Trieste: Where Mad Minds Can Fly

The morning sun is already high and hot as we enter the grounds of San Giovanni Park, the former asylum in Italy’s north-eastern city Trieste, through Europe’s largest rose garden – 3000 varieties in mid to full bloom, hot-pinks and blood-reds, lemons, peaches and creams. ‘A multitude in place of economic and moral servitude’, our guide Pantxo Ramas suggests, motioning towards the old pavilions ahead of us, where interned patients were forced to work for free in the name of ‘ergotherapy’ before the old regime was dismantled in the 1970s. The gardens, initiated in 2009 by Franco Rotelli (by then the director of Trieste’s Healthcare System), were intended for staff and service users to ‘touch the earth and water the roses’ while ‘changing things’. Today they are maintained by a social cooperative and offer a gathering point for all kinds of visitors, like the group of young service users we will meet later, who meet weekly to garden, socialise, and discuss the history and politics of this place.

‘Beauty is truth, truth is beauty’, reads a banner hanging along the walkway, drawing me towards the tall perimeter wall which once imprisoned over 1300 locals. I lean against the rough stone for a while, taking it all in. The group I’m with, an international network of researchers, practitioners, survivors, and activists, are among thousands to have travelled to this epicentre of Italy’s movement for Democratic Psychiatry, which led to the definitive closure of the country’s asylums. The last one shut in 1999. At the movement’s height in the 1970s and 1980s, health workers, trade unionists, artists, students, leftists, feminists, housing campaigners, ravers, musicians and various public figures and intellectuals, flocked to participate in this simultaneous destruction of an old and hated institution while inventing new forms of care rooted in the life of the city. Now recognised by the World Health Organisation (WHO) as one of the most advanced public mental healthcare services in the world, people continue to come, in my case carrying a curiosity that lies very close to home.

In 1971, the year San Giovanni’s new medical director Franco Basaglia arrived at the asylum with an agenda to overturn it, my uncle was embarking on what would turn out to be a thirty-year stretch under a hospital order in England’s high-security psychiatric system. Family visits to see him in Broadmoor, the most notorious of these ‘hospitals’, brought my first encounters with carceral institutions and a whole world of suffering that I was too young to understand but would soon become familiar with. Decades later, Rotelli’s acknowledgement that ‘using language to enter into madness is like using a tape measure to measure a liquid’ has already warmed me to the humanism at the heart of this project to revolutionise how mental suffering is understood and treated. The gardens bring home to me its affinity with Ruth Wilson Gilmore’s ‘abolition geography’: the ‘premise that freedom is a place’ where ‘we figure out how to combine people, and land’. For Rotelli, the beauty of a collectively tended garden was to serve as ‘the cypher of what is possible, of what has not become true in that true life that we wanted to live, for us, for the loonies, suffering brothers and sisters with whom we have done a long walk’.

It all began with a no

In Britain, the Italian movement is often associated with the ‘anti-psychiatry’ movement – R. D. Laing, David Cooper, Thomas Szasz and Erving Goffman, among others – whose scathing attacks on powerful institutions captured the popular mood in the 1960s and 1970s. There were indeed generative encounters between the Italian and British movement, although Basaglia rejected the term anti-psychiatry, describing its ‘great success’ as deriving ‘from the ideological more than the practical view’. In this acknowledgement of success, Basaglia also identified the danger of caricature when it comes to flattening the variety of critiques and experiments that emerged in the UK, and were, in turn, part of an international movement operating in divergent contexts, notably France, Brazil and Algeria where anti-fascist and national liberation struggles were central.

Today in Britain, the post-WW2 asylum closures are often associated with neglectful ‘community care’ policies which have been accompanied since the early 1990s, by rising rates of compulsory detentions and the imposition of ‘community treatment orders’. Similar associations can arise in relation to Italy’s headline grabbing ‘Law 180’- which ordered the closure of asylums while introducing a raft of equally significant but less well publicised measures: the integration of mental health treatment into a newly established national health service; removal of ‘dangerousness’ as a basis for detention (something that remains at the heart of UK mental health law); and emphasis on voluntary, community-based treatment with strict limits on the use of compulsion. Limited knowledge of these constructive aspects of Italy’s reform movement is compounded by the unavailability of Basaglia’s key works in English, including the collectively written L’Istituzione Negata (The Institution Denied, 1968). Changes in mental health provision have also impacted unevenly across the country’s twenty regions, and everywhere the hopes of those early days have suffered from the ravages of neoliberalism, successive economic and political crises, and gains by far-right parties and fascist groups.

