Sezione Medicina

from Leadership Medica n. 3/2000

Approaching the year 2000 Psychiatry will have to face, like Medicine in general, very complex  problems linked both to an increase in patients, more differentiated  and with more demanding needs, and to a therapeutic and technological potential that, though it reached an exponential growth in the last fifty years, it has not always come up to our expectations.

The enormous growth, in fact, of therapeutic possibilities has often "paradoxically" determined a downright worsening in the physician-patient relation.

Overspecialization and hypertechnology have turned the ill person into an organ or function to repair. They forced the physician, oblivious of M. Balint's famous phrase "the cure the physician more often gives is himself", to propose an aseptic and distant relation, experienced by the patient as unconcern or even enmity. 


The evidence of this situation is given by the high percentage of contentious procedures: in Italy presently there are about 12000 civil and criminal law suits brought by patients against their physicians.
This situation, that I called the "paradox of King Midas" (N. Lalli 1991), is linked to the complete lost of the patient's trust in his physician.
In addition to this paradox one must also take into consideration a socio-culturally-based phenomenon that can be identified as "drug culture".
By this expression I mean to indicate that socio-cultural trend that envisages the utilization of a specific "pill" to eradicate any existential problems (from any interpersonal difficulties to boredom, from anxiety to sadness).

We are now approaching the more specifically psychiatric field, as it is unquestionable that some kind of psychiatry based only on the psychopharmacological and biological approach has widely contributed in building and supporting such ideology, starting with the pill against anxiety on to that against depression -soon called "pill for happiness"- and to that against shyness or social inhibitions, etc..
Man has always tried to relieve pain or to attain an altered consciousness making drug use: but this was always a phe­nomenon linked to precise socio-cultural groups.

Within the "drug culture", instead, such a trend has become a mass ideology, and the real problem lies in the fact that only the comforts of such an approach are emphasized, whereas its risks and dangers are scrupulously concealed or mystified.

Why then should we marvel at the use of the "saturday night pill"? Since there is a "soothing pill" for any problem, it was easy for drug dealers to promote and make believe to youngsters, in a total lack of discernment, that thanks to a "special pill" one could win any kind of tiredness and could extend, beyond any physiological limits, the fun. 
Unfortunately tragic accidents finally determined the coming to the forefront of a phenomenon that has been well-known to experts for at least ten years.

Who will, instead, take care of alerting all those patients under psychopharmacological treatment  -a treatment that may also be indefinitely extended thanks to self-prescription- of the risks linked to addiction, to the decrease of mnestic capabilities, etc..?
How many times have we been asked help by a patient to free himself from the tyranny of a psychotrope drug, that initially proved efficacious and releasing?

It is within this cultural, psychological and social framework that we should think of a possible change of psychiatry; not only will it have to denounce (and not collude with such ideology), but also propose solutions to these primary issues.

To this purpose Psychiatry must necessarily become Psychotherapy: that is it has to rehabilitate the physician-patient relationship and has to emphasize its therapeutic worth.
Asserting that Psychiatry is Psychotherapy does not mean to aprioristically and ideologically censure psychopharmacology, but it is intended to stress that it cannot represent an independent variable. On the contrary, it has to be set up, when necessary, within a complete therapeutic project focused on the person and on the interpersonal context and not only on symptoms.

As I already suggested on another occasion1 , the psychotrope drug can be utilized as "transitive purpose" in the context of the therapeutical relation; operating, then, with the same function of link and growth that the transitive purpose has in the evolutionary phase of  life's early years.

But a psychotherapeutic point of view of the mental illness focuses, besides the treatment, also on rehabilitation and on prevention.

Psychotherapy As Treatment

Many and very differentiated descriptions of the psychotherapy as treatment of the psychic illness were provided referring to theoretical and operative models.There evidently are different intervention procedures with their indications and contra-indications of which each operator has to be aware, even if only works with a specific procedure of psychotherapy.

In this historical phase the general orientation is that of identifying and quantifying the results concerning short, medium and long-term outcomes, and that of more clearly discovering the correlations among the different models of psychotherapy and the different needs of patients, starting not only from their psychopathology, but also taking into consideration the different phases of the vital cycle, the difference in the manifestation of the disorder and the personal and environmental conditions surrounding the patient.  In case of major disorders (psychosis), especially in the early phase, the need to prescribe an integrated psychotherapeutic and psycho­pharmacological treatment is widely proven; but the operator must obviously be as much informed of the interpersonal dynamics as of the psychopharmacological effect.

