Trieste: History of a transformation
" … the important thing is that we have shown that the
impossible becomes possible. Ten, fifteen, twenty years ago, it was unthinkable
that an asylum could be dismantled. Asylums could become closed, and more
closed than before - I do not know -, but, at any account, we have
shown that the mad can be assisted in another way, and this evidence is
basic. I do not believe that the fact that an action can become general
means that one has won. The important point is another one: Now one knows
what can be done. This is what I have already said thousands of times.
In our weakness, in the minority we represent, we cannot win, because
it is the power to always win. We can at most convince. In the moment
we convince, we win, that is we give rise to a transformation situation,
difficult to recover."
Franco Basaglia, Brazilian Conferences, 1979
The annual World Health Day, April 7th, 2001 was devoted to mental health.
On that occasion, Mrs. Gro Harlem Brundtland, WHO General Manager, exhorted
all governments to take concrete action and launch information campaigns in
order to combat the prejudice, and social exclusion which still affected the
lives of the more than 200 million men and women worldwide who suffer from
mental disorders. With the slogan "Stop exclusion. Dare to care"
the WHO also underlined its invitation to close all psychiatric hospitals,
in both developed and undeveloped countries.
In a booklet published on that occasion, we read:
"...In Italy, the 1978 Reform Law initiated a process to supersede psychiatric
hospitals with the creation of community-based services which enabled patients
to continue living their lives in normal social contexts. The Italian city
of Trieste created a significant network of community-based services, protected
flats, and coops that train and employ psychiatric patients. The Trieste psychiatric
hospital was shutdown and replaced by 24hr community services. These centres
provide care, psycho-social rehabilitation, social assistance and crisis interventions
if necessary. A number of protected flats were set up for chronic and severe
patients, offering a friendly non-medical environment, while employment opportunities
have made full social reintegration possible for many patients..."
This authoritative opinion represents the culmination of a 30-year transformation
process. While the history of this long journey has yet to be written, we
can sketch out the salient moments and phases.
Moving beyond the Psychiatric Hospital
In August 1971, Franco Basaglia became Director of the Trieste Psychiatric
Hospital. Upon assuming his post, he formed a team of young doctors, sociologists,
social workers, volunteers, and students from all over Italy and Europe, who
had been attracted to Trieste by the current debate on psychiatry and total
institutions, which involved operators, scholars, politicians and the media.
Basaglia had achieved national notoriety with the publication of "L'istituzione
negata" ("The Institution Denied") in 1968, which was based
on his attempts to apply the therapeutic community model in the neighbouring
town of Gorizia during the 1960s. In documenting his efforts to humanise the
institution, Basaglia declared for the first time that psychiatric hospitals
could not be reformed: as instruments of social control they could not provide
the care for which they were intended and, in fact, produced the very illness
they were supposed to cure.
His intention in coming to Trieste was thus to finish the work begun in Gorizia,
to go beyond the asylum and establish a network of alternative community services
that could perform all of the functions of care, hospitality, protection and
assistance that it had been the psychiatric hospital's task to provide.
This was an extremely difficult challenge, for despite several attempts at
reform in France and England after WWII, noone had actually succeeded in shifting
the axis of care from the hospital to the community. The intended reform had
no know-how or consolidated practices upon which to model itself, while the
legal framework was still based on the concept of danger.
In 1964, Basaglia had written as follows on the urgent need to "deconstruct
the psychiatric hospital:
"When the ill person enters within the walls of internment, he enters
a new dimension of emotional void (what Burton calls "institutional neurosis",
but I would simply call "institutionalisation"). He enters a space
which was originally created to render him inoffensive while providing a cure,
but which is instead, and paradoxically so, designed to the total annihilitation
of his individuality and his full objectivication. If mental illness is, at
its root, the loss of individuality and freedom, in the asylum the ill person
finds the place where they will be ultimately lost and become the object of
the illness and of repeat admissions. The absence of any project or future,
the constant dependency on others without any personal incentive, the organisation
of each day according to the dictates of the institution which, as such, is
incapable of seeing the person or his individual needs: this is the institutionalising
scheme which asylum life is based on."
Changing the Internal Organisation
On December 31st, 1971, there were 1182 inmates hospitalised in theTrieste
Psychiatric Hospital, with a yearly turnover of about 1300 patients. More
than 90% of these were mandatory internments (Italian Law 36/1904), with very
few persons benefiting from the voluntary hospitalisation which had been recently
introduced in Italian legislation (Italian Law 431/1968). The use of voluntary
hospitalisation would, in fact, become an important tool for guaranteeing
patients their rights by increasing their freedom of movement both inside
and outside of the hospital and giving them more power in terms of care and
From the very outset of Basaglia's directorship, great stress was placed on
the reorganisation of internal spaces and on breaking down the rigid, professional
hierarchy which regulated the relationship between staff and patients. The
transformation was initially conceived as a progressive reduction and restructuring
of the hospital into "open communities", with the hospital divided
into 5 "areas", each with their own staff, that corresponded to
five geographical areas with the city and province.
