“Phenomenology I raise zero. The Body to Body Between Madness and Care” by Gilberto Di Petta.
Any 2023
Gilberto Di Petta, heir and interpreter of the best Italian tradition of phenomenological psychopathology, has just published a volume entitled Phenomenologia alzo zero for Quodlibet. The most attentive reader will find articles published on the Pol.it website, the largest Italian platform on mental health issues, online since 1995 thanks to the tenacity and passion of Francesco Bollorino. “Heart of Darkness. Journey to the end of psychiatry” is the title of Di Petta’s column, evocative of the journey to the depths of the human soul and the encounter with Evil that Marlow narrates in Conrad’s novel of the same name.
But Phenomenologia alzo zero is not just the description of the thousand contradictions that have characterized the progress of psychiatry in the last 50 years. As Giovanni Stanghellini recalls, who embellishes the volume with a sharp introduction on the pettiness and grayness of so-called mainstream Italian psychiatry, the stories that take place in the nocturnal atmospheres of an emergency department disturb, yes, but they suggest and finally signify, re-assigning value to the apparently incomprehensible lives of patients and nobility to the profession of the healer, which emerges beyond any conceptual superstructure.
In his “melee between madness and cure” (subtitle of the volume) Di Petta moves on a thematic register that merges the innocence of the clinician, his amazed eyes in the face of the changing conformations of psychic suffering, and the rigor of the researcher , of his method based on encounters and the stubborn desire to understand. In this he did not spare himself, but rather laid bare his humanity, as in the moving story of his last analysis session: “only now my being a man and my being a psychiatrist are finally meeting.” Feeling oneself “simply human among humans” is perhaps also the cornerstone that prevents passion from collapsing under the weight of disillusionment, of such widespread pessimism (the phenomenon of retirements and mass resignations from the NHS is testimony to this) among those who feel they belong to a “lost generation”, which was unable to keep alive and consolidate the great achievements of the 1970s.
Disillusionment and pessimism do not prevent Di Petta from carrying out, in the twilight atmospheres in which he writes, a ruthless analysis of the causes that have led us to the current situation and from asking a series of questions which could rightly be the cardinal points with which to orient ourselves for a desirable reconstruction of the existing. By highlighting annoying, sometimes unpleasant contradictions in the reassuring (even if frustrating) reproduction of reality, Di Petta brings us back to the meaning of the things we do and the distance between these and the values in which we believe. In the stories he tells with extraordinary capacity for language, Di Petta represents the emergency that the Mental Health system is experiencing in our country, the frustration and lack of hope that unites operators and users, the residual and containment use that psychiatry seems to be relegated.
A defensive psychiatry, dominated by diagnostic and therapeutic algorithms centered on an organic model, criticized in words but practiced in deeds. A Public Service that welcomes suffering to pigeonhole it into the schemes dictated by efficiency and productivity. An offer of private or affiliated services without public management which requires the user or family member to navigate the labyrinth of acronyms, structures, specialist approaches, and often to spend out of their own pocket to obtain what they are entitled to.
And again: the hospital component of the DSM, the SPDC, i.e. the center that expresses the greatest intensity of healthcare which becomes the usual reference for problems of all kinds. It is even superfluous to argue about the causes that generate these flows, but I like to grasp the very current analogy with general medicine. On an organizational level, the best response to improper use of the hospital emergency room is considered to be greater responsibility for primary care, general practitioners and their aggregation in local structures (the Health Centers) to guarantee a 12-hour presence, with the possibility in some cases of accommodating even short stays, and with the continuity of care service to respond to night-time emergencies. Therefore: territorial proximity, continuity of care, possibility of response within 24 hours. But weren’t these the characteristics that Mental Health Centers should have had? What prevented this visionary plan from coming to fruition?
Another aspect that emerges several times in the story is the reductionism in the therapeutic approach, the sedative, containment “psychopharmacological bath”. There is no psychiatrist today, even the most ardent organicist, who is not willing to admit that the possibilities of a favorable prognosis increase exponentially if the therapeutic approach is inspired by the integration of pharmacological, psychotherapeutic and social interventions, the latter extended to user’s proximate relational network. If we add to this the consolidated evidence on the not at all negligible iatrogenic effects that are attributed to psychotropic drugs – especially when taken long-term -, it is not clear how an intervention based exclusively on drugs is ethically and deontologically sustainable.
In the folds of the various stories presented, what is also striking is the description of the role that users and family members assume in relation to the use of the emergency room and possibly hospitalization: on the one hand passivity and endurance, on the other the search for relief, albeit temporary, with a which considers itself inevitable and invincible. In evoking and sustaining this feeling, the shelter denounces its failure even before it has been built. There is a real antinomy between this way of interpreting the use of hospital admission and the idea that the intervention, to be therapeutic, must aim to give the user and family back the negotiating control over their existence; and the ability of the Services to actively involve the people assisted in the life projects that concern them; and in short the fact of being the subject or object of a treatment process.
Finally, I want to grasp the reference that Di Petta addresses to the academy, to specialization schools (the “letter to a specialist” is memorable in this sense), asking what and how much training they receive to understand and orient the opportunities that a crisis, in its unveiling of a field of possibility, it offers. And how adequate is the current university system to accompany and support the reforms of the national health system or does it rather constitute an embarrassing burden. Also in this case the request refers to questions of broader scope, which ask us about the coherence between university teaching programming and the skills that are now indispensable for working in the network of community health and social services. But how can we pursue this coherence of goals in self-referential contexts that remain separate from the health and social system, without a real possibility of integration into local mental health?
The volume ends with words of regret and hope at the same time. Remembering the years of the conferences in which different visions were compared, not necessarily antagonistic, enriched by the arguments of the Masters, with whom we learned “in the workshop” and not on the elaborate version of the Bignami-DSM5, nostalgia is inevitable. In the face of a “poor” psychiatry, because it is adorned with trinkets and junk, even the belated theses of those who reevaluate holistic approaches (having ignored and removed them for a lifetime) appear to be luminous intuitions. It is not to these exercises of scientific transformationism that our hopes should be entrusted, but rather to the awakening of the curiosity of those who have recognized themselves in Di Petta’s words. The hope is that things change, of course, but for this to happen it is necessary to be hopeful and not simply have it.