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02 2019

Caring ecologies 1 - Almost a manifesto

Francesco Salvini

If it weren't so long, this text would (like to) be a manifesto. It is not an analytical essay that interprets a site or a critical history of the movement lead by Franco Basaglia. Rather it is a deriva, an unplanned itinerary through and with a number of reflections, events, and objects I have encountered in my relationship with the contemporary healthcare system of Trieste. It is a result of a long engagement with the agents that inhabit and build this system every day, with the memories of a collective practice of care, the artefacts and places that constitute the material possibility of a practice of caring with each other, an engagement with what Franco Rotelli (2013, Cogliati 2018), one of the protagonists of the Trieste's trajectory and director of the Mental Health Department of Trieste during the 1980s and the 1990s, has called una città che cura, a city that heals, a city that cares.

This text has two areas of concern. First, it is an attempt to contribute to the critique of (and the reinvention of) institutional analysis by proposing it as an ecology: a practice of organisation “in the middle of troubles” in Donna Haraway’s language (2016), rather than an external diagnosis of someone else’s problem or an autonomous practice far from the contradictions of actually being engaged in the work. An ecology deals with time in a diagrammatic rather than linear way, instituting a relationship between social dynamics and the political imaginary as a concrete exploration in constant tension with the present, both as it is and as it could be.

The singularity of Trieste began in the general turmoil of the 1970s, but is situated today in the frame of contemporary patterns of governance in (the South of) Europe: the dismantling of the welfare system has affected not only the provision of services, but also the legitimacy of public policy’s role in taking care of society. The space of Trieste does not escape this scenario. Basaglia’s revolution is now immersed in the conditions of precarity and austerity, the mud of privatisation and institutional counter-reform, and the consequences of the neoliberal understanding of care as a project about the individualisation of affects, and the commodification of lives.

The choices of prior generations constitute our contemporary spaces of possibility. And the space of possibility today is that of the collapse of welfare. We live in a damaged world: the past pushes upon the present and the contemporary thickens at the precarious brink of modernity, in the crisis of the paradigm that announced (prematurely, yet again) the end of history. In order to escape the trap of infernal alternatives (Stengers and Pignarre, 2011), of having to choose between market-driven welfare destruction or state-driven authoritarian paternalism – I will attempt to institute a space of storytelling and fabulation that can, I hope, push Trieste’s singularity as a practice of concrete imagination beyond its boundaries.

The second issue this essay takes up is the role of caring in constituting the social modes of organisation in an ecology. The contemporary engagements with care are multiple and sometimes contradictory: care is a disputed category in the critical analysis of social reproduction, but it has also recently become omnipresent in moral marketing and neoliberal governance, marking, as Maria Puig de la Bellacasa calls it, a “pervasive order of individualised biopolitical morality” (2017). Aware of this second meaning, I nonetheless try to stay and participate in the critical debates, especially in/given the plural spaces of feminisms that have been constructing a complex understanding of care over the last (at least) fifty years.

Care is an ambivalent territory. It is crucial in the analysis of contemporary forms of capitalism as a micro and biopolitical machine that organises social reproduction: care perpetuates exploitation, dispossession, and abstraction (Barbagallo, 2016; Federici, 2013; Fraser, 2016), especially (but not only) beyond the sphere of the production of commodities by means of commodities, in Sraffa’s terms (1975). At the same time, care is a space of autonomy and organisation that is capable of instituting new grounds of possibility in and against the processes of annihilation that the capitalist mode of social organisation of reproduction... triggers (bell hooks, 2009; Precarias a la Deriva, 2004).

Amid this tension, recently new chains, dynamics and agents have gotten involved in the analysis of care – intertwining the geopolitics of power and the processes of articulation of race, gender, and class with the continuous cycles of social production that care, as ontology, sustains. Moreover, the critical analysis of care today engages with the more-than-human and more-than-social dimensions that care involves: on the edge of other worlds, it is made by the sensible agency of matters and by the urgent temporalities of sustainability and catastrophe (de la Bellacasa, 2017).

On the waves of these multiple debates and approaches, I will try to balance along a different edge, crossing institutional analysis with the complexities and the singularities of care, as the molecular processes that configure the material functioning of care, as well as with the logic of organisation that reproduces the institutional rationale, that is the molar lines that order the institution. To put it more concretely, I am trying to stay with care at the point where it intersects with an instituent critique of citizenship.

