whereas
the student of psychopathology may believe it ideologically legitimate
to pursue his quest for a solution to such a monstrosity, maintaining a
detachment from the reality that is not directly before his eyes, the
psychiatrist within a hospital structure inevitably finds himself constrained to make an immediate choice. Either he must accept the parameters of traditional psychiatry and so attempt to effect a fit between
them and the patient and his symptoms (attached as virtual labels to the
patient's person), theory invariably carrying the day in the conflict
between theory and practice (which, of course, means establishing with
the patient the obvious authoritarian, hierarchical relationship required
by his role), or he must approach the patient as he is, seeking to
understand what he has become by reason of the parameters that have
placed a sanction on his otherness, as a brand, this time giving pride of
place to reality as the one and only touchstone of the true. Thus, the
alternatives are an ideological interpretation of illness, i.e., establishing an exact diagnosis by pigeonholing the various symptoms in a
preestablished syndromal pattern, or approaching the "mental patient" in a real dimension in which a classification of the disorder is
both important and not important, inasmuch as the level of regression
that has created a likeness between the particular patient and other
patients is related more to a range of institutional contingencies they
share-what Goffman calls "career contingencies" -than to his syndrome itself. Not only is there a regression in illness: there is also an
institutional regression.
L. Binswanger has pointed out (La conception de 1'homrne chez
Freud ala lumiere de l' anthropologie philosophique, Evolut. Psychiat. ,
1973,1[3]) the danger inherent in a scientific method that, "in moving
away from us, proceeds to theoretical conception, observation, examination, and dismembering of the real person with a view toward scientifically reconstructing an image of him. " Such a method is equipped
only with a series of images and preestablished categories of such a
nature that the psychiatrist finds himself face to face with a person who
is "mentally ill." So the psychiatrist has to bracket the illness, the
diagnosis, and the syndrome with which the patient has been labeled if
he wishes to understand him and, above all else, succeed in helping
him, since the patient has been destroyed more by what the illness has
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WHAT IS PSYCHIATRY?
been held to be and by the' 'protective measures" imposed by such an
interpretation than by the illness itself.
Yet, as soon as we call into question traditional psychiatry, which
has shown itself to be inadequate to its task (by reason of having
accepted the metaphysical value of the parameters on which it bases its
system), a similar impasse awaits us whenever we plunge into practice
without here, too, maintaining a critical stance. Once again the psychiatrist "de-situates himself," although in a different way.
The upshot of all this is that if we wish to start with the' 'mental
patient, ' , the inmate in our institutions, as the one and only reality with
which to begin, we run the risk of assuming a merely emotional approach to the problem. The negative image of the coercive and authoritarian system of the old asylum then acquires a positive coloration, and
there is a risk of injecting into the guilt we feel toward patients a
humanitarian impulse capable only of confusing the terms of the problem once again. No longer mixed in with offenders, but kept behind
walls no less forbidding than the former ones, ascribed a role not much
different from that of the punished lawbreaker, and alienated and isolated in that he is considered by science to be psychologically and biologically incomprehensible, the patient now risks becoming the "poor
patient" who has paid the price for all, for whom new structures,
providing shelter and succor, must now be designed. The "bad" patient, whose wardship in prison-type systems was required, is now on
the way to becoming the" good" patient; and efforts are then undertaken to reintegrate him into society, with the aid of new therapeutic
structures, all the while maintaining intact the system of privileges,
prevarications, fears, and prejudices that characterize this society. The
means for doing this is a network of institutions that steadfastly preserves the society and protects it from the otherness that mental illness
still represents. In a Manichaean world, the figure of the mental patient
cannot be confronted as a problem that calls that world into question; at
the very most he can change roles within the system itself, for it is the
tranquillity of that system that must be safeguarded above all else.
Jean-Paul Sartre's reply in a recent interview (J.-P. Sartre repond.
