Tracce Freudiane

by Diego Busiol

 

I recently attended an interesting “International Meeting on Mental Health”, a four-day conference on psychiatry in developing countries: current status, ideas, projects, exchanges of experiences. Something unique in this field, especially for the enthusiasm of both speakers and participants. So I had a unique opportunity to make few considerations on different aspects of the so-called mental health and I could reorganize some thoughts which in last years arose from my practice both as social worker in a psychiatric house and as psychologist.

I start from the focus of the conference: mental health. Why talking about mental health? It would seem obvious, being a symposium on psychiatry. But would not be enough to talk just about health? What is that we call “mental”?

Still we are taken into this Cartesian division following which there would be a body separated from a mind. Separation understandable at a first sight, but then rather difficult to be supported, both theoretically and clinically. The mind is a philosophical construction, an ideal entity to which we refer skills, cognitions, disorders. But the mind is a fantasy animal, a creature that does not exist anywhere. Do we really need an ontology of the mind? Is it really necessary to postulate its existence, in order to face the topic of psychosis or health in general? And then, clinical experience shows every day that res cogitans and res extensa are not separable, not two entities that work in parallel, rather difficult to draw a line that divides them.

It is interesting to have a look to the history of psychiatry, or even better, to retrace how during the ages men have approached the madness. In last centuries there have been periods in which men tried to face the folly, alternating moments of exclusion and inclusion, for example trying to isolate physically the “insane”, or trying to submit them to the reason. And being impossible to submit the folly to the reason, a new segregation, a new exclusion was ready to come. The only common denominator in this alternating behavior (which demonstrate the ubiquity of madness and the helplessness of reason) is the force, the coercion. And the growing moralism.

Facing the folly, it is easy to find itself in one of these positions. It seems that one has to re-run in his own steps that others have made over the centuries, fascinating overlap of ontogeny and phylogeny.

Still today we debate around the body/mind division and we consider folly when the body is not subjected to the mind (and here we should dedicate an entire chapter about the subject, and whom we define as subjects). Crazy, disturbed, would be the one who fails to put the reason above everything else. Thus the neurosis is considered as a lesser evil, as cure of psychosis.

Why the psychiatric hospitals?

After the cliff, the ship of fools, islands and prisons, here we have the psychiatric hospitals, modern picklock to unhinge mental illnesses. Beyond any ideology, psychiatric hospitals are not the result of a sadistic mind. They are rather the natural consequence of the ideology which supported, and in part still holds, the conception of the psychosis as a disorder, as a deficit, and that pretend to treat the “formations of the unconscious” as formations of the brain. Furthermore, a ill brain. Taking the unconscious as an organ, the focus is brought on the brain, as location of the mind to be healed.
Even today, the main argument of those who consider psychotropic drugs the primary tool for dealing with mental disorder is the parallel with other diseases such as diabetes, “you will need to take medicines during all life, just like a diabetic has to take insulin throughout all life “. But this is at least a misunderstanding, when not a mystification: what would be the damaged organ here, where would be the altered gene, the missing enzyme? What would be the deficit to be corrected in the case of a “mental disorder”?

Psychiatric hospitals have failed in several aspects. Not only because they often became places of reclusion similar to prisons (in the worst cases during the past, in Italy, few doctors and nurses have been implicated in important processes and have been sentenced guilty of mistreatment and harassment to patients. At present life conditions in many psychiatric hospitals in foreigners countries are still embarrassing). Not only because they have showed to be not at all cheap. Psychiatric hospitals failed, first of all, because they never showed any therapeutic effectivenesses, since no patient came out (if and when came out) in better conditions then when he/she entered. Not to mention the collateral effects of years of massive doses of psychotropic drugs, many psychiatric patients with a long history of institutionalization have also developed real “survival” conducts (as swallow the entire meal in two minutes, not to have it rub from another) and stereotyped behaviors (such as walking aimlessly for hours through the corridors, begging for cigarettes and coffee, in search of every kind of barter with other patients), as to say that psychiatric hospitals have created its own patients. Just in the same way they have had a strong, a significant imprinting on all other figures working there: psychiatrists, nurses, social worker in general.