Historically, industrial citizenship and social welfare constituted the utopian horizon for the 20th century struggles (of white and male workers): the goal was a homogeneous image of civil society organised through the nation-state. The Basaglian movement constituted another conception of the citizen, starting from the existing institutional denial of the matto as a citizen, Loon, as linguistic re-appropriation of the pejorative term, and from the assertive formulation of the question of citizenship through the lenses of singularity and fragility.

Today the question of citizenship can become something else: how can we produce a quotidian practice of democracy in the current situation? How can the loonies (we as loonies), society’s internal outsiders, affirm their social, civil and political rights, without being trapped in the double-bind of exclusion-vs-normality? How can the welfare state support the constitutively difficult freedom of singularities within urban life, instead of constituting/normalising the citizen as a homogeneous identity entitled to and recognised by rights?

Citizenship, in other words (in Precarias a la Deriva's word cui-dadanía, 2004; a pun that we could tentatively translate as care-zen-ship), revolves around the constitutive role of caring in the making of social and urban life. In Trieste, this question was initially articulated in two ways: as an institutional problem, that is how to dismantle the institutional tendency to objectify sociality; and as an institutional challenge, that is, how to invent transformative practices within the institution, practices capable of sustaining the freedom of those in a moment of fragility.

De-institutionalisation was a practice meant to reclaim alter-subjectivation against the objectifying mode of the total institution: an objectivation that not only affected the confined bodies of the sectioned, but also those of the workers who served as technicians of oppression. The objectifications practiced by psychiatry can usefully be seen as the limit in the tendency of all institutions to reproduce themselves, and their power over society, rather than sustaining the social reproduction (and permanent invention, Rotelli, 1988) of the collective means organised to respond to social desires (as Gilles Deleuze, 2004 defines, more or less, an institution).

In Trieste, this practice of citizenship as emancipation has been articulated in the molar dimension, the attack on the order of the institution: through social movements, medical critique, media campaigns, legal trials and urban conflicts, through legal regulation and institutional production and a long et cetera of strategies, all aimed at defending the invention of a different practice of care. At the same time, this practice has been, and continues to be, an experiment that deals with a radical understanding of citizenship, as an endeavour of care that involves users and citizens within the molecular politics of caring.

In the attempt of contributing to this experiment, I engage with an ecology of care (or caring ecologies, since care is a process, and is always plural). Ecology of care means, then, making care (and making sense) through the permanently unresolved and unpredictable modes of social reproduction; making care through the composition of different processes of subjective transformation; making care “with the surroundings” (Stengers, 2013, but also Harney and Moten, 2013, or Deleuze and Guattari, 1988), i.e., acknowledging the interdependence of care within the social, mental, and environmental organisation of everyday life.

Caring ecologies move through the living tensions and compositions of care, within, around, and outside institutional practice. Using the space of Trieste as the ground for this concrete imagination, I will use the next pages to try to sketch the ecology of care as an assemblage of concepts, materialities, relations, and experiences.

Trieste, città libera?

This story takes place in a singular space, Trieste. Throughout the 20th Century, Trieste has almost always been a frontier before the unknown: the edge of the crisis of the Austro-Hungarian empire after the Great War; the limit of expansion for the Italian Fascist regime; the last markers of Western 'democracy', along the edges of the iron curtain.

Although, Trieste has been a boundary for centuries: a place of global exchange and cultural conviviality among religions, communities, and cultures. The fall of the Austro-Hungarian empire and the inclusion of Trieste as part of Italy caused the collapse of the city as a financial centre, as well as the rise of identity conflicts among Italian, Slavic, and other ethnicities in the city. Since the 1950s, waves of relocation from Yugoslavia sustained the development of steel factories and other industries. After the industrial crisis of the 1980s and the fall of the iron curtain, Trieste has been in a long economic and environmental crisis made more difficult by the demographic reality of an aging population.

In this place of inertia, the Basaglian movement has constituted a plural and global rupture since the late 1960s. The story starts in 1961 in the city of Gorizia, where Franco Basaglia and his equip transformed the mental asylum into a therapeutic community, while simultaneously contesting the relationship of power embedded in their own practice of institutional reform, until the crisis of the Gorizian model in 1968 when the impossibility of a collaboration with local government moved Basaglia to resign. Already in 1964, The destruction of the Mental Hospital as a place of institutionalisation (Basaglia, 1964) defined a new framework for critical and radical psychiatry, including a self-critique of the same therapeutic community model they were experimenting with.

