ALTERNATIVE APPROACHES TO THE TREATMENT OF ANTISOCIAL BEHAVIOUR
Gemma Brandi, M.D., Psychiatrist Psychoanalist
Department of Mental Health of Florence, Chief of ‘Justice and Psychiatry Interdisciplinary Group'
Psychiatric Consulent of Italian Ministery of Justice
Director ofa magazine ‘Il reo e il folle' (The Wicked and the Mad)
Mario Iannucci, M.D., Psychiatrist Psychoanalist
Department of Mental Health of Florence, Member of ‘Justice and Psychiatry Interdisciplinary Group'
Psychiatric Consulent of Italian Ministery of Justice
President of S.I.P.Pen. (Italia Society of Penitentiary Psychiatry)
This work presents clinical points of view which are "transgressive" with regard to the therapy of patients who manifest their disturbance through antisocial behaviour. Indications towards treatment of such patients can come from that clinical work which is ever more frequently being conducted from within closed institutions.
Starting with their own intra moenia therapeutic experiences and rejecting prejudice, the authors outline a therapeutic strategy in which many elements converge. These elements include error and the capacity to "seize the moment", art and myth, supervision and transference, trauma and "countertrauma", "stonewalling" and mutuality.
The present work is subdivided into two sections: The Falsely Strong and The New Wicked: The Rebel Angels of the Year 2000; and The Better the Grasp, the Greater the Yield written respectively by Gemma Brandi, who co-ordinated the overall drafting of the chapter, and Mario Jannucci (Note 1).
Gemma Brandi identifies three clinical figures: the victim, the compulsive sufferer or "escentra" (Note 2), and the cynic. All three of these figures are linked by the fact that each one has adopted an inappropriate sense of guilt and by their antisocial inclinations. Brandi discusses these figures as forms of transgressive illness and traces a relationship between these life disorders and other realms of suffering such as drug addiction, bulimia and anorexia, conditions to which greater psychiatric attention has always been granted. She tries to show how the cure for such patients passes through a countertraumatic strategy that calls for: a fusion of theoretical and clinical work, a therapist who is able to "seize the moment", a therapeutic relationship, a point of view in which the subject is not passive, a recognition of the weakness of the falsely strong (an indispensable premise for the utilization of the disability), and a homeopathic supervision of the clinical activity.
Mario Jannucci shows how, with patients who manifest antisocial behaviour, it is absolutely necessary to have a good therapeutic hold. This hold proves to be very difficult in that these patients show a constant tendency of avoiding therapy, of rebelling against the rules of therapy just as against the rules of society, and of being prisoners of the so-called negative therapeutic reaction. In order to carry out an efficient hold on these patients, one needs a therapist who is prepared and patient, a therapist who has been and is still able to recognize his own errors and to learn from them, one who does not underestimate the value of poena. A patient therapist is able to recognize and to tolerate the errors of others without judging and condemning them, without being an "incurable tyrant".
THE FALSELY STRONG AND THE NEW WICKED: THE REBEL ANGELS OF THE YEAR 2000. Suggestions for Treatment from Clinical Work
Patients affected by the disorder which I have defined as transgressive illness (Note 3) are people who, because of their tendency to express their disease through symptomatic behaviour, require forms of containment which are not always possible within a given jurisdiction. These patients therefore call for therapists who are able to adopt flexible tools; tools which fit the needs of the individual, which are neither schematic nor routine.
The conditions necessary for the progress of the therapy include the letting go of foreseeable prejudice and of rigid positions, renouncing any occasional indescribable heterodoxy, utilizing courageous creativity and having an inclination towards theory.Cogliere l'occasione (seizing the moment) is the essence of the treatment for these subjects. The Greeks refer to this as "eucairìa" (Note 4) which stands for the opportunity, the fortuitous circumstance that is brief in duration and which permits one to achieve the purpose with limited struggle. One must proceed by way of trauma -a word that is misused to the point that we may question its significance without running the risk of appearing completely ignorant. Trauma is the unfortunate combination-surprising, unpleasant, sudden and silent- that creates discontinuity in the existential fabric and breaks the narrative character of one's life. Life starts over from the point of trauma which determines a turning point and creates the need to continually repeat the trauma, while the subject pursues the tense and tormenting search for his missing theory. The possibility of treatment starts from the recovered tale of this unfortunate combination. By bringing the trauma to light, the original thought is restored and the painful tension can become creative, transforming the transgressive illness into transgressive creativity, thus breaking the compulsion to repeat the trauma. To arrive at this point, one needs a countertraumatic occasion, consisting in a situation that echoes the trauma but then overturns the emotions at play. As well as the trauma, the countertraumatic occasionmust be surprising and sudden, yet it also must be reassuring to the point of allowing the patient to recognize the trauma and to talk about it, to assume the responsibility of an apparently irreparable choice, to correctly attribute the inappropriately carried guilt and to adopt preventative strategies which are indispensable for traumatized people.
There has been much talk of guilt in relation to the psychodynamics of depression and of trauma in relation to personality disorders. I would like to emphasize the importance of the hendiadys guilt and trauma -in the sense of traumatic guilt- in the clinical and theoretical work in the field which I am dealing with: that of the falsely strong and the new wicked.
The frequency of the negative therapeutic reaction in these subjects and the possibility of tracking in them the ‘borrowed' unconscious sense of guilt (Note 5) which Freud spoke of, sustain the connection between the theme of moral consciousnessand our topic. We can deduce this connection also from the fact that the rebel angels of the year 2000 take drugs, suffer from AIDS, live a rejected existence, commit gratuitous acts (Note 6). They show, in fact, an altogether clear and tenaciousinclination towards self-punishment that has an undeniable relationship with guilt. Although they induce suffering in others, they are also authentic self-punishers, "eautòntimoreùmenoi" (Note 7) as the Greeks would say.
In justifying traumatic determinism, there is the fact that these lives are frequently marked by dramatic abandonment, insistent abuse, offensive indifference, incoherent punishments: they are traumatic lives, specifically labelled as such. Furthermore, it appears quite significant how frequently we find that these patients, during imprisonment, maintain that they find themselves able to talk, for the first time, about experiences that have never before been mentioned, in very intense transference situations and in settings that are decisively unconventional. A countertraumatic occasion is thus achieved since the helpful meeting is held unexpectedly in an environment that is, by definition, traumatic, thereby taking the subject by surprise; a surprise that, this time around, is a pleasant one. In this sense Aichorn had opportunely emphasized the value of