For Basaglia and the broader ‘Democratic Psychiatry diaspora’ – a term coined by John Foot in The Man Who Closed the Asylums to capture a campaign that involved many different actors across numerous cities – the asylums’ ‘destruction’ was only the beginning. Necessary to release those designated ‘mad’ from the death of social exclusion in order that they might re-enter life in the city and create alternative forms of care as part of a ‘radical change in social relations’. Shaped by Italy’s intense labour struggles, Democratic Psychiatry was distinctively class oriented in its analysis of mental suffering and assertion of the liberatory potential of ‘loonies’ as part of a working class invested in social solidarity. ‘We cannot understand what disease is as long as the primary needs of men are not met’, Basaglia argued. This is captured beautifully in Fit to be Untied, produced by the Italian film collective 11 Marzo Cinematografic, when a worker reflects on his experience of labouring alongside people previously institutionalised as ‘subnormal’: ‘they taught us something we had lost, our humanity, how to love’. Above all, Democratic Psychiatry was about practice, or the ‘practically true’ as Basaglia would say – invoking Sartre – pursuing an art of the possible by working through the contradictions of everyday life.

It is true that Italy’s movement ‘all began with a no’, as Franca Ongaro – Basaglia’s long-time collaborator, who penned most of his written work alongside her own – put it. Arriving at Gorizia asylum, about thirty miles north of Trieste, in 1962 for his first medical directorship, Basaglia was hit with a ‘terrible smell of death’, the ‘symbolic smell of shit’ which took him ‘straight back to the war’ and the Venetian prison he had been incarcerated in for chalking up anti-fascist slogans at his university. That night he refused to sign the usual order for restraining patients. ‘Violence [is] exercised by those who hold the knife on the side of the handle’, Basaglia wrote, ‘against those who are hopelessly dominated’. Basaglia had broken out of prison in 1945 in an uprising of prisoners and guards which drove the Nazis out of Venice. He had seen hope in the most miserable of places and knew which side he was on.

Gorizia’s asylum, like the town, was deeply marked by war and empire: built under the Hasburg monarchy, destroyed during the First World War and divided by the iron curtain after the Second. Among those detained were Hungarians, Slovens, Austrians, concentration camp survivors and others who were deemed ‘unreturnable’. ‘At the border between life and death, between normality and non-normality’, suggest two members of Radio Fragola Gorizia Guillermo and Alessandro, when we meet them at their small studio in ‘Area 174’ – formerly the asylum mortuary nestling right on the boundary with Slovenia. ‘This is the house of the crow’ Guillermo says pointing upwards at the sky where imposing, blue-black birds make a regular appearance, ‘they’re known as kavkaz’. We later realise the correct translation is jackdaw, but looking out to the flimsy wire fence, just a few metres away from where tanks once patrolled, and back over the sweeping vegetation surrounding what is now Gorizia’s twenty-four-hour mental health walk-in centre (MHC), it’s hard not to think of Kafka’s outcast crows doing the impossible: trespassing forbidden territories.

When we are guided into the main building by Marco, the MHC’s clinical psychologist, we are greeted by a member of the centre’s archiving team with descriptions of the asylum’s ‘shocking’ conditions before Basaglia: grey uniforms, patients tied to beds – toilet holes dug into the mattresses for those immobilised, locked cells, and the smell. These conditions were standard across Italy’s asylums then governed by a 1904 law which authorised the detention of anyone ‘affected by mental illness’ considered ‘dangerous to themselves or to others’, or the cause of ‘public scandal’. The violences described are familiar to me. I already know about the tactic of wrapping a patient’s head in a wet sheet (sometimes covered in urine) and tightening round the neck to cause unconsciousness – ‘throttling out’ as my uncle recalls it from Broadmoor and Rampton Hospital. And that deathly smell he could not escape during his first months in Broadmoor’s admission block, an ‘uncomfortable’ and ‘fearful’ smell.