A phenomenologist, Basaglia distinguished the temporary mental distress and fragility of persons needing care from institutionalisation, which he identified as the main problem. It was the dramatic and violent role of psychiatry (and medicine) in the delivery of care that had to be, in the first place, ended and transformed.

In the traditional asylum, the phrenologic asylum, Basaglia and Franca Ongaro argue (1987), psychiatry is a practice of violence that roots its legitimacy in a totalitarian understanding of the relationship between the state and society. In this framework, caring is not an option (and care becomes a practice of repression and control). However, the discovery and use of new pharmacological approaches after the Second World War allowed Basaglia to argue for a radical refusal of the traditional means of the asylum and propose a new approach to care. In this new pharmacological, institutional and political frame, de-institutionalisation, institutional psychotherapy, radical and anti-psychiatry, ethno-psychiatry and the likes gained a renewed centrality, first in England and France, later in Italy, Germany, Spain, Brazil.

Originating with the followers of the critical institutional practices of John Connolly and others in the late 19th century, this debate arose around the experience of Saint Alban and La Borde in France, the Northfield Military Hospital and the anti-psychiatric practice of Kingsley Hall and the Philadelphia Association in the UK, as well as the anti-institutional Italian movement, especially in Trieste, Trento, Reggio Emilia. In Italy, some of the key participants in these debates were Franco Basaglia, Franca Ongaro, Mariagrazia Giannichedda, and Franco Rotelli. Also important were and are the publications of Giovanni Jervis, Mario Tommasini, Assunta Signorelli, Giovanna Del Giudice, Giovanna Gallio, Mariagrazia Cogliati, Peppe Dell'Acqua. At the same time, thinkers such as Michel Foucault, Mony Elkalm, Robert Castel and artists such as Marco Bellocchio, Silvano Agosti, Dario Fo and Franca Rame, among many others, were expanding the space for critique beyond psychiatry.

There were and are many individuals involved, but, most of all, this new practice of care in Trieste has been possible thanks to a new generation of users, nurses, doctors and citizens who, seeing the asylum as a space of experimentation and discussion, inhabited it from the 1970s on: hundreds of volunteers, artists, activists, students throughout the 1970s and 1980s who forged the material realisation of a collective imagination of freedom and emancipation as the ground for caring. Together these people, allies, parts, and counterparts of the institutional management, imagined and sustained an intrusion in the institution that brought a new understanding of how to approach mental health, but also an invasion that was able to resist the conservative counterattacks and the restoration of traditional models.

Some historical facts to ground my reflections around the caring ecologies of Trieste: in 1971, Franco Basaglia was named Director of the Asylum and given the political mandate by the Christian Democratic provincial president, Michele Zanetti, to permanently close the Psychiatric Hospital. There were 1300 inmates in Trieste at the time; more than a hundred thousand people were sectioned in Italy. After a profound social, medical, political and media effort, in 1978, the Italian legislation ordered a structural reform, forbidding detention, recognising the inalienability of users’ civil, social and political rights, and defining a protocol for the dismantlement of all psychiatric hospitals and the institution of local and community services and psychiatric wards in general hospitals.

However, deinstitutionalisation in these debates and practices was not intended as a practice of reform that would establish a new, perhaps less violent, power relation that would be articulated through negotiation around new drugs and open services. Instead, the strategy of the Italian radical psychiatric movement in the 1970s was to destroy the institution in such a way that the asylum's deinstitutionalisation was part of a wider critique of medicine and the welfare state.

“Con l'ospedale alle spalle, non vale”, Alessandro Saullo, a young psychiatrist, recently said me, explaining the logic of destruction back then: mental health cannot be a practice of emancipation if the psychiatric hospital is maintained as a threat of discipline for the person in distress. The journey of recovery cannot be just one of healing; it is one of emancipation, of the appropriation of the places and objects of life as autonomous ground for the production of new social relations, both in and out of the institution, and thus can only occur through the welfare system and, at the same time, in the open dynamics of urban life. Mariagrazia Giannichedda (2015) summarises this effort as the capacity of the public healthcare system - i.e. the state - to sustain the constitutively difficult freedom of urban life. At stake is the process of subjectivation as opposed to the institutional objectivation of the person in distress, but also through the politics of things, as an active engagement with the question of how to enrich, in material terms, those lives reduced to bare existences: breaking the locks, dismantling the caged-beds, choosing furniture appropriate for places where people lived, and generally thinking politically about the places and the objects of life.