Psychiatric hospitals have rather had the function of “containing” the folly. Contain is a term much in vogue among the “psy” population (psychiatrists, psychologists and related professionals). There are several ways to contain: containment can be physical, as it was the contention of the bars, it can be chemical, as in the case of drugs, or can be symbolic, like the containment that a so-called place of cure can give, with its structure and the presence of professionals. We should really investigate why some users, sometimes, almost beg to be sheltered in places that most of the people would consider sad and narrow like the psychiatric wards. What sense of security and tranquility can give four walls surrounding an area! An what sens of detachment that walls can give isolating the inside from the outside! Few patients told me that they like to return to the psychiatric ward sometimes, just as they are going on vacation: they can “switch off the brain”, they can stop thinking of anything, they can just do nothing. I have always been impressed by the words they use, being the same that many friends of mine use to talk about touristic resorts. And it is amazing how in these places patients are able to build new friendships, to find mates and how, paradoxically, they live those moments as evasion from the everyday life.

But finally, in what have the psychiatric hospitals failed? They have failed not considering the dimension of the transference. The transference, what moves a person to address a question to another, for example a patient to his doctor; what shows that there is no simply dialogue (because there is always a rest that can not be caught nor explained and always refers to other) and there is no similar (because the other is always caught through one’s own phantasm). Thus there is no relation, because there is always something more, something mysterious, which goes further and can not be reduced. The transference is a sign of sexuality and desire.

The misunderstanding of the transference leads to the concept of personality as a set of traits and patterns that only would be enough to describe the functioning of an individual. These descriptions results finally totally abstract and ridiculous, they might describe a very generic and static person, while the clinic experience shows that the presence of a minimum of transference can overturn any schema. In the institutions is easy to make such experience every day, so that even the more chronic patients can completely change, depending on whether they relate to an educator rather than another, if they are with a doctor, with outsiders, and depending if they are in institutions or in a bar or in a totally different place, like during summer holidays. Among nurses and social workers circulates a joke about psychiatric patients, who says “they are crazy, not stupid”. Although colorful, this “clinical” notation underscores the fact that the dimensions of the transference and desire are not extraneous to psychosis. Even the more chronic psychiatric patients are absolutely able to act a series of tricks and strategies to achieve their objectives, all abilities that the various tests of intelligence can not grasp.

Not only. Many experienced professionals agree to recognize to most of the patients a deep sensitivity and a unique ability to capture immediately the qualities and the weaknesses of those whose they deal with, and an extraordinary ability to work on these. They might be not able to listen to their unconscious, but they go easily in touch with the unconscious of others! As to say that the unconscious is not sick and does not lack for anything. Indeed, in psychosis, perhaps even more than in neurosis, a caricatural, a fictional trait is marked. There is an element of theatricality that escapes to psychiatrists and psychologists who do not recognize the dimension of the transference. But the non-recognition of the transference leads many professionals to take everything on a personal level, and then the patient becomes “provocative”, “resistant to treatment,” does not fit into the pedagogy of the operator, is not “cooperative”, “does not change”.

When the transference is considered a negative resistance, a weakness of the personality, a disorder, an error, objective become the standardization, the elimination of the transference. The misrecognition of the transference as engine of the cure found the concept of dependence. But there is nothing risky in the transference, which, by the way is not unidirectional from the patient to the doctor. The patient is not affected by the the risk of being plagiarized, and the practitioner is not liable to be bogged down in a relation: the transference shows that there is no relation. For example in psychoanalysis the use is to refer with the 3^rd singular person, instead then with the “you”, pointing that there is always Other breaking the relation: it is not a dialogue between me and you, between Mr. Smith and Mr. Brown, there is always Other. The analyst occupies a particular symbolic position and he should preserve it, not intervening with his knowledges or beliefs, as a teacher or a friend can do. He should proceed by subtraction, escaping the representations of the patient, giving him the opportunity to articulate its question.