Daily meetings were held each day by the entire staff, as well as by each
individual workgroup in order to discuss and debate the work being done. The
inmates also participated in periodic meetings coordinated by Basaglia in
order to discuss the changes taking place. The doors of the wards were unlocked
and shock therapy and all forms of physical restraint were prohibited. Division
by gender was also abolished, and mixed wards established.
Life in the hospital was enlivened by parties, bars and an inmate newspaper,
and patients began to circulate within the city, both alone and in small groups.
Thanks to funding by the Provincial Administration, inmates began to receive
subsidies which permitted them access to public places.
The changes taking place began to create resistance in the nursing staff and
alarm in the local population.
"...the dominant ideology was that the ill were dangerous and had to
be shut up in an asylum. The first thing to do, therefore, was to convince
people that this was simply not true. Day by day we attempted to show that
changing the relationship with inmates also changed the meaning of those relationships.
As nurses began to realise that their work could be different, they became
agents for change. In order to change the views of the general public, it
was first necessary to reintroduce the mentally ill into the streets, into
social life. This provoked an aggressive reaction on the part of the local
population, but it was necessary to create this state of tension in order
to show that a change was taking place. In training the nurses, the important
thing was to create a new type of operator who was not dependent on doctors
but could take decisions on his or her own." (Franco Basaglia, Brazilian
The Restoration of Rights
The first five years were dedicated to reconstructing the needs and personal
life stories of the interned, in order to reestablish relationships with their
families and places of origin. With the break-up of the large wards, living
groups and group apartments were created, first within the hospital and then
within the city. There was a systematic involvement and training of nurses
in order to enable them to abandon their traditional functions as "guardians"
and begin to take an active and responsible role in the transformation process.
One of the most important initiatives was the establishment of the "United
Workers" Cooperative" in 1972, which organised 60 inmates in order
to clean the wards and kitchen and maintain the asylum grounds. Each coop
member/asylum inmate signed a contract and received a union wage, completely
inverting the exploitation of inmates which went under the name "ergotherapy"
and opening up the way to the important use of social coops in therapy and
rehabilitation in later years.
The recognition of the right to work, and the dismantling of large wards into
smaller autonomous living units clearly showed that it was not disability
or illness in themselves, but the legal/administrative status of "inmates"
which prevented rehabilitation. Negotiations thus began with the provincial
administration to make day/nighttime care and hospitality available –
as a right - to those people who, while not requiring hospitalisation, still
needed to remain as "guests" because of the lack of housing, work
and a social network.
"In those first years, attention was given to speaking with families
and caregivers in order to change the status of the patients with respect
to the restoration of civil rights and the possibilities of income.This was
the only thing that could enable us to emancipate people from psychiatric
control. Inmates had to be recognised as people with identities that had not
been totally objectified by the institution and psychiatry. We concluded that
it was not possible to have a proper relationship with them if their status
as citizens had been first given back to them." (interview to Franco
Creating a Relationship Between the Hospital and the Community
Although the greatest effort was concentrated on the institution, in 1973
several important initiatives had already begun to look beyond the ayslum
walls and towards the community, especially the restoring of family relationships,
the accompaniment of inmates within the city and the search for work and housing
for those inmates who were ready to be released. During this same period,
the hospital began to open up to the city with exhibitions, parites and concerts
on the asylum grounds open to the public. These experiences would lay the
foundation for an alliance between psychiatry and sectors of the general population,
including the women's and students' movements, political organisations and
trade unions, the media and opinion-makers and intellectuals and artists.
A painting/sculpture/theatre/writing workshop was established in the first
ward t o be completely emptied ("P"). Here "Marco Cavallo"
was built, an 8ft tall blue-painted horse of paper-machè and wood which
became the symbol of the desire for freedom on the part of all the inmates.
On the last Sunday in March, 1973, Marco Cavallo was carried around the streets
of the city at the head of a procession of operators, patients, artists and
ordinary people. During this period, holidays and daytrips into the city and
elsewhere also became more and more frequent.
In 1973-74 the hospital was reorganised, with patients being grouped not according
to the severity of their illness (agitated, violent, chronic, etc.) but based
on their area of origin within the city, a division of the territory which
is essentially maintained by the 4 Mental Healthcare Centres today. A workstyle
was thus introduced which aimed at releasing and supporting patients in their
own homes and neighbourhoods. The assumption of new cases also came to rely
ncreasingly on cooperation with other institutions, agencies and citizens
groups in the city.
The work outside the hospital, with its problems, successes and conflicts,
brought about the first and most significant changes in both the therapeutic
practice and the institutional and administrative organisation, and became
the "hands on" training school for doctors and nurses alike.
