Our Necessary Shadow by Tom Burns

Author:Tom Burns
Language: eng
Format: epub
Publisher: Pegasus Books
Published: 2014-12-07T16:00:00+00:00

WHAT IS THE ALTERNATIVE TO THE ASYLUM?

What has not been so successful is the long-term care for a new generation of patients who would previously have become long-stay. These so-called ‘new long-stay’ patients spend repeated periods in hospital but between admissions are enormously difficult to support in the community. Unlike the previous generation, perhaps precisely because they have escaped the effects of institutionalization, they are often fiercely independent and resist the help offered. Their illnesses are also often made much worse by heavy drug and alcohol abuse, though this is often not that different from their healthy neighbours. As a result they are highly visible, both distressed and distressing, especially in large cities. They may become homeless and live undignified and squalid lives on the streets, like the ‘bag lady’ drifting with all her possessions and scavenged trash. Contrary to popular belief, most are known to both health and social services but vigorously reject regularly offered help. This can only be forced upon them when they are very ill indeed. Mental health services no longer struggle with the rehabilitation and resettlement of long-stay mental hospital patients; there are very few such left. Their current problem is the long-term care of those with severe illnesses who vigorously resist hospital care.

The Paris student riots of 1968 and the upheaval that followed them had a more far-reaching impact on continental Europe than is often recognized in the UK and USA. Universities and professions were shaken to their core and the challenge to accepted authority was profound. In Italy a charismatic psychiatrist, Franco Basaglia (1924–80), led a veritable revolution reforming Italy’s neglected and inadequate mental hospitals. A Gramscian Marxist, Basaglia focused on the corrosive effects of the power imbalance in the psychiatrist-patient relationship. His movement was called Psichiatria Democratica and its slogan was ‘liberty is cure’.

Basaglia was energetic, eloquent and influential. It also helped that his wife was an Italian senator. Consequently the 1978 Italian mental health reform, Law 180, was a truly radical affair; mental hospitals were effectively outlawed. From the date the law was enacted no new patients could be compulsorily admitted to a mental hospital, none. From then on new patients could only be admitted compulsorily to small diagnostic wards in general hospitals each with a maximum of fifteen beds, and then only for seven days at a time. Mental hospitals could readmit known patients but were obliged to formally close, even to them, within three years. They often did this by redesignating some of their wards as freestanding residential units. Perhaps not quite the complete revolution envisaged, but still an enormous change with a more equal and participatory atmosphere. The Italians closed the ‘front door’ to the institution.

The success or otherwise of the Italian reforms generates endless debate within the psychiatric professions. They were only executed comprehensively in the rich and educated north and hardly heeded in the south (Italians seem remarkably relaxed about legislation). The quality of their best is outstanding, their approach to community care and their engagement of psychotic patients in society exemplary.

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