In my opinion the psychiatric hospitals would fail also today, even though the supporters of psychotropic drugs still argue that today the result would be different, thanks to the new medicines. Because the mistake consists in thinking that the disease arises in a precise area of the brain, is localizable, and that it is finally due to a mismatch of neurotransmitters. A delusion is not only the product of a series of synapses that are not working correctly and must be repaired. But first of all a delusion is not a mistake of the brain! It is not a cognitive deficit, nor a disorder: even a delusion or an hallucination may already be an attempt of therapy.

Delusion may be a need for a so-called psychotic, and it may be riskful, as well as an authoritarian and presumptuous act, to try to extinguish a delusion. A delusion might be for example a defense from a deep unsustainable anguish (agony).

Instead repressing the delusion, it may be important to let the delusion talk, trying to turn the delusion into a telling. This might be the opportunity to insert new elements and cause a change, and eventually move the delusion in another direction.

There are many forms of delusion and many ways to rave. Probably the point is to add some elements of novelty which may give some mobility to the delusion. Important is that a delusion is not crystallized, not always equal to itself and not founding in the life of a person, not affecting all its life. The point is to transform a limit in a resource, making even in case of delusion, a delusion of quality.

The clinic experience shows that the suppression of a symptom easily lead to the appearance of new symptoms. Extinguished a delusion, extinguished an obsession, something else will show up. But then, what is health? A certain ideology of medical functioning seems to say that mental health would coincide with the control of the unconscious, through the cancellation of its pathogens contents. In fact when a patient is sedated, according to the absurd rhetoric of the healthcare institutions he finally is “quiet”, “adequate”, “cooperative”. Unfortunately he sleeps fifteen hours a day because of the drugs …

It is not the case to take position against medicines. There are no good or bad psychotropic drugs, giving psychotropic drugs is not right nor wrong. Medicines can have a function, they can for example allow a person to stand an unsustainable anguish, or not to be tormented by voices. A medicine can in some ways be functional when it puts a person in condition of speaking.

Curiously, however, psychotropic drugs in the imaginative vocabulary of mental health become “the therapy”, while the word is considered a surplus, an optional, something that we can avoid, thus restricted to the so-called “support therapy”. This is at least misleading: psychotropic drugs do not cure and do not heal, even the chemical changes that they produce are short-term. The only durable effects we have are effects of language, and are introduced by the word, as result of an intellectual travel which can occur regardless of the “seriousness” of the “disease” of a person, his age, his studies. Today no one would talk of “cure”, rather then of “taking care”. Because neurotic or psychotic symptoms are not alien to the speaker, they refers to his discourse. They are rather the attempt of repression or deny of the unconscious, of the Other, that returns from the outside (in forms of voices, hallucinations, delusions).

Psychosis was initially considered as a moral disease, such the unwillingness of an individual to work and be part of a civil society. In other ages and other cultures hystericals and psychotics were even considered possessed by the devil. Even today. A young girl, very psychotic, who spent few years in the psychiatric house where I work, before being taken in charge by the social services has been brought by her parents to an exorcist! But in general a lot of people prefer to visit a charlatan with the hope to find the magic solution to their problems, in order to quit the “disturb” and not think about it anymore.

For the medicine is clear what is a disorder, what is the pain, what is a symptom or a illness. For charlatans is similar: “I know your problem, without that you even talk”. Both ways try to avoid the language. But things are not so simple anymore, if we accept the question of the language. When a person complain for a problem, this does not make a symptom yet. And when we have a symptom, this is not simply a disorder, not only a disturb; important is that we are able to catch it as a chance, something that we must question and that could lead us to say something new. A physical disease must be turned into the speech and from symptom must become question, this is the challenge and the opportunity we have. Health is result of a daily taking care, giving words to the formations of the unconscious, not avoiding the word.