The First Community Mental Healthcare Centres
At the beginning of 1975, there were 800 inmates in the hospital, 90 of
which were interned, 150 voluntary and 460 guests, with a turnover of about
1700 annually. Many of those who had been released had found new living accomadations,
either with families or, more often, in group homes or council housing.
The first community residences were activated in 1975-76. Initially intended
for patients recently released from the psychiatric hospital, almost immediately
they began to be used for crisis situations and as day centres, thereby reducing
the number, frequency and length of hospitalisations.
The first Mental Healthcare Centres were thus established before Law 180,
working and developing alongside the still functioning psychiatric hospital
despite the lack of a regulatory or legal framework (Italian Law 431 (1968)
only provided for "Mental Hygiene Centres"). This was, in fact,
the most delicate phase during the entire transformation process, with two
organisational, financial and care systems (especially nursing care) working
simultaneously. The risk was paralysis, but with the strengthening of the
community services and the growth and development of the 24hr Mental Healthcare
Centres it was possible to successfully pass through this transitional period.
At the beginning of 1977, there were 132 inmates, 51 of whom were involuntary,
and the remainder voluntary, with 433 guests. In February of the same year,
a 24hr psychiatric care service was established in the Emergency Room of the
General Hospital, with the aim of filtering the psychiatric demand and providing
more appropriate forms of crisis response than the automatic and routine recourse
to mandatory hospitalisation. The service would remain active until 1980 when,
pursuant to Law 180, it became the Psychiatric Diagnosis and Care Service,
with the functions of primary care, consultancy in hospitals wards and referrel
of cases to MHCs.
At the end of 1976, with the crisis of the Provincial Council, headed by Michele
Zanetti, which had supported the reform process until that moment, Basaglia
decided to publicly announce the closure of the psychiatric hospital as an
"An important result for us is that the community Centres, despite the
sometimes uneven levels of care, have increasingly become points of aggregation
for former inmates, new users, and other citizens. These persons, who often
have nothing in common at the outset, progressively discover a substantial
alliance based on their common needs and the common oppressions to which they
are subject. The other important fact is that so-called "management of
the ill" changes from the total management of the person and his life
within the hospital. With the end of paternalism and the beginning of negotiation,
this total takeover of a person's life is replaced by a mutual process which
allows for disagreement." (The Closing of the Psychiatric Hospital, Press
The Closure of the Psychiatric Hospital
On May 13, 1978, due to intense pressure by the deinstitutionalisation movement
in Trieste and elsewhere in Italy and the threat of an abrogative referendum
on Law 36/1904 which, if successful, would have created a legal void for psychiatry
in Italy, the Italian Parliament passed the Psychiatric Reform Act (Law 180)
which provided for the gradual closing down of psychiatric hospitals and their
replacement by community-based services. However, at the time the Law was
passed, the Trieste psychiatric hospital had already ceased most of its former
In November 1979, Franco Basaglia left Trieste for Rome, where he had been
summoned to direct the psychiatric services in the Lazio Region. In Trieste
his place was taken by Franco Rotelli, who had the difficult task of finally
closing down the psychiatric hospital and confronting the mounting criticism
regarding its "state of confusion and decline". The new management
also had to reinforce the still poorly-defined community services and completely
reorganise the use of resources. These were thus transitional years in terms
of organisation, adminstration and management, in which the psychiatric reform
had to be reconciled with the National Healthcare Service and the transfer
of competencies from the Province to the newly instituted Local Healthcare
On April 21, 1980, the Provincial administration passed a resolution declaring
that the Trieste Psychiatric Hospital "could cease its functions and
therefore be abolished". Franco Basaglia would die in August of the same
The Establishment of the Mental Healthcare Department
In 1981, the Mental Healthcare Department was established, thereby guaranteeing
the technical, administrative and planning unity of the community services
network, together with its programmes and activities. The operational standards
of the 5 Mental Healthcare Centres (reduced to 4 in 1996) were more precisely
defined, with each MHC serving a catchment area of about 50,000, and equipped
with 8 beds and a canteen for day visitors and overnight guests.
Together with the walk-in service, home care and social support, the Department,
based on a special agreement with the Justice Ministry, also began to work
intensely in the local prison in order to provide therapeutic continuity for
inmates with preexisting disorders, as well as care for those who developed
problems during their incarceration. The service also worked to promote alternative
measures to imprisonment and avoid transfers to forensic prisons.
Residentiality was reinforced in each area, in order to provide hospitality
not only to those recently released from the psychiatric hospital, but also
for users with difficult family or housing situations. Rehabilitation, training
and socialisation programmes were developed, which included leisure activities,
workshops and remedial education and literacy programmes. In the mid-1980s
the coops were also strengthened in order to provide more occupational training
and employment opportunities for primarily young, disadvantaged users. During
the 1990s, "social enterprise" would coincide with an intense programme
for the full exercise of the rights of citizenship by users of the mental
healthcare services. A series of empowerment/emancipation programmes focussed
on housing, work, socialisation, education and training, giving rise to networks,
forums and self-help groups for risk groups (especially young adults).
