Letter From Trieste – February 2010

It doesn’t usually snow in Trieste in February, said my guide as we battled through a blizzard up the steep slopes of the Parco San Giovanni.   I was in a Trieste at the request of Dr. Franco Rotelli  to give the opening keynote address at a major international conference on “what is mental health today?’  Trieste, as many will know, was in the heartland of the movement for democratic psychiatry in Italy,  the movement led by Franco Basaglia that resulted in the famous Law 180 of  1978, that froze admissions to psychiatric hospitals and led – or was supposed to lead – to the gradual phasing out of the asylum in favour of community mental health services.    Basaglia’s influences ran from phenomenology and Marxism through to US critics of the ‘total institution and founders of the therapeutic community movement in the UK such as Maxwell Jones.[1]  After initial struggles over the 1960s to transform  the asylum at Gorizia in north-east Italy on the border with what was then Yugoslavia, opening the locked wards and developing various forms of collective participation of the patients and staff, Basaglia became director of the nearby Trieste psychiatric hospital which housed 1200 inmates.  It was the closure of this asylum over the period from 1971 to 1979 that demonstrated, for those who were his students, followers, supporters and co-workers, and for many of those who had been patients, that there was a psychiatric future beyond incarceration, and beyond that fundamental dichotomy of care and control that, for Basaglia, ran through the very heart of the psychiatric system as it had developed since the mid-nineteenth century.  And the location of the conference was indeed the former asylum, a sprawling collection of buildings on the steep slopes that led up from the outskirts of Trieste – which is built on a narrow strip of land bordering the Adriatic Sea – to the forbidding mountainous hills that rise immediately behind.

In the partially refurbished buildings of the old asylum, now used by the university, for cultural events, and for small cooperative ventures, around 1000 people a day gathered, despite the freezing conditions,  to consider the legacy of the Basaglia reforms, not just in Italy but in the context of the transformations of psychiatry across the world, and the revelations about the appalling asylum conditions in many of the countries that had been Soviet satellite states.  For a number of reasons,  I had been reluctant to be among the speakers, although I have been engaged with the radical and critical psychiatry movement in various ways since my days at University,  and had followed the work of Basaglia and the Italian reforms quite closely.[2]  This was mainly because my research over the last few years has focussed on developments within psychiatry, rather than in the politics of mental health more broadly.  But it was also because I have some criticisms of the new doctrine of ‘recovery’ that has become the mantra of much of the radical movement in mental health, and also of the bureaucratisation of ‘the community’ that had often accompanied the transformation of community mental health from the demand of a critical movement into an elaborate professionalised apparatus.  But in the end, overcoming all my feeble objections, and not least by offering me the services of his personal driver to whisk me from Venice to Trieste and back,  Dr. Rotelli – one of Basaglia’s students and now Director of Mental Health Services in the Trieste region –  prevailed.  Thus, as the formal opening statements from the great and good ended,  I found myself, still shaking off the snow,  with the somewhat scary honour of addressing a very large audience in the renamed Basaglia Theatre,  trying to outline what I considered to be the new territory for the politics of mental health today.

What is this space?  Well, I suggested, it was defined by two dimensions.  Along the first, the external space of everyday life in which one sees the expert management of mental health ‘in the community’ meets the internal space of the brain  and the experts of the neuromolecular gaze.  Along the second, the language of the user’s voice, rights and ‘recovery’ meets the language of the national and global ‘burden’ of mental disorder.   And in order to demonstrate that, I described the rise of ‘disorders without borders’ – the estimates of the prevalence of ‘brain disease’ that rate it as soon to be the most significant cause of life years lost by disability, and suggest that in any one year almost one third of adults in the general population (not in psychiatric care) suffer from a DSM [3]diagnosable mental disorder – this is the discourse on ‘the burden of mental disorder’ that some see as the best way to make politicians to devote funds and attention to these conditions, and others, notably those from the mental patients, users and survivors movements, find deeply offensive.  I showed the data that demonstrates that,  over the 1990s, in almost all advanced liberal societies, the rate of consumption of psychiatric drugs had risen remarkably, notably of course, the new drugs for the treatment of depression and anxiety, but more generally the acceptance of the routine modulation of mental states by psychopharmacology – that seemed to indicate that we had become, in this limited sense at least ‘neurochemical selves’.  I examined the rise of neuropsychiatry, and the argument, now so much repeated that it seems to be ‘in the true’ that all mental disorders are, at root, disorders of the brain, and the ways in which the early beliefs that one could find relatively straightforward genomic and functional correlates of psychiatric disorders were proving unfounded leading many researchers themselves to seek more complex models of the relations between genes, neurons, brains, persons and societies.  I explored the history of diagnosis in psychiatry, examining the successive ‘blurring of the boundaries’ that one could observe: in the 1950s, between the inside and outside asylum; in the 1960s, between neuroses and psychoses; in the 1980s, between mental and physical disorders which DSM III termed  “a reductionist anachronism of mind/body dualism”; in the 1990s, between states (of illness) and traits (of personality) as now variations in both are explained in same terms; and in the 2000s, between illness and pre-illness, with the rise of the language of biomarkers and the search for susceptibilities.   This, I suggested, was the new territory for the politics of mental health.

