Madness and Society

Lessons on addiction and mental illness from a rural Italian village.

At six o’clock each morning, the alcoholics, addicts, and mentally ill residents of San Donato Val di Comino, Italy, emerge from their homes and congregate—sometimes together, but mostly alone—in the cafés around the town’s main square. Some of the hardened alcoholics order an espresso with a shot of liquor, then climb into work trucks and head out to farms and construction sites. The mentally ill—who suffer predominantly from depression, bipolar disorder, and schizophrenia—order cups of coffee or sit at the patio tables emptyhanded, an indication that they have run out of cash for the month.

My father was born in this village, where I’ve observed this early-morning ritual during family vacations over the past two decades, but this time it struck me in a new way. For the past 18 months, I’ve reported on homelessness, addiction, and mental illness in American cities and spent many hours with America’s most vulnerable residents, who, on the surface, struggle with the same afflictions as the residents here in San Donato.

In fact, the contrast is profound. In West Coast cities, tens of thousands of addicts and mentally ill people live outdoors in horrific conditions and survive on a combination of panhandling, prostitution, and property crime, which, in turn, creates disorder on urban streets. Not in San Donato, however: here, addicts and the mentally ill are deeply integrated into the community and maintain a dignified standard of living. Their families and relatives look after them and stay involved in their lives. When necessary, the municipal government provides employment sweeping the streets, and local businesses sometimes pay mentally disabled residents to serve as lo spanno, an informal occupation that entails walking through the streets with a loudspeaker announcing products newly available in the town market. The community plays a role in helping the most vulnerable, not through compulsion or formalized social programs but instead through the values of self-help and community responsibility.

In San Donato, a man found sleeping on the streets would suggest a moral scandal. The village would shame the homeless man’s family into taking him in to provide financial, practical, and psychological support. The reason that nobody sleeps on the streets here isn’t medical or technical—it’s cultural. Despite massive economic and social change over the past century, Italians have retained a culture of family and responsibility that strictly limits the expression of pathological behavior and enforces a standard of dignity that encourages addicts and the mentally ill to participate in society despite their condition.

It’s true that a small village like San Donato can’t be compared with an urban environment like San Francisco, but the dislocation and devastation in small-town America is arguably worse than in its cities. The difference is not only a matter of scale. Some might argue that higher taxes and more generous public-welfare programs prevent Italians from falling into homelessness and despair—but America actually spends more per capita on social services than Italy, with worse outcomes.

The dominant policy prescriptions for addressing addiction and mental illness in the U.S. involve professionalization, medicalization, and destigmatization. Despite mounting evidence of failure over the past half century, we continue to add social programs, to treat addiction as a disease, and to destigmatize everything from heroin consumption to homeless encampments. Yet America is more addicted, more despairing, and more disordered than ever before. Public administrators and academics treat the suggestion that family and cultural norms are key to solving the addiction and homelessness crisis as naïve or even immoral. But San Donato presents a case that traditional societies have a superior understanding of social problems, with cultural expectations playing a decisive role in curbing the most destructive human tendencies.

Many years ago, a friend referred to San Donato as a manicomio all’aperto—an open-air madhouse. He captured the poetic truth that we all fall somewhere on the spectrum of human irrationality, and that a good society integrates the sane and the insane into its common cultural institutions. Though a traditional shame culture exists in San Donato, residents express compassion toward the addicted and mentally ill—actually living with them and looking after them—while remaining intolerant of the pathological behavior accepted by American progressives.

The lesson for Americans: culture matters. If we want to reverse the destruction of human life through addiction, mental illness, homelessness, and violence, we must reimagine our moral and cultural possibilities and seek to reestablish familial and communal bonds that can prevent the most vulnerable from falling into the abyss. No doctor, pill, or public policy can replace a truly compassionate society—one that loves the mad and the addicted but restrains them from harming themselves and their neighbors.

Originally Published at City Journal.