The love for diagnosis…

Some words of the dialect of mental health are so very popular that they became “keywords”. Keywords may follow the fashion of the moment, the trend, or they might be the products of some simplifying ideology. Psychiatry has always fascinated with its diagnostic categories, particularly the younger students, who usually have a more naïve and mechanistic conceptualization. But it also fascinates many people, who believe that just by giving a name to a “disorder”, finding the illness, then they might receive the solution. The mistake lie in the belief that diagnostic categories really describe an external reality, and that the goal of diagnosis should be to make the right match between a case and its nosographic category.

The psychiatric nosography always strikes the popular imagination with its quite fantastic vocabulary. But how many ways there are to make a diagnosis? We may refer to a psychiatric diagnosis (which already is not the only one), but what are we saying by meaning psychiatry? Phenomenology, organic psychiatry, psychodynamic? Or can not we even say that probably there are as many psychiatries as there are psychiatrists? Or we should not even talk about psychiatric diagnosis anymore, since diagnoses today are made starting from the end, meaning that classifications depend more by the effectiveness of a medicine rather then theoretical considerations?

Psychiatry takes the symptoms as signs. Psychiatry is the “clinic of the visible” and therefore bases diagnosis on what is shown, on what appears, on conducts, on behaviors. The symptom is taken as a sign of illness, in a unique relationship: objective is to collect a certain number of symptoms (statistical criteria) to reach a diagnosis, and consequently prognosis and techniques of treatment.
After few years of experience in the psychiatric field, having read many diagnosis, I look at this point always with less interest. Especially diagnosis that refer to the DSM, rather than all’ICD, are in my opinion of any help. It may be interesting the moment of the diagnosis (as an opportunity of making theory, a moment to make questions rather then to give answers), but not the diagnosis in itself. I even doubt that they have any clinical value. When we receive a patient in the psychiatric house where I work, I usually prefer not to read immediately his diagnosis, as I prefer not to be driven in the observation and knowledge of a person by what someone else believe to have seen.

A diagnosis, first of all, refers to a specific theoretical frame, it is not absolute. But the theory can only be renewed. The theory catch the specific, the particular as opportunity to say something new. Making theory goes in the direction of an overture, it is not closing issues, while diagnoses point to classify, to bring the specific back to the general. These are two opposing movements. Each diagnosis is problematic, it does not exhaust the questions, it raises new questions. I have never seen two “schizophrenic” similar, or even two “obsessives” or two “hystericals”. Not only: most of the psychiatric patients I have met (also young people) have received at least two or three diagnoses over the years, also very different one from each other, depending on the moment and especially according to the psychiatrist they have found. I believe that the diagnosis often represent the limit of those who make it, and, what is worst, a limit for those who receive it, since it introduces a sort of justification that leads to deresponsibilization: “it is not my fault, it is not up to me, you see it is my pathology, it is stronger then me, I can not do anything…”. (Which is ideological because of course it is not a matter of “fault”, but everyone should become responsible of what he says, of what he does, beyond any “pathology”). And often professionals are caught in the same ideology, which may limit any kind of work with a person: “what you want to do with this person, what do you expect, this person is too severe, we can not expect much…”

We should really give up a medical model of intervention based on the categorizations of the DSM, on pathologies and nosography, and prefer an approach that recognizes and work on the resources of each person. We must work on our desire, in order to make something happen, even when we face apparently most severe cases of neurosis or psychosis. No prognosis is possible, the result is never written from the beginning. It is unthinkable to be not directly involved in the process of observation; it is unthinkable not to become part of the same complex system which is being observed, without changing it at the same time. Rather than trying to make the “setting” at every costs, we should instead create dispositives, laboratories, places where patients stop to be sleeping patients in bed and are put in conditions to do and speak, places where patients can work on their resources, where they can become active and then, first of all, where they are lead to make themselves questions and can begin a telling.