This process of emancipation implied not only a cultural transformation and a political struggle, but also collective disobedience of existing laws and the production of new jurisprudence that recognised the social, civil, and political rights of people confined in the asylum. And though the 1978 law forbade institutionalisation, the application of the reform was uneven throughout the 1980s and ‘90s. The last Italian asylum closed officially in 1999, but the practices and protocols of healthcare that have the stated aim of helping people in distress remain problematic in most of the country.

After Basaglia’s death in 1980, via grief and the profound commitment of Basaglia's equip, the radicality of this process was reconstructed and translated into the affirmation of an urban logic of care. In Trieste, when the asylum closed in 1981, care was already decentralised. Centres in each district of the city were open 24/7: doors were unlocked; since the late 1980s, tens of social cooperatives had been organised with the support of the Department of Mental Health which also supported educational grants, community budgets, and other forms of economic support. Nowadays this ecology involves apartments, neighbourhood services, mechanisms for family integration or for users’ independent lives.  Starting from the creation of the local districts of health in the early 2000s and the local programmes in 2005, both of which I discuss later in this text, the spread of Basaglian critique into the general medical practice has transformed community healthcare and the general hospital, leading eventually to new legislative regulations like the Regional Law of Healthcare System Reform of 2014.

But to understand the complexity of the ecology of care, it is also useful to understand the subjective configuration of the workers in Trieste’s public healthcare system. It is heterogeneous and can be sketched as follows: a part from the Basaglian equip of the 1970s (nowadays retired from work, but still very active) a first group, in executive positions, proceeds from the long trajectory of the Basaglian movement. Some in this group maintain a political engagement with the whole system of health and care, some focus on the development of radical but disciplinary practices of care, in psychiatry and beyond it. The second group of professionals have come via a typical career path and is fairly distant from the ethics of the Basaglian movement. A third group, younger and smaller than the other two, was drawn to Trieste by the Basaglian legacy, and work in experimental services in mental health and urban health. At the same time, the space of social cooperative enterprises around care today involves hundreds of people as carers and users, which have an affective and moral attachment to the Basaglian movement. Most of the younger workers in the healthcare system (which employs around three thousand) are not aware of the singularity of the system; many locals are aware of the exceptionality of Trieste’s model of care provision and of Basaglia's legacy, but the majority is not.

The permanent ongoing reinvention of the Basaglian process is built on these muddy grounds, constituted on the everyday level by the appropriation of (and failures to appropriate) institutional spaces. This attempt is to dismantle the separation of the places of care from social life by displacing care from institutions and centring it in the life of the city (“la cura dei luoghi, invece de i luoghi di cura,” the care of places instead of the places of care, as Ota De Leonardis and Emmenegger put it, 2005).

What is at stake is the fragile possibility of affirming a different common sense as an activating practice through institutions (a common sense not with its Kantian connotations, but rather next to what Christoph Brunner, 2018, calls an “activist sense”): a common sense of emancipation that can sustain a different and radically democratic instituent practice that is immersed in the dynamics and the contradictions of urban life. And, finally, a common sense of the state as a site of crystalized resources that can be used to sustain the commons. As Franco Rotelli puts it, “What if we recreate these crossing points, this new alliance, between the designated institutions and the people? We could then really imagine that the citizens constitute themselves as those that have the right to care, and that this care is a responsibility of the city: a city that cares for every single one of its citizens and that, by doing so, constitutes citizenship and constitutes itself as a city” (2019).

This common sense responds to the possibility of being stuck with, as Nic Beuret (2018) has beautifully paraphrased Donna Haraway, the vulnerabilities of social life. It offers a way to displace the operative resources of the state into the richly multiple processes of social reproduction. This attempt, and its permanent failure, is the starting point of this journey through caring ecologies where concepts, materialities, relations and experiences flashing up from the Trieste experience can hopefully allow us to think through our present, “at a moment of danger” (Benjamin, 2009).