The Institution Negated

Basaglia, like many other critical voices of the time, identified the ‘sickness’ in front of him as induced by the institution, and drew on his knowledge of the ‘therapeutic commnunity’ at Dingleton Hospital in Scotland and Institutional Psychotherapy in France to begin the work of ‘negating’ it. Interviews with patients in L’Istitutzione Negata capture some of these experiences: Marghertia, Daisy and Carla (a holocaust survivor), tearing nets and padlocks from the beds that had imprisoned them, removing leather binds and straightjackets and entering the grounds untied for the first time, having previously been bound to trees and benches; Andrea, president of the daily assemblies, ‘begging’ people who were ‘frightened after being closed for so many years’, to ‘open their mouths’ and participate in this new democracy; Furio, editor of the new patient magazine Il Picchio (The Woodpecker), who had found daily life ‘tortuous’ after being interned for attempting suicide, joyfully joining others to pull down the asylum walls.

It was a complex, messy and at times violent process. Many staff, some fascist sympathisers, resisted the changes. Patients who had endured years of subjection and institutionalisation were afraid and still looked for permission or authorisation to act. There remained problems of paternalism. Pent up rage. Chronicity induced by years of internment and inhumane treatment. The stakes were high. In 1968, Milena Kristianic was killed by her husband after he was released into the community. While the state pursued criminal charges against Basaglia, patients, staff and volunteers in the asylum sought ways of making sense of what had taken place – considering their responsibility for these events and taking steps to relate to those patients who remained less engaged. A different sort of accounting for a terrible harm that those of us pursuing responses outside of carceral systems still grapple with today.

Influenced by various thinkers and political currents, including Gramsci, Sartre, Primo Levi, Surrealism, aspects of Maoism, autonomist Marxism, phenomenology and Robert Castel, Basaglia and the asylum’s larger équipe of staff, sought to go beyond models of a therapeutic community that functioned like ‘a micro-society’, ‘reduced to an internal perfectionism’ and ‘unable to effect outside’. It was not only the asylum that was being critiqued, but institutional treatments of human suffering that ‘emptied’ madness of its social content; severing its relationship with ‘a system of production that organises the masses … reduced to so many bodies deprived of subjectivity.’

The struggle to understand and alleviate human suffering therefore could not be confined to a psychiatric practice conceived as a discrete branch of medicine requiring technical improvements. It had to be located within the political sphere. Not only because social conditions – poverty, housing or workplace stress, social isolation and oppression – drive mental distress but because survival inside a globally violent system involves forms of suffering that are so entangled with our social fabric that they can only truly become knowable, and perhaps transformed, as part of a struggle to overturn it.

‘New forms of research and new therapeutic structures’ were required (Basaglia), existing hierarchies between ‘technicians’ and patients needed to be upended, and both needed to join the ‘struggle for health in the factories, the workplaces, homes and the hospital’ (Ongaro). This emphasis on patients’ political agency with daily assemblies serving not simply as forums for democratising institutional life but as spaces for self-organisation and realisation, was of course part of a larger wave of protest sweeping Italy most visible in student-worker occupations and assemblies. Gorizia, the town, however, remained ‘absent from the whole experience’ and it was this that Basaglia set out to change in Trieste.

Peacetime Crimes

By the time Basaglia arrived in Trieste in 1971, he was part of a movement of challenge and experimentation across Italy and carried the support of the province’s governing majority to act on conditions that were causing public scandal. During the Second World War it was one of many European cities to host concentration camps, and the only one in Italy with a crematorium. Thousands had been deported to death camps and up to 5000 Jews and political prisoners had been murdered on site. Lying on bordered lands, the people of Gorizia and Trieste had been traumatised by successive imperialist conflicts. Trieste’s large refugee population, targeted by fascist organisation, also helped to make it a place where affinities between different communities could emerge.

