Mario Novello
The city of Pisa honored with great affection and participation Barbara Copovani, the psychiatrist attacked and killed by a patient.
The killing of colleague Barbara Capovani, which took place in Pisa last April 25tharoused indignation and anger, pity and closeness for the family, colleagues and people who found a reference in her. The attestations of esteem show that he had chosen a field characterized not by dangers and violence, as is emphasized today, but by meaning and value, while continuing society to generate increasingly large areas of psycho-social suffering and marginalization, downloading them on services public who are thus weakened (1). Vocations decrease and valid professionals quit, contributing to the depletion of resources.
In the past, I myself had fortunately escaped a sudden and very violent, potentially lethal attack, on the doorstep of my house by a man with a history of great psycho-social difficulties, released from prison because he was ill and for whom I had been, for two years, the main reference next to the Mental Health Center. that aggression two preliminary observations: i) a positive therapeutic and supportive relationship can turn into hatred and destructiveness, beyond errors, faults, bad practices and/or disservices; ii) whoever reaches such actions is in any case a person with his own psycho-social history of trauma and pain, to be reconstructed and understood. Understanding is, in fact, an ethical, professional and human duty, a question of method and avoids leaving dangerous gaps that feed unconscious errors in behaviour, relationships and organisations, but understanding does not mean justifying. Each remains responsible for his actions until proven otherwise.
It’s not acceptable that someone has to die so absurdly, but it happens. Admitting it doesn’t mean accepting it with resignation and inertia that it happens, as an ineluctable fatality, but, after the pain, we are forced to take a lucid and rational position to try to prevent it from happening again. If it happened, something got out of hand and we didn’t understand it, even without fault. Understanding is an ethical, professional and institutional obligation towards those who work and towards citizens who express health needs, but also towards the victims, attributing meaning to their death for others so that it does not happen again. It’s painful but death and life have deep relationships, as Barbara’s organ donation testifies.
Whenever an accident occurs, for example to an aircraft or a ship, it is normal to set up a commission to ascertain the facts to prevent it from happening again, carrying out an investigation without prejudice with the sole purpose of highlighting the problem and remedying it. Also in this case it would be desirable to set up a commission, of crystalline intellectual honesty and capable of moving freely within the broad repertoire of knowledge of psychiatry and the rich experiences of mental health. Knowing the murderer, Seung, poses some problems that open up others in a chain, in a labyrinth in which we must not lose the thread.
Here are some cardinal points:
- the meeting problem and history is a complex question, one of the fundamental contradictions of psychiatry, and can decline between two extremes:
- the first is characterized by a gaze that seeks the symptom and the disease as an object, to which subjectivity, personal history and interpersonal encounters are extraneous. It is the gaze that petrifies, establishes a distance and predetermines certain types of paths and organizations, identities and destinies, relationships/non-relations/counter-relations, conditioning the disease and falsifying it.
- the second is characterized by acceptance and understanding, not in a naive and feel-good sense, but phenomenological. Eugenio Borgna (2) writes : « The restoration of subjectivity and intersubjectivity in psychiatry….…and the consequent bitter contestation of the sense (nonsense) of an abstract and formal psychic «normality», have led in any case (beyond any practical realization) to the reconsideration of the epistemological foundations of psychiatry».
In everyday life, the Services meet people and their needs, mostly offering the affectivity and subjectivity of those who work there, but the two polarities, two antithetical ways of conceiving science, of seeing the world and of acting, structure the field of action.
- the problem of diagnosis. We read that the murderer presented a personality disorder with antisocial traits, an exponent of a neo-Lombrosian bio-psycho-social category of individuals with violent (“antisocial”) behavior, the “dangerous” regardless of the diagnosis, from which the society must defend itself, as established by the ancient asylum law. Nosographic schemes constitute conventions between experts that change over time according to knowledge perspectives and reflect different needs and interests (diagnostic coding and insurance systems). In everyday life, nosographic schemes (the DSM 5 diagnostic system is the most widespread) produce and reproduce a “double” of reality that does not represent reality.