… and the passion for training

In a relation of “cure” love comes just as in any other relation. But here at least one of the members should be a little aware of this, transforming a possible resistance into the engine of the cure. In any case love, and thus the transference and the desire, remain central. Not the technique. The technique does not exists in advance. Although the technique is more easily transmissible, being a knowledge, it is not the element that sustain a relation of cure. No work is possible with psychosis, but even with hysteria, if one is not sustained by the desire. A psychiatric patient recognize immediately the lack of desire, or a sense of coldness and distance. That does not mean having to be “empathetic” or “sympathetic”, nor to be “maternal” or “welcoming”. Unconscious is not sick and any patient, even seriously “disturbed”, can feel instantly any non-authentic behavior by another person. Non-authentic in the way a word is not moved by desire rather then by calculation, by strategy. A word which sounds abused, like a sentence taken from a book. In no human relations work these artfully phrases prepared for the occasion: they sound always out of place. So why thinking that this might work with psychiatric patients, which if possible are often even more sensitive then many people? And why thinking that some kind of training could transfer to other abilities that one only can gain trough experience?

Who is usually a very good educator in the community? The cook! The cook is obviously not (supposed to be) an educator and hardly even receive any training. Yet often, the kitchen is a wonderful place to work with psychosis, and to the cook are accorded freedoms that few other persons have. The kitchen is usually a sort of gray area within the structure: an intern place, which however is a kind of fiefdom of a stranger. It is a place where no one can enter without permission, and being the cook not a “psy” professional (psychiatrist, nurse, psychologist, educator) is less easily caught by patients in their paranoid projections. The cook is indeed in a better position in respect to guests to enforce the law (the symbolic law, the law of the language) by distributing the tasks and rebuking who is not working as he should: in one word making work the symbolic dimension of the word. Moreover, in the kitchen there is an exceptional instrument which at the same time introduces a third element (which is fundamental with psychosis) and allows an symbolic exchange without equal: the food.

The kitchen is in short a place of extraordinary interaction, with its rules, schedules, precise hierarchies of work. It can be a great dispositive. And the cook has only her technique: cooking techniques. I mean that there are no titles, strategies or techniques that can ensure the effectiveness of a cure. One can perhaps influence a person, but the unconscious is not impressed by the knowledge of the so-called professional and play with it (here the caricatural aspect of psychosis), if the professional at first is not ready to doubt and to put in tension a little this knowledge. Finally, which is the desire that can sustain a cure? Certainly not the desire to heal, the furor sanandi: if there is a cure, it result as effect of other. I like to think that desire that can sustain a cure is desire of suspension, suspension of judgment, opinions, decisions, that means to put in tension every belief, every phrase, every preconceived knowledge, both by the “psy” as by the “patient”. Such desire has no end and it is probably the only desire that can be transferred to the patient, as difficult as this passage can be.

How does a dispositive works?

How to transform a space into a place? How to turn a place into a dispositive? And how this dispositive can produce effects for who is involved? Clearly, a dispositive is such if it is able to produce effects for everyone who is involved, beyond every distinction professional/user. A dispositive is what permits that there is profit, for everyone who is involved.

I would say that is necessary some identification to the place, avoiding any representation of the roles. For example, it is necessary to recognize itself as part of a team, without that this identification is fixed in the belief of being really a doctor, or a psychologist, that is, knowing that it is a symbolic mandate and not something that only can guarantee of the truth of what is said and sustain the effectiveness of one’s own word.

In other words, a psychiatric house should be for everyone dispositive to make theory, a dispositive to put in tension any representations, an opportunity to try to write a project of life and not a parking, not a “retirement residence for young people” as often happens. A psychiatric house is not a ward for terminally ills or for baby-pensioners: it can and should become for everyone an extraordinary moment of experimentation, experiencing, and discovery.