Well, as you can imagine, my approach was not welcomed by all.  “Forget psychiatry, take recovery into your own hands” – this was the injunction of the somewhat evangelical speaker from the recovery movement who followed me, whose rhetoric veered between that of the travelling preacher to that of the Trotskyist cadres with whom I wrangled in my earlier Marxist days.  And indeed the ‘spontaneous philosophy’ of many who attended, though by no means all, was ‘anti-medicalization’, and many were sceptical of my suggestion that the hard reductionism of neuropsychiatry was running into the sand, and a new and more complex set of arguments about brains and their openness offered some opportunities for alliances between the human sciences and the neurosciences.   I tried to spell this out in a rather exhausting series of newspaper and television interviews that followed, as well as on the WebTV that was being filmed throughout the whole event.  And I was pleased to find, again as one might expect, that these arguments fell on more fertile ground with a new generation of young critical psychiatrists, avid readers of Michel Foucault, who recognised that it was futile and counterproductive to draw up battle lines ‘for or against’ drugs, ‘for or against’ psychiatry, let alone ‘for or against’ the idea that who we are and how we are as human beings has anything to do with our brains. 

But before I was to meet up again with those young psychiatrists, rather later and by chance, I also participated in two other sessions.   As I tramped my way through the blizzard to the first of these – “New Drugs for Old Illnesses?” – I was expecting a relaxed round table discussion, but instead,  without any notice I found myself in a five hour session without breaks, in Italian (with simultaneous translation more or less just for me) in which I was expected to deliver – and hence  to extemporise – an hour long presentation on the nature of psychopharmacological societies.  And indeed, as we debated the data of the rising trends of drug use in different regions, and the strange and inexplicable variations between different countries, and listened to the various presentations on patterns of drug use in Italy, many of our assumptions about what shaped this phenomenon were thrown into question.  Notably, while the early period of closure of the asylums in Italy had been accompanied by very high use of drugs in the community mental health centres, it seems that today Italy, and the Friuli-Venezia Giulia region of which Trieste is the capital, has not substituted exceptionally widespread consumption of psycho-pharmaceuticals for hospital inpatient treatment.  There are, I was told, no forensic psychiatric beds at all used in this region of around 210,000 people, and indeed very few in-patient beds at all  – I seemed to hear that there were less than a dozen for the whole region, but by this time, the cold was spreading up from my feet to the parts of my body where I try to think, so I would not vouch for that.  And yet the consumption of psychiatric drugs per head of population in this region seems to be low and falling.  And with that puzzle in my mind, some 11 hours later, I skidded my way back through the snow and ice to my hotel, and to warmth and to read Haruki Murakami’s rather wonderful little book, named What I Talk About When I Talk About Running (after Raymond Carver’s short story collection, What We talk About When We talk About Love).  A book from which one can learn a great deal about what it is to be the certain kind of animal that is a human being, with a certain kind of body – a book that reminds me of another lovely book – this time about swimming – called something like Haunts of the Black Lagoon

