The formation of deinstitutionalization discourses in Italy and England: a cross-national archaeological study By: Maria Teresa Ferazzoli A thesis submitted in partial fulfilment of the requirements for the degree of Doctor of Philosophy The University of Sheffield Faculty of Social Science Department of Sociological Studies November 2018 ABSTRACT This thesis offers new insights into deinstitutionalization and a fresh perspective on international differences in mental health care systems. Deinstitutionalization is a term used to describe a major transformation in the provision of psychiatric care (Bachrach, 1976), the move away from care delivery exclusively in long-stay psychiatric hospitals and towards the creation of community-based services. Although such shifts have been acknowledged as an international trend (Goldman et al., 1982), mental health care scenarios are characterized by high levels of differentiation. The rationale for this study was that these differences required more careful consideration. The thesis challenges the widely held assumption that deinstitutionalization is an international trend. It presents a cross-national archaeology of the emergence of the deinstitutionalization discourses in Italy and in England. Legal and psychiatric documents produced in the two countries are analysed as evidence of the national conditions that allowed the acceptance of this shift in the two countries. The findings drawn from the analysis show multiple ruptures and different strategies at the core of the national discourses and practices. In summary, in the English case the emergence of deinstitutionalization was strictly related to a government driven process of rationalization, whilst in the Italian case deinstitutionalization was the result of a strategy aimed at the demolition of the system established during the Fascist period. The thesis illustrates how these differences led to the emergence of heterogeneous psychiatric and legal practices in the two countries. The most striking of these is the complete abolishment of the psychiatric hospitals in Italy. Through the comparison of, and the analysis of the differences between, how the English and Italian deinstitutionalization discourses and practices emerged, this study challenges what is often taken for granted, for instance the notion of the role of the introduction of drugs in the acceptance of treating psychiatric patients in the community or the idea of anti-psychiatry as an international movement. Key words: deinstitutionalization; discourse; archaeology; Foucault; cross-national 1 ACKNOWLEDGEMENTS Following Foucault’s insight, I am aware that a document is never just a text, but it is an event. This thesis is an event, not just because is the realization of a dream but because it was the product of a journey that made me meet people, acquire new skills and make new memories. Looking at each line, I can think to, and thank someone. I would like to express my gratitude to my supervisors, Kate and Matthias, who have believed in my project since the very beginning. Even before I knew what shape this research would have taken. This journey would not have been possible without the support of my family and my friends. I am indebted to Nic who supported and believed in me through each moment. I must thank my parents for listening me, even if almost sleeping, during my boring skype calls talking about Foucault. Thank to my brother who made soups for me while I was struggling with my literature review. Each line reminds me a moment that I shared with some friend or colleague: a glass of wine with my friend Lou talking about problematization, infinite discussions with Pete on entanglement at the café, or the tea breaks with Ruth and Lauren discussing of power and Marxist theories. Each moment, each chapter, each word is a piece of my heart and I have to thank all of you. I would like to give special thanks to Prof Crossley and Dr Moses who have kindly accepted to be my evaluators, becoming part of this journey. Finally, I would like to thank my aunt Teresa who always encouraged me and is already making me think of what I am going to do after this achievement. 2 Contents ACKNOWLEDGEMENTS ................................................................................................... 2 LIST OF FIGURES ............................................................................................................. 6 LIST OF TABLES ............................................................................................................... 7 CHAPTER II: THE MOVEMENT OF PSYCHIATRIC CARE FROM THE ASYLUM TO THE COMMUNITY: A REVIEW OF THE LITERATURE ............................................................... 19 Introduction ....................................................................................................... 19 DEINSTITUTIONALIZATION ........................................................................................ 20 Tracing the main transformations of the concept ........................................... 20 The exodus of psychiatric patients in England and in Italy ...................................... 25 MAIN APPROACHES TO THE STUDY OF DEINSTITUTIONALIZATION ............................. 33 Deinstitutionalization as a goal ........................................................................ 33 What has been learned from the past? ............................................................. 37 Decarceration and social control ...................................................................... 43 Governmentality Studies ................................................................................... 47 Conclusion .......................................................................................................... 51 CHAPTER III: METHODOLOGICAL CHAPTER ................................................................... 57 Introduction ....................................................................................................... 57 THEORETICAL STANDPOINTS ..................................................................................... 57 The Materiality of Discourse ............................................................................. 58 The history of the Present ................................................................................. 61 Diagnostician of the present ............................................................................. 63 PUTTING FOUCAULT TO WORK ................................................................................. 65 Untangling the plot: from the unity of discourse to the definition of statements .......................................................................................................... 69 The selection of the discursive formations and the forms of grouping ......... 75 Cross-national design and the archaeological method: an analytical challenge ............................................................................................................ 81 Conclusion .......................................................................................................... 84 CHAPTER IV: THE TRANSFORMATION OF PSYCHIATRIC KNOWLEDGE IN ENGLAND AND IN ITALY ........................................................................................................................... 85 Introduction ....................................................................................................... 85 THE BIRTH OF THE SOCIAL PSYCHIATRIC DISCOURSE IN ENGLAND .............................. 86 War neuroses: the call for psychiatric expertise ............................................. 86 3 The birth of social psychiatry and the problematization of the psychiatric hospital .............................................................................................................. 92 Social psychiatry: a “contribution to the national life” ................................... 97 THE NEW PSYCHIATRY IN ITALY .............................................................................. 104 What is Psychiatry?: the crisis of the institution ........................................... 104 Where does psychiatry go?: the process of politicization ............................. 112 Anti-psychiatry and the new psychiatry in Italy ........................................... 119 Conclusion ........................................................................................................ 125 CHAPTER V: THE FORMATION OF THE DEINSTITUTIONALIZATION DISCOURSES IN ENGLAND AND IN ITALY ............................................................................................. 128 Introduction ..................................................................................................... 128 THE FORMATION OF THE ENGLISH DEINSTITUTIONALIZATION DISCOURSE .......... 129 The Lunacy system and double standards ..................................................... 129 The will of the patient: from custody to treatment ....................................... 134 Mental health and community care: population coverage ........................... 139 ITALIAN DISCOURSE ON DEINSTITUTIONALIZATION ............................................. 143 Manicomi and social order ............................................................................. 143 The Italian Republic, the Constitutional paper and the process of medicalization ................................................................................................. 151 The alliance between psychiatrists and