Walking through the main grounds of San Giovanni Park past the hubbub of the café and social centre Il poste dell fragole and along the old living quarters – pavilions now bright yellow with bold red slogans painted on the walls such as ‘Freedom is Therapeutic’ – I stop at a steel sculpture. A winged figure emerges from a cage overlooking a long boulevard, part of the original layout of ‘The Magnificent Psychiatric Hospital’ opened in 1908, where guards in long black steely buttoned coats and peak caps used to stand watch. It’s called ‘The Dive’. To fly or fall?

Just below, the Mental Health Department (MHD) coordinates services for the regions of Trieste and Gorizia from a pavilion previously used to detain patients labelled sudici (dirty) or paralitici (with disabilities). Pantxo has a friend who was interned at St Giovanni and remembers the nurses calling it ‘the pavilion of the cagoni – literally the ‘shitters’ – his friend was just seven when they threatened to send him there as punishment.

The department’s location is intentional, harking back to the early days of San Giovanni’s ‘negation’, when the most degrading blocks were closed or repurposed. A wall poster designed for the patient magazine 847 in 1974 indicates the closures of Block C and P (for the ‘agitated’ and ‘semi-agitated’) with a large X. Block P was later used as an art space called Laboratory P, while women in Block C were moved to supported flats in the administration block. This was part of a larger reorganisation of residents into five open communities grouped according to people’s connection with the city – where they had lived or worked – rather than their perceived ‘dangerousness’. The poster is one in a series of graphics displaying San Giovanni’s transformation: from the ‘total institution’ in 1908, to ‘the institution negated’ in 1971, the ‘institution invented’ in 1979 and finally ‘the city that heals’ in 1996. Together they capture the central strategy pursued by Basaglia’s team of embedding an ‘ecology of care’ into Trieste’s urban space (described in detail by Pantxo in Caring Ecologies, 2019).

In Peacetime Crimes, written in 1974, Basaglia and Ongaro sought a ‘higher level of clarity and struggle’ to challenge ‘the logic of capital’ as it was imposed not only on healthcare but ‘every institution’ forced to function like ‘a productive organism’. Instead of being geared towards the valorisation of labour, the organisation of health and society needed to start from the ‘value of [human beings]’ where ‘health and normality cannot be the norm because the human condition is that of being healthy and ill together, normal and simultaneously abnormal’. It strikes me that this understanding of health as part of a broader strategy of collectivising social reproduction and its expansive view of class struggle shares an affinity with social reproduction theory. Given the spread of insurgent struggles into so many aspects of society encompassing workplaces and universities, the street, housing, health, abortion rights and a strong feminist movement, this is perhaps not surprising, but is in stark contrast to the relative marginalisation of mental health as a political issue on the UK left.

It was a huge undertaking and, fifty years on, San Giovanni Park still vibrates with the history of unmaking the old asylum while inventing new ways to care. Black and white photos throughout the buildings show the emergence of everyday life where torture and terror once resided: eating, chatting around a table, smiling, reading newspapers, making art, drinking tea, recording a radio programme, playing draughts, meeting, debating. Ugo Guarino’s sculptures, assembled from bits of old asylum furniture thrown out and smashed up, occupy corners like hauntings from the past. There was ‘nothing left, just the walls’, the former head nurse Graziella Tiselli recalls in Erika Rossi’s film Trieste Racconta Basaglia. One netted bed seems to have survived, now displayed on an outdoor balcony, and our hosts at the MHD, Claudia and Elisabetta, have to remind us that the spacious, sunny rooms we walk through once served as patient dormitories or living rooms where people would be caged in all day.

I squint and think of my uncle’s descriptions of being locked in Broadmoor’s dorms overnight, ‘packed like sardines’ in beds ‘inches apart’, no plumbed toilet, night terrors, threats. Or the women in the adjacent blocks to him, forced to piss and shit in buckets in the day rooms. ‘It was not a lovely atmosphere’, he says.