How to avoid the representation? How could a psychiatrist or an educator deal with persons without represents them as incapable of understanding and willing, retarded or limited? And how can users do not represent such a place of care as a prison, a punishment or an inevitable constraint? It is necessary that for everyone a third element breaks in the dyad professionals/users. It is necessary that some theory arise, that facts and symptoms become questions and that questions find their intellectual dimension, that they are able to move to other questions, to open new scenarios. Unfortunately it is not always easy. Often professionals are taken by the routine, by an overload of work, by requests they can not face and instead of walking the intellectual way, they find easier to refugee behind the supposition of the knowledge and the arrogance and their role. When this assumption is shared by users, also their intellectual curiosity lacks: “If the doctor is the one who knows, then I do not need to question.” As a result of the lack of any intellectual curiosity, instead of any intellectual tension there is only emotional tension through persons.

What makes the difference is thus that a structure become dispositive for everyone, not simply a structure that hosts patients confined to bed. Neither patients nor impatients, neither sufferings nor unsufferings.

The time is the time of the word, it results as effect of language, no one can force it. Through a dispositive questions can arises for everyone and can lead to a telling. Impossible to fix the time before the word. We must not represent the “seriousness of the case”, no prognosis is possible. No pre-diction of the doctor, no projects of life written by others, no objectives decided in advance. The project can only written by the person in question, and can only be written as a work-in-progress. A person may enter a psychiatric house with thousands of ideas and every kind of expectations. This must be questioned constantly. The goal is not to replace an “idealistic” objective of the patient with a more “appropriate” one. The goal is not the return to the productive life of a person. The only possible goal is the production of word. But a word of quality, which is not fixed in slogan, either by professionals or by users.

A dispositive is such only if it takes account of the dimension of transference and does not attempt to remove it in favor of an ideal of aseptic. The transference is a dimension of the word. Rather than suppressing the transference, as some medicine would do, it should becomes the engine of the cure. It means not representing himself in a role, it means not interpreting the discourse of the other rather then being direct to someone else, it means breaking the dual dimension of the speech, it means that every phrase refers to other, to something else. It means that there is no technique, no knowledge, no strategy. For everyone the risk is to be caught in his own phantasm, one’s own personal questions.

A matter of Style

One should pass trough the appropriation of a technique, before drop it and develop his own style. The technique does not consider the word in act, does not consider the other and does not consider the unconscious. The unconscious is unpredictable. The technique calls for a law which is not the law of the language, it is rather in the representation of the relation, it refers to an hypostatization of the word.

On the contrary, the style is not transmissible, each person must find his own. The style, the art of telling, the art of diplomacy, the way things are said and done. The technique aims to the efficiency, the style to the effectiveness.

The technique refers to an idealistic case, and in fact goes hand in hand with the diagnosis. The style is always personal, different, points to the individual differences not as defects to be corrected, but as strengths and resources. The technique is imitation, repetition. Style is for everyone invention, discovery. Impossible to copy the style, ridiculous to ape the master, caricatural.
The technique can not guarantee the effectiveness of an intervention. Only experiencing the word can allow the word to comes to efficacy. Beyond any techniques, anyone who pretend to help someone else must first of all learn to recognize and deal his own phantasms. No technique is able to guarantee “the right word at the right time.” These coordinates are not already given, it is the same word that traces them every time. There is not the right word to say, in advance. When the technique is replaced by the style, the question move from the what? to the how?

From the Puzzle to the Game of the 15

That “therapeutic community” is really therapeutic is not at all granted. The cliché wants that the container is filled out of contents, that a place of care is invested in medical, psychological, psychopharmacological knowledge, and that patients are engaged in occupational therapy, groups of self-mutual-help, art workshops, laboratories, etc…

This is not what makes the difference for a patient. This might be what serves to justify the existence of this structure to donors, to whom who work in, to the public opinion, families of patients.
A therapeutic community is not a finished product. Within a community must co-exist a rigorous and unwavering attention to the clinic, with the maximum flexibility in the ways and forms of work. Limits of the cure are often limits on professionals who, for example, represent their patients instead of facing questions with a clinical and theoretical attitude. Limits of doctors, overburdened by work and patients, doctors taken by the routine and without that desire, that intellectual curiosity, that disposition to the surprise that only allows to achieve something in life, and even more in this field.