Psychotherapists-psychiatrists represent an important experience in terms of collection of data on the specific effects of psychotrope drugs, both from a symptomatic point of view (with reference to the symtpoms' remission but also to the onset of secondary symptoms), and from that of the psychic dynamic that goes with their utilization. The utilization of the psychotrope drug from the person experiencing the psychic disorder always implies a specific change in the image of himself/herself and in the relational dynamic with the person taking care of him/her, the spouse, the family, the service and more in general the surrounding milieu.

Psychotherapy as Rehabilitation

Many times when the psychic disorder has become chronic (this is often due to "iatrogenic" reasons) a therapy in terms of transformation is not always possible: it is therefore necessary to acknowledge the presence of limits that have to be respected. 
In these cases, the main objective is that of a social adjustment, more than that of a overall change.

There is significant evidence showing that often when psychotherapy is rehabilitation-oriented, it obtains more positive results than if it aimed at reactivating evolutionary projects.
One example of this is the therapy with families that enables to work on affectivity with young adult psychotic patients, reducing hypercriticism and enmity at the bottom of the becoming chronic dynamics and of the repeated hospitalizations.Further examples are given by those that treat the psychotic patient through an overall approach based on the work of a multiprofessional team, or again by those that work with psychotherapy within therapeutical communities. 

Psychotherapy as Prevention

In the framework of the research carried out by the development psychologists and most of all by those who deal with psychopathology of the evolutionary age, it clearly emerged  that psychic disorder of parents is a risk factor for the evolution of children and for the onset of disorders in their psychic dynamics.
Let it suffice to cite the many studies on the relation between depressed mothers and newborn babies (Tronick) or the observation of trasmission models of defence mechanisms from parents on to children (Fonagy), or the correspondence between models of affection called irresolute/disorganized in adults and styles of disorganized affection in children (M. Main).
There are many psychotherapists that, in treating adults, were able to detect the alterations the psychic disorder may cause in the parents-children relationship: child-abusing parents (S. Cirillo), drug-addicts (S. Mazzoni), alcoholics or with border-line diagnosis (O. Kernberg; H. Kohut). They all reveal, during the psychotherapy, their incapability of establishing a relation with their children enabling them to take care of them, creating affective bonds based on the respect for the other as a person with his/her needs, desires and motives.

Once overcome the idea that the "trauma is caused by a childlike fantasy", there is important evidence emerged during the psychotherapy on the correlation between a difficult relationship with the parents and the onset of a long-lasting psychic disorder (A. Miller). 
Psychotherapy plays, therefore, an important role on the prevention level when it faces psychic disorder in adults before it may affect the development of children.

Psychiatry will have, as a first thing, to change itself as to the issues I mentioned before if it aims at being a methodology for evolutionary change and not for a mere remission of symptoms.
Given the complexity and the vastness of the subject-matter discussed, I suggest the text: "Manuale di Psichiatria e Psico­terapia, Seconda Edizione ampliata" (1240 pages) that accounts for the synthesis of a thirty-year psychiatric-psychotherapeutic experience on the field and stands for the evidence of the possibility of integrating Psychiatry and Psychotherapy in one sole method capable of indicating a different interpretation of mental illness and of a actually possible treatment of the psychiatric patient.

Nicola Lalli
Titolare di Clinica Psichiatrica - Docente di Psicoterapia
Università "La Sapienza"Roma

Bibliography

1. Balint, M., Medico, paziente e malattia, (pp.1-420), Feltrinelli, Milano, 1970
2. Canguilhem, G., Le normal et le pathologique, (pp. 1-284), Presses Universitaires de France, Paris, 1966.
3. Fagioli, M., Istinto di morte e conoscenza, (pp. 1-310), Nuove edizioni Romane, Roma, 1987, (settima edizione).
4. Kuhn, T.S., La struttura della rivoluzione scientifica, (pp. 1-430), Einaudi, Torino, 1978.
5. Lalli, N., Lo spazio della mente: saggi di psicosomatica, (pp.1-280),Liguori Editore, Napoli, 1997.
6. Lalli, N., L'isola dei Feaci. Percorsi psicoanalitici, nella clinica, nella storia, nell'arte. (pp.1-320), Nuove Edizioni Romane, Roma, 1998.
7. Lalli, N., Manuale di Psichiatria e Psicoterapia, (pp. 1-1340), Liguori Editore, Napoli, 2000, (seconda edizione ampliata).
8. Lalli, N., Lo psicofarmaco come oggetto “transizionale”,
Relazione Convegno Internazionale di Psicoterapia Analitica, Roma, Gennaio 1999. In: Lalli, N., Manuale di Psichiatria e Psicoterapia.