To obey is no longer a virtue

One of the slogans daubed on the pavilion walls above the wreckage of dismantled beds implores, ‘Dear women, to obey is no longer a virtue’. In another photo, people crowd round in debate, one among thousands of assemblies and perpetual discussions which ‘gave dignity to words’, a nurse observes in Trieste Racconta Basaglia, where silence and compliance had ruled. These words would lead to the establishment of Italy’s first social cooperative in December 1972, Cooperativa Lavoratori Uniti (CLU – United Workers Cooperative) after patients who had kept the asylum running in the kitchens and gardens, cleaning and shovelling coal for cigarettes and minor ‘privileges’, demanded wages and recognition as workers. Since the 1904 legislation excluded them from any citizen rights, these demands were initially refused until rising agitation and strike action forced an intervention by the provincial council which approved their demands by resolution. And so, the wretched made history.

In former Pavilion M, now host to Lister Sartoria Sociale (a tailoring cooperative), I come across a 1975 poster advertising an excursion over Trieste which saw 100+ patients fly over the Friuli Venezia Giulia area, their journey celebrated by the Association of Partigiani (veterans of the WWII resistance) who threw a party, celebrating with a live band and dancing to Bella Ciao in the Communist Party’s association premises.

Just down the corridor I meet Diego Porporati, one of the resident artists who offers to draw my portrait, shapeshifting me into a horse with his pen – a homage, I realise, to Marco Cavallo, the life-size paper mâché horse made by patients in 1973 during two months of art making and storytelling. Named after the asylum’s laundry horse (one of the few ‘residents’ able to leave the grounds until he was slaughtered) and painted a bright sky-blue, Cavallo turned fable when he was symbolically broken out of the asylum and marched into the city to join a local festival with several hundred patients, nurses, artists and volunteers in a joyous carnival of the mad.

In the context of a politically polarised debate about mental illness and ‘dangerousness’, spectacle and propaganda mattered. But these initiatives were also part of a ‘medicine’ that was concerned with attending to the multiplicity of people’s needs and desires, energising collective yearnings as part of a radical project for social change and finding imaginative ways of bringing people together. In preparation for the flight, the air-craft crew worked one day for free visiting patients to discuss their curiosity and fears. Marching with Cavallo, striking nurses raised demands about workers’ and patients’ treatment and conditions.

Basaglia had said the system makes the patients and nurses sick, but this sort of unity was not a given. He formed an équipe at San Giovanni out of newly qualified medical students, doctors and volunteers – those who were less likely to be contaminated by prevailing medical cultures. (Block C had been closed with the help of volunteers – conscientious objectors – who chose to help at San Giovanni as their penalty for refusing military service). But change needed the nurses who, numbering 350+, were the majority. ‘Many were glad to be no longer victimised’, Giovanna Battaglia, a nurse interviewed by Asylum magazine, explains referencing the ‘rigid hierarchy system’, but were ‘strongly opposed to being stripped of their own power’. There was also significant resistance from locals, stoked by different political and business interests, along with the media, which seized on a small number of serious and tragic cases. A former patient who killed his parents. A woman who after being denied hospitalisation killed her son. Another former patient who died of neglect in his family home.

Such deaths understandably provoke concerns about the capacity of a social movement to look out for vulnerable people. The proximity of mental suffering to deathly feelings and suicidality is pressure enough against taking risks. So I was moved to discover Stories from the Asylum in San Giovanni’s documentation centre, edited by a member of Basaglia’s équipe, Peppe Dell’Acqua, which evidences a remarkable attention to detail in the work undertaken to help individuals access liveable lives. These included Elda who had been diagnosed with ‘schizophrenia’ during the Second World War while assisting partisans in need of safe passage to fight the Nazi occupation. Having been hospitalised for good in 1960, she was found in 1971 without teeth, like many patients subjected to ECT or beatings, sitting under tables, eating with her hands, and unable to take visits. By 1973 Elda was participating in art classes, enjoying spending her newly discovered war pension on clothes and personal effects, making sense of shifting geo-politics (is fascism over? is Russia capitalist?), and was ultimately offered a home by a woman living in the city. It was in removing the psychiatric screen from those interned, Dell’Acqua argued, that ‘unsolved problems’ were revealed, and it was in seeking to address them that solutions were sought in the city.