A dangerous conception has been developing: it is considered that personality disorders, a recent “invention”, cannot be modified by psychotropic drugs and, therefore, that taking charge is useless/impossible. Aspects of psychosis and social needs have been included in the category: the diagnostic label can hide very deep suffering, observed only in the “antisocial” behavioral aspect and which are not recognized[1].
Declared of “non competence” and abandoned to their fate, people do not find a side of help and treatment, bounced between prison and Psychiatric Service for Diagnosis and Treatment, they will be all the more “antisocial” the more they are rejected, often even with the violent complication of taking psychotropic substances. This is a very dangerous conception of an “alienated” psychiatry which is based and measured on the efficacy of drugs, expelling from itself and from its competence what drugs do not have a measurable and evident effect, including knowledge.
Thus people with complex levels of suffering that require acceptance and care are rejected. Who should they contact? Basaglia’s question comes up every day “What is Psychiatry?”.
And Basaglia writes: «We had a very agile external structure, in which the disease was dealt with outside the asylum. We saw that the problems related to the dangerousness of the patient began to decrease: we began to have before us no longer an “illness” but a “crisis”. Today we highlight that every situation brought to us is a “vital crisis” and not a “schizophrenia”, or rather an institutionalized situation, a diagnosis. At the time we saw that schizophrenia was the expression of an existential, social, family “crisis”, it doesn’t matter, it was a crisis anyway. It is one thing to consider the problem a crisis and one thing to consider it a diagnosis, because the diagnosis is an object while the crisis is a subjectivity, a subjectivity that puts the doctor in crisis, creating that tension we talked about earlier» (3).
- the type of services (of Psychiatry or Mental Health) and their institutional dynamics have a reciprocal and interactive link with the criteria that animate and underlie them. The murder of the colleague requires a precise recognition of the structure of the Services, of their functioning, of the objectives and dynamics, of the paths of the people in the “psychiatric circuit”, of the failures and frustrations (no one is exempt), of the positions of proactivity or wait-and-see and more. The problem of resources is fundamental but not sufficient if objectives, styles and methods are not verified.
- the problem of violence: GP Seung’s story should also be viewed through the lens of violence, the one he may have suffered and the one he may have acted on right up to the end, identifying the contexts of reinforcement (social media in primis). In the Western world we are witnessing a sort of mental “clearance” of violence. Continuous attacks in the healthcare world and in schools (“everything happened to me immediately” by ‘fathers and mothers of families’), feminicides, sexual violence, bullying and massacres, growing crime against minors – marginalized or not, pedophilia and incitement to self-destruction (anorexia and suicide) on the net, violence in stadiums and in the suburbs, difficult to control by the forces of order and with inadequate policies, show a profound crisis of society within which the colleague’s drama is also part.
Without denying the possible weight of the disease and the institutional dynamics or Seung’s personal responsibility, but without unloading everything on his individuality.
Some professional sectors require organizational and legislative measures:
- the sacrosanct protection of those who work in the field of Health and of fundamental activities for the community, but every measure implies the qualitative and quantitative implementation of the Services
- but which also allow internment for social danger, certifiable without committing crimes, regardless of the Constitution and jurisprudence.
In other words, a return to the Law of 1904 is required, when admissions to asylums took place with the sole ‘diagnosis’ of social danger and this must be rejected with absolute determination.
Mario Novello, psychiatrist
Bibliography
- Basaglia F, Ongaro Basaglia F. The deviant majority. 1971. Einaudi, Turin.
- Borgna E. Introduction to: Binswanger L. The Suzanne Urban case. History of a schizophrenia. 1994. Marsilio Editori, Venice.
- Basaglia F. Brazilian conferences. Raffaello Cortina Publisher, Milan.
[1]According to the press, the murderer Seung manifested delusional contents, reinforced by social networks and perhaps by substances, but documentary confirmations are needed.