The dominant ideology is that a therapeutic community, a therapeutic project, should be already given, decided in advance. That means, there should be something that, in any case, regardless of the people who will be involved, should ensure (for economics? scientific? social issues?) the result. Guarantor of this should be the right mix of components: the team of professionals, defined roles, schedules, rules of behavior for users, the deontological code for professionals, the training, diagnosis, the appropriate techniques of treatment, the supporting therapies. Everything defined at the table, the table where is set up the therapeutic puzzle. This entire vocabulary seems to indicate that any activity done in the community is in itself therapeutic: the point would just be assembling the pieces, making the right “copy and paste” to find the balance, so that patients might be stimulated…but not too much. At that point, the puzzle is completed, the problem solved, the circle closed.

Rather than a puzzle, I think that we should play the “game of the 15″ (the game with 16 boxes and 15 squares with numbers to put in crescent order). The point is not simply putting together, with a patience of a Job, a series of elements that fit, following a predefined schema. The goal is not to rebuild a picture where the elements have to occupy a predetermined position, as when composing a puzzle.

In the institutions there is always who believes to be the only true referral for the patient, the only one who have understood him, the one who works better than others. Psychiatrists, practitioners, psychologists, social workers, volunteers: each believes that he really understood what the patient wants, what he needs, everyone is jealous of his representation of the patient. So being in doubt on who’s reason, being in doubt on what level one should act (Pharmacological? Educational? Psychiatric? Psychological? Social? Familiar? Supportive? Etc. ..) when writing a project in this field it is considered that a good project should contain and combine the largest number of these aspects.
Probably we should replace an attitude at doing with an attitude at listening. Listening the patients, listening of their unconscious, and listening of what support our practice: our ideas, our theories, our prejudices. Probably we should suspend for a while the idea of the efficiency of the institution, its perfect performance at all costs, and be less scared by the error or by the unexpected.
The goal is not the perfect functioning of the machine; the goal is not that the institution deform pieces to complete the puzzle at any cost, forcing people to adapt to predefined roles, modern Procrustean bed (and I am speaking of patients, but also of professionals, who undergo the same imprinting, the same standards, drown in the same vocabulary and in the same commonplaces, never say something genial).

But a frame like a therapeutic community is, should be enough rigid just to allow the emergence of the error, and then working on it. The intervention should not be moralizing and punitive. Professionals should not be considered bad professionals if they are not able to predict and avoid accidents, and users should not be considered irresponsible and untrustable if they do not respect someone else’s prescriptions. The perfect therapeutic community is not the one where nothing happens.
I like the idea of the game of 15 because differently by the puzzle there is always one empty box, and it is exactly this empty box which allow the game. It is the empty box that allows some mobility, that allows that something happen. By contrast, in the puzzle, where there is no empty space, there is fixity, the picture is already given from the beginning there is no game, it simply consists in a long, repetitive, process of comparison.

And who might try to fill that empty space, if not us? Why considering ourselves the only responsible for the cure of someone? Why thinking that without us, one would not have been able to reach the same results? Important for the cure of someone is not our knowledge, the years of our experience, or what we do for others, how much we spend for others. No, this is still in the representation of the other (and bring professionals to think that their knowledge is better then others, their intervention is more useful, etc…). Important is how much we can put the other in the position to recognize and work his questions, important is the the telling pass through his word. And so, probably trying to fill that empty place, and not one of the 15 squares (which can be the other 15 figures of reference he has already), our intervention can be different and make the difference. Occupying that position is probably more difficult, but it is the only opportunity to put the other in the position to make a shift, to move to another position.

The author:

Diego Busiol is an italian psychologist. From 7 years he works as educator or social worker in therapeutic community, while he is attending a postgraduate school of psychotherapy and leads his private practice as psychologist.