Results of the Deinstitutionalisation Process
After more 25 years without a psychiatric hospital in Trieste the situation
is as follows: the number of people referring to the mental healthcare services
each year is about 13.5/1000 population (3500 users/year). Private psychiatric
services remain fairly undeveloped. There has been no phenomena of transfer
or placement in other institutions (trans-institutionalisation), with the
exception of transfers to general medical wards for primarily elderly persons
with organic illnesses concommitant with mental disorders. After the creation
of the Substance Dependency Service in the early 1980s, the Mental Healthcare
Department has collaborated with this Service in numerous programmes (coops,
workshops, leisure time, sports).
The San Giovanni Compound, site of the former Psychiatric Hospital, currently
hosts less than 50 people in a number of small residences (no patients have
been hospitalised here since 1980). The service network is made up of 4 Mental
Healthcare Centres for a population of 240,000 inhabitants. In 1999, the University
Psychiatric Clinic became an integral part of the MHD, with its own Mental
Healthcare Centre. Costs for psychiatric care have been reduced by half: in
1971 total expenditures were the equivalent of 26 million Euros; in 2003,
the MHD spent less than 15 million Euros.
Staff has been reduced from 524 units in 1971 to 242 units in 2004; beds have
been cut from 1160 hospital beds in 1971 to 122 beds total in 2004 (including
MHCs, PDCS and residences). Recourse to the private sector is very limited
with only 90 people from Trieste (2% of users) being hospitalised in private
clinics outside of the Region in 2002. And finally, a single care institution,
the psychiatric hospital, has been replaced by nearly 40 structures with different
functions and tasks.
While these indicators illustrate the institutional change, other data indicate
the meaning of the deinstitutionalisation process, with the clear confutation
of commonly held prejudices and cliches:
- 24 people were admitted to forensic hospitals in 1971, with an average of
20 annually during the 1970s, while in 2004 only 2 people were interned in
forensic hospitals, with an average of 0.5 over the past decade (prejudice
- mandatory hospitalisations averaged 150 in the 1970s (60/100,000 pop.);
in 2003 there were only 28 Mandatory Healthcare Treatments (MHT), with an
average of 11 MHTs/100,000 in recent years (prejudice of the refusal of care).
- the suicide rate from 1985-96 was 23/100,000; in 2003 it was 17.5/100,000
Towards New Scenarios
In evaluating the community-based work of the past 25 years, the single
most important indicator validating the work of the services is crisis intervention.
The non-bureaucratic, demedicalised approach to crisis reduces hospitalisations,
favours a more rapid return to stability and reduces relapses. In our view,
crisis is part of a person's life-story, with its own meaning which must be
understood and restored using the resources and relationships that exist in
each person's own context.
The community services are very low threshold walk-in services. They avoid
standardised responses and protocols and instead focus on reconstructing social
relationships and networks, enhancing personal resources and capacities and
aim at quality in every aspect of the therapeutic work in order to guarantee
a quality relationship.
Numerous self-help groups for users and their families have been organised
in recent years, with courses, regular meetings and increasingly diversified
social, educational and leisure activities. The area if social enterprise
and training in sectors as diverse as information technology, fashion and
radio broadcasting also continues to develop, and will certainly be one of
the key elements for health and emancipation in the future.
The scenarios of social enterprise, self-help, family and caretaker participation,
training and diversity are indicators that confirm the effectiveness and validity
of community-based mental healthcare services.
San Giovanni Compound
After being dismantled and shutdown in the 1970s, the grounds and many structures
of the former Trieste Psychiatric Hospital, which first opened its doors in
1908, have gradually been restored to the City.
Currently, the San Giovanni Compound hosts several faculties and offices of
the University of Trieste, 2 Slovene language high schools, the Local Healthcare
Agency Administration Building, the head office of the International Maritime
Academy, a Civic Theatre, a centre for the disabled, the Substance Dependency
Department the offices of Industrial Medicine and the District 4 offices with
The Mental Healthcare Department currently utilises ten buildings, including
the Administration Building, several small residences and the former ward
Pavilion "M", which hosts the Rehabilitation and Residence Department,
the Polytechnic and several social coops. The historic "Il posto della
fragole" bar-restaurant also remains very active, with a wide range of
customers that include students, operators, users and visitors.
The San Giovanni Compound, with its beautiful landscaping and architecture,
and the surrounding neighbourhoods are emblematic of the history of Trieste
with its ethnic and cultural diversity, and offer the possibility for new
forms of belonging and coexistence in diversity in the future.