L'Arc, 1966, No. 30), taking up again the issue he had broached in the
essay quoted earlier, seems so suitable to our argument that I should
like to reproduce an excerpt from it. Sartre replies to the interviewer,
who challenged his statement that' 'No book can resist a child dying of
hunger,"
.~
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FRANCO BASAGLlA
The distance between the hunger of the child and the book is
beyond measure. But if it is the emotion I feel in the face of hunger
that drives me to write, I shall not be able to fill the void. To struggle
against hunger, the political and economic system must be changed;
and in this, literature can play only a secondary role-secondary, but
still better than nothing. There is an ambiguity in words: on the one
hand, there are only "words" - "literature"; on the other, these
words designate something; and they, in turn, act upon that which
designates, changing it. Literature should play on this ambiguity. If
the accent is placed on one aspect more than on another, either
literature becomes propaganda or it is reduced to the nothingness it
strives to avoid ... But if the ambiguity is firmly maintained, if
neither aspect of words is sacrificed, we shall already be in a good
position to produce true literature: a challenge that challenges itself
(Emphasis added.-F.B.)
Once again Sartre has a direct bearing on the point I am trying to
make. The mental patient we encounter in psychiatric asylums is in fact
a reality that is as much a challenge to psychiatry as the child dying of
hunger is a challenge to "literature." But if it is only the emotion I feel
when I am confronted with the patient that drives me to act on his
behalf, it is not possible to fill the void that separates him from the
science whose concern he should be. Thus, there are two possibilities:
either language retains the ambiguity inherent in being "words" that
designate and at the same time alter what they designate (in which case
psychiatry must be a science that acts directly upon the patient, as that
which psychiatric discourse must designate in order to effect change),
or only one pole of the ambiguity is dealt with. If the latter, on the one
hand we make "literature" (discussing classifications and subclassifications or syndromes) and, on the other hand, we undertake an emotive
analysis of the' 'patient" and his deplorable situation. But if instead we
reject both sterile psychiatric' 'literature" and an equally sterile, purely
humanitarian relationship, we shall begin to sense the need for a psychiatry that endeavors constantly to test itself on the touchstone of
reality and finds in that reality the elements of challenge for the sake of
challenging itself.
Asylum psychiatry must therefore concede defeat in its encounter
with reality, fleeing, as it did, the validation it could have obtained by
submitting itself to the test of that reality. Once reality had escaped it, it
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WHAT IS PSYCHIATRY?
could only continue to make' 'literature," nothing else, elaborating its
ideological theories; and the "patient" was forced to suffer the consequence of this schism, enclosed in the only surroundings deemed suitable for him-segregated in the asylum.
But just as for Sartre the role of literature in the struggle against
hunger is secondary because' 'To struggle against hunger, the political
and economic system must be changed," so in our field as well, to
struggle against the consequences of a science enveloped in ideology
we must struggle to change the system supporting it. Although psychiatry has, through its scientific avowal of the incomprehensibility of
symptoms, played its part in the banishment of the "mental patient,"
this must also be considered an expression of a system that hitherto has
believed it was negating and annulling its own contradictions by turning them out, away from itself, and rejecting their dialectic, in an
attempt to identify itself ideologically as a society without contradictions-just as it will now attempt to mitigate the asperities of those
contradictions, seeking to absorb them through apsychiatryo!propaganda (the literature of propaganda of which Sartre was speaking in his
interview), which is then offered as a new alternative.
Hence, the group of patients, physicians, psychologists, hospital
attendants, and administrators represented in this book by their discussions and essays about asylum reality have, on the basis of an examination of that reality, embarked on a struggle that must be conducted on
both a scientific and a political level at the same time. If in fact the
patient is the only reality to which we should refer, we must also
confront the two faces of that reality, namely, his being a patient with a
psychopathological problem (dialectical, not ideological) and his being
excluded and socially stigmatized. A community that aspires to be
therapeutic must take into account this dual reality-the illness and its
stigmatization-if it is to be able to reconstruct, step by step, the
patient's identity as it must have been before society, with its numerous
acts of exclusion, and the institution it invented, acted upon him with
their negativity.