Anyhow, next day, thankfully with rather less snow, it was back to the conference, where  most of my time was taken up by a very long interview for an Italian magazine, followed by a two and a half hour ‘author meets readers’ session on my book The Politics of Life Itself  which has recently come out in Italian.  To my surprise, given the make-up of the audience at this conference, lots of people came along and I found myself signing dozens of copies – not quite Harry Potter numbers – but still something I found deeply embarrassing for some reason.  It was an honour to have my book introduced by Dr. Rotelli himself, and by Pier Aldo Rovatti, a leading Italian philosopher and writer on Michel Foucault, editor of the journal Aut Aut  – in which, coincidentally, the very first version of my argument on ‘the politics of life itself’ was published in Italian ten years ago.  And my translator this time was Erik Schneider, the American Joyce scholar who is curator of the excellent Joyce Museum in Trieste – in his hands, my words translated acquired a certain continental elegance.   Nevertheless, the themes of the discussions were similar to those I get in the UK or the US – what an excellent description and analysis, but where is the critique, what side am I on, surely we should be condemning all this biologisation and medicalisation, that condemns us to passivity in the hands of those who claim to know.  Well, as I tried to spell out, I read contemporary developments in the life sciences rather differently.  But in any event, my line, then and now, is that one writes the books, not to judge but to make judgement – careful critical, clinical judgement – possible.  And indeed, should one not, as Deleuze puts it somewhere, have an end to judgement – not to feel obliged to conduct each study as if it was some kind of legal tribunal, and not feel that by virtue of writing one had acquired, or wanted to acquire, the power to bring some miscreant to the dock and to pronounce a verdict “guilty as charged!” – with all the dubious pleasure of self-righteousness that some find in this .    I wanted also to explore the proposition –becoming popular among zoo-ontologists and apparently rat-ified by Jacques Derrida in his last writings – that perhaps we should not be afraid of thinking that we are, in some crucial respects, animals.  Very peculiar animals, it is true, but animals after all.  Of course, to say that in Europe, and in the shadow of the asylum is very risky.  Recall Goering’s notorious statements to the effect that Jews were like lice and that their extermination was delousing.  A whole generation of post war European philosophers reacted, to their credit, against the dire consequences of such animalisation of the human.  And if one wanted another, slightly less murderous but still ghastly reminder of the animalisation of the human, on the walls of the old asylum buildings in Trieste were  many photographs of the conditions of the inmates, often naked, being ‘bathed’ with cold water jetted on them from hoses – indeed reduced to the state of animals.   Closer to home,  less actually harmful, but no less intellectually bankrupt, one finds the arguments of the socio-biologists and the evolutionary psychologists, picking from among the many species of animals and their behaviour, the ones that happen to match their own predilections about the determinants of human conduct.  And yet, as I struggle with my own work on the life sciences and the neurosciences, I feel it important to try to grasp the new sense of our bodies and brains that is taking shape within these truth discourses, and to overcome the reflex critique from the human sciences.  That, I think, is the intellectual challenge for the human sciences for the next decades.   

I saw and heard far too little of the conference, and sadly had to leave before the end of what was a moving and heartening event  – despite or because of the snow, the rather ‘spontaneous’ nature of the organization, and the fact that everyone was overwhelmed by the sheer numbers of those present – a heady mixture of high state officials, psychiatrists of all persuasions, NGO activists and former inmates, users and survivors of psychiatry.  But on my last evening in Trieste, after dinner in a local restaurant, I found myself, by accident, in the midst of twenty or so young trainee psychiatrists from across Europe who were attending the conference.   They had been to my talks and were in a merry mood.    What did it mean, they asked me among the multiple toasts to Michel Foucault and Franco Basaglia, to say that we humans were, after all, animals?  Our answers that night are best left in the conviviality of that restaurant.  But the question remains an important one, for me and perhaps for BIOS itself, as we struggle to grasp the ways in which our new knowledges and technologies of life itself are changing what it means to be human.

[1]      Details of Basaglia’s career, and his key writings, can be found in Nancy Scheper-Hughes and Anne M. Lovell, eds., 1987,  Psychiatry Inside Out: Selected Writings of Franco Basaglia, New York: Columbia University Press.  Nancy Scheper-Hughes was at the conference and still works with many of those involved in democratic psychiatry in Italy.

[2]      See, for example, P. Miller and N. Rose, eds.,  1986, The Power of Psychiatry,  Cambridge: Polity Press.

[3]      DSM is shorthand for the successive editions of the Diagnostic and Statistical Manual of Mental Disorders, published in successive editions by the American Psychiatric Association since 1952.