An Ecology of Care

By 1975, 646 patients remained resident in San Giovanni, 403 of whom were ‘guests’ – no longer under a compulsory order or considered in need of treatment, but with nowhere to go. Between 1975-7, six mental health centres were established across different districts in Trieste, each evolving to serve as an access point for care, medication and therapeutic support, meals, community, social activities including cinema, art, a library, and short-term overnight accommodation. These centres would become a key node in an infrastructure of care concerned with cultivating collaborative relationships between doctors, nurses, ‘patient’ and ‘citizen’ and advocating an acceptance of illness and madness as part of life – ‘up close no one is normal’, Basaglia would say. An ‘availability service’ was established in the general hospital to act as an ‘emergency aid station’ for people in crisis, thus averting many from being sent to the asylum’s admission ward which remained open until Law 180 took effect. With the final closure of the asylum, the aid station formed the basis of a Psychiatric Emergency Unit in the General Hospital (Servizio Psichiatrico di Diagnosi e Cura SPDC) that is operational today, just seven beds to replace 1300. These facilities connected mental health with the general health system, while social housing, cooperatives and a broader network of associations and local solidarities served as the tissue for this emergent ecology.

Affordable housing was scarce in the city. The search for solutions – individual residences, supported housing and group homes – led to an occupation in 1978 of Case del Marinaio (Sailors House) to secure a space ‘for 200/300 patients who have not yet left San Giovanni but also a very large segment of the Trieste population’. The action agitated for the introduction of a social wage. This broader struggle to address people’s need for a secure income was at the heart of Ongaro’s 1980s campaign to achieve legal recognition of social cooperatives. Passed in 1991, Law 381 conferred benefits and funding to cooperatives employing 30+ per cent of workers with a ‘disability’.

Today these enterprises employ around 500 people across Trieste, providing employment designed to be supportive and flexible around people’s lives be they dealing with illness, addiction, a history of imprisonment, child-care responsibilities, or other forms of marginalisation. The cooperatives are critical to the city’s mental health infrastructure and practice, Pantxo says, serving as the basis of a network of service users who, beyond nurses, psychologists and social workers, support the ‘sociality of others’. I think of my first encounters at Gorizia MHC, of the workers tending flowers at an entrance once dominated by the old water tower, the receptionists who greet people when they first arrive looking for help, and others who visit people in supported housing, convene groups and social activities.

Pino Rosati, who helped establish Lister as a social cooperative in the wake of the 2010 economic crash, shows me how he uses the work of upcycling waste objects (especially umbrellas frequently destroyed by the strong winds known as ‘the bora’) to create bags, kites, rain capes and more, as a metaphor for the wider system. ‘We give what we have taken. We look for equilibrium, we don’t want to produce a surplus’ he says softly between short breaths. ‘Like a patchwork, we sew parts of society, young and old, working in the kindergartens and the prisons. This is not only about ecology but transformation’. Pino, who arrived at San Giovanni in 1983 conveys the precarious nature of the work. ‘We have eight workers, but it isn’t easy. We are hidden in the wood like a fairy tale. We are always in a struggle, a search, a battle. At night when the things we make are moved out of the corridor, the asylum comes back’.

At night the asylum comes back

These problems speak to the systemic contradictions this project occupies. ‘Fanon was able to choose revolution’ Basaglia wrote, after his resignation from a hospital post in Algeria to join the anti-colonial resistance. ‘Our situation is that we are forced to live through the contradictions of a system which creates us, managing an institution we deny/negate’. Pantxo defines this approach as a ‘counter practice of welfare’, ‘acting through the hierarchies of institutional health care to disrupt the institutional logic’ – neoliberal or social democratic, entrepreneurial or paternalistic. If the space for configuring care along these lines has narrowed, some practices have endured and even advanced. The MHD has resisted privatisation which has seen so much parasitic activity by companies; ensuring no private facilities are funded by public money with a quarter of their income preserved for service users’ ‘personal budgets’, used to support individuals to access their needs directly.

Another initiative is the Habitat Microareas established in 2004 to encourage cooperation between health, housing, and social services (the ASUGI Healthcare District, Regional Housing Authority – ATER – and Trieste Welfare Services) in collaboration with residents. There are now seventeen catchment areas covering around 19,000 inhabitants in total, ‘like an octopus that reaches into the social fabric’ Christiana, our guide, suggests, organised in a way to encourage the co-creation of care by empowering residents to make use of the state resources to meet their needs. She takes our group to the smallest project involving 190 residents where Antonella, the neighbourhood ‘concierge’ greets us. Antonella lives on the estate in accommodation provided by ATER and ASUGI, supported by a ‘work bursary’ as part of her health budget, and is paid to maintain the central hub, a one bed flat with a garden which functions as an open meeting point for workers and residents to meet, share meals, discuss care needs and plan activities. These include a programme for children (no doubt welcome to the high number of single parents), and a peer-support and consciousness-raising group for women.

Christiana shares an example of the co-production of care made possible, narrating the story of a local woman in her eighties whose son was hospitalised following a stroke, leaving her without support. An ‘extended family conference’ with staff, neighbours, friends, and family members was called to discuss solutions that would avoid her being placed in a home or leave her nearest relative carrying sole responsibility for care. A plan was developed, and a health budget organised to support her to remain living independently with the company and support of others. ‘We are always criticised for being too social and not clinical enough’ Claudia and Elisabetta say, but in their view ‘needs are rights’.

The centring of rights is evident in the ongoing commitment to an ‘open door’, no restraint policy, which means that there are no locked doors across the service and a commitment to not using restraint on patients by medical staff, regardless of the circumstances. During our visit to Gorizia’s MHC, I notice a reproduction of an Ugo Guarino cartoon in the office depicting footprints charting people’s flight from a cage. What, I ask Marco, would he say to those in the UK, who insist on the need for these physical measures, at least in ‘emergency situations’. ‘You talk’, he says. ‘You negotiate, you stay with the person, you go with them. If they go to the mountain you go, if they go to the sea, if they go to the bar, to their home, you go’. ‘You can do it one way’ (he imitates a perfunctory conversation): ‘How are you? Good? And the medicine? Good ok then.’ ‘But’, he continues, ‘that way you won’t get to build a relationship.’ To do that you have to go beyond the small talk and be prepared to ‘emotionally expose yourself’.

I realise there are limits to this. Before visiting Trieste, I had workshopped the questions I would bring with my uncle. Having found our quite different encounters with the UK mental health system frightening and disturbing, we both know that it is not for me to judge people’s experiences from the outside. There are however some markers. Can people in Italy refuse medication in all circumstances? Can they be sectioned? The answer to the latter is yes. Compulsory orders can be made. They are limited to seven days and must be authorised, with the support of two doctors, by the city mayor rather than a judge. This places the decision at least nominally within a sphere of public accountability. Since these restrictions were introduced, compulsory admissions in Italy have more than halved, from 20,000 in 1978 to less than 9,000. This is in stark contrast to the UK, which since the late 1980s has seen what Modernising the MHA 2018 describes as an ‘inexorable rise in detentions’, with the Care Quality Commission identifying ‘too many abusive and closed cultures’ in mental health’ in its 2022-3 annual report. I’ve experienced just how far the threat of a section can poison your capacity to access help when it is desperately needed, even if it is far more likely you will be ignored, put on a waiting list, given an IAPT referral, maybe CBT, or a drug prescription. Unless, that is, you are racialised or suffer from a form of distress that bears the brunt of societal discrimination. Trieste’s service users also talk about avoiding compulsory orders only by agreeing to take medication. Practitioners may seek to negotiate with the state, but neither they nor those deemed sanctionable can escape its disciplinary functions.

This is most apparent where mental health intersects with the police and criminal justice system. When Law 180 ordered the closure of asylums, it did not include Ospedali Psichatrici Giudiziari’s (OPGs) used to detain people convicted of criminal offences and deemed to be mentally ill. This is just one example of how an intact state remains empowered to redraw the line between those considered deserving of freedom and those not. After a sustained campaign and facing international condemnation, Law 81 (2014) finally mandated Italy’s regions to replace OPGs with Residential facilities for Security Measures (REMS) to provide care to people judged to be dangerous and in need of psychiatric treatment. It is stipulated that these must be used as a last resort, located in the same region where the person lives, based on a mandatory personal care plan in forty-five days, with no restraint, and for no longer than the maximum penalty for that crime. Having seen my uncle serve thirty years in the UK for an offence bearing a maximum criminal penalty of five, I know how significant these measures are.

The numbers held in these institutions is around 600 across Italy, 40 per cent less than those detained in OPGs at the time of closure, with just two ‘guests’ detained at Trieste’s facility (six across the Friuli-Venezia Giulia region). When we arrive at the facility I notice that the external wall is not sealed, we hear about the ways in which a routine is first established with new arrivals through negotiation and request, walk around the surrounding gardens where activities are opened up to the local community, and view several spare rooms used to accommodate the family and friends of those detained when they visit. These are all progressive measures.

However it is impossible not to feel the tension between an ethics centred on ‘freedom’, which emphasises the protagonism of people experiencing mental distress, and the limits imposed on residents’ mobility, as well as their use of space and time, even if indirectly. Staff may only be able to advise residents not to breach the boundaries of the facility, but if they do so the police will arrest them. As Alessandro N, who coordinates the team in this service, is keen to point out (referencing Basaglia), ‘The sentence of the asylum implied and implies the rewriting of psychiatric knowledge … In the same way the condemnation and the overcoming of the OPG, must lead to the rewriting of the judicial knowledge, because in this case the judiciary was and still is, the strong technical power’.

Unfortunately, that rewriting has not taken place. And this lack of change has occurred in parallel with a 42 per cent increase in Italy’s prison population between 1991 and 2022, with almost a third now classed as ‘foreign residents’ despite composing just 8 per cent of wider society. There are also people stuck in prison unable to get into a REMS.

The cypher of what is possible

On the final day of our visit, we gather with Trieste’s service users and staff for an object exchange. Different generations and experiences fill the room as we place our chosen artefacts on red cloth laid out in the middle of the room. Guillermo has brought a tiny machinic device, a gift from Diego who used to make these constructions in the outdoors ‘to cure sickness in society’ until their increasing scale led to police visits. He is ‘a technician of the imagination’ Guillermo says, ‘and helped me into radio’. Carlotta has brought a toilet roll which ‘saved her’ during a hard time in hospital, when one day feeling its rough texture she was inspired to start making art out of it.

I have brought my uncle’s words, his experiences at Broadmoor typed out in Italian and accompanied by photographs of a seclusion cell, a corridor, a day room and the admission block. Broadmoor, I tell them, was one of the inspirations for Italy’s early asylums and shares similarities with San Giovanni in the bad old days. They read the words. Guillermo is visibly shocked and wonders aloud about the different fates of patients between the two institutions. I tell him I’ve been thinking the same. What if my uncle had been in San Giovanni instead of Broadmoor in 1972? What if Basaglia had turned up in Reading instead of Trieste? I don’t share my fabulation, featuring Marco Cavallo’s festival of the mad arriving at Broadmoor’s gates, dancing with trumpets as I stand trembling, diminished and alone, waiting for the long walk of locks and keys. Still, the recognition of different histories of pain between us is like a balm.

Before I leave Trieste, I take one more walk around the rose garden. I can’t put my finger on the feelings – wanting to weep and laugh at the same time. I think of Gargi Bhattacharyya’s We the Heartbroken: ‘There can be no remaking of the world without ways to allow for our collective sorrow’. Tentatively I allow my sadness to swell as the sweet smells of Italy’s warm summer air lift me.

Black and white photos by Emilio Tremolada apart from Marco Cavallo parade by Claudio-Ernè and the laundry horse by Tiziano Neppi. All other photos by Han Dee. Interviews conducted with Rachel Wilson.

Thanks to Pantxo Ramas for introducing me and our team to Trieste’s history and services, and to all the wonderful people involved in the work who hosted, greeted and gave their time.

Han Dee is a writer and PhD candidate in creative writing at Queen Mary University London. Their research is a non-fiction narrative centred on a near relative’s experiences of incarceration in England’s high-security psychiatric institutions 1972-2002: Broadmoor, Rampton and Ashworth. Han is a member of the Mental Health & Social Justice Network, Subtexts creative writers’ group @subtexts_sed_qmul and TIAN—Transversal Institutional Analysis Network— connecting researchers, practitioners and organisers who study, invent, and reshape institutions: https://institutionalanalysis.net/