It is only by bearing in mind the extreme ambiguity of the situation
we are experiencing that we shall be able to avoid the creation of a new
ideology: the ideology of the open hospital or therapeutic community,
offered as solutions to the problem of the mentally ill. Our reality is
resting on a profoundly contradictory foundation, and the patient's
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FRANCO BASAGLIA
conquest of freedom must coincide with the conquest of freedom by the
"whole community. " The aim is toward a new psychiatry based on a
psychotherapeutic approach to the patient, yet we are still entangled in
a psychiatric reality bound to old positivist paradigms. The trend is
toward the formation of hospital centers that will keep a watchful eye
on the dynamic interactions intrinsic to groups and a11 that interpersonal relations bring to them, yet there are no models to which to refer
other than those of an authoritarian and hierarchical system. Efforts are
being made to transform the mental hospital into a center organized, to
the extent possible, on a community principle; yet against our wills we
find ourselves part of a social reality that is highly repressive and
competitive. The aim is to approach the mentally ill person in the
context of the community, to extricate him from the regressed state into
which he has been driven; yet we run theriskin doing soofdriving him into a
new type of maladjustment to the institutionalized climate of society.
The therapeutic community may be considered to have been a necessary step in the evolution of the mental hospital (necessary, above a11, in
the function it had, and continues to have, in exposing what the mental
patient has been held to be and in fact is not, and because it has
redefined roles that previously had no existence outside an authoritarian
context), but it cannot be regarded as the ultimate goal. It was a
transitory phase, a holding action, until the situation itself evolved,
bringing us new insights. What is important for the moment is that we
should be able to maintain, confront, and accept our contradictions
without yielding to the temptation to run away from and thus deny
them. The present task of psychiatry, therefore, must be to reject
seeking the soluiion to the question of mental illness as illness, and
instead approach this type of patient as a problem that (merely because
it is present in our own reality) will presumably represent one of the
contradictory aspects of that reality, resolution of which will have to
rely on the development of new types of research and the creation of
new therapeutic structures.
This has been shown clearly in the open hospital: the patient-no
longer isolated and removed from the view of the physician-is there as
an ever-present problem-as, therefore, one of the poles of a reality
that cannot be denied. But is it possible that only the psychiatrist should
experience the patient as a problem, while society continues to try to
envelop him in the role of patient so that it need not undertake to face
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WHAT IS PSYCHIATRY?
him as he is in his everyday life? The psychiatrist cannot cope with such
an experience if society is not aligned in the same direction; the only
possibility that then remains (which is not a solution, and does not
claim to be) is to accept the problem of the mentally ill as part of our
reality. Only when the problem has become part of the experience of
each and every one of us will society feel obliged to come up with real
solutions through the establishment of truly therapeutic measures-the
only way to cope with the mental patient's disagreeable presence in our
reality. So long as he is cared for elsewhere, by others, we shall
continue to deny the problem, for fear of recognizing and identifying
ourselves in it.
Although the new psychiatric structures are still confined within the
traditional system, even where that system may have been turned inside
out, it is becoming more and more evident that the mental hospital is
not an institution that cures, but a community that cures itself by
confronting its own contradictions, inasmuch as hospitals themselves
are real communities, full of all the contradictions that characterize
reality itself. Hence, once the institutional world is no longer enclosed
within an artificial reality, it will perforce come face to face with the
world outside, which, in turn, will teach it how to accept its own
contradictions, since it will not be possible to relegate them elsewhere.
In a certain sense one can speak of a meeting of the two communities
(the external and the internal) that has already assumed physically
concrete form as the city has expanded to the periphery, to which
madhouses had, in the past, been banished. And as the closed community evolves, revealing itself as a live, real, and contradictory community, it will find itself dialectically clashing with the reality that begot it.
So it is that we can undermine, at one and the same time, both the
ideology of the hospital as a mechanism that cures, as a therapeutic
fantasy, and as a place without contradictions, and the ideology of a
soCiety that, by denying its own contradictions, would like to be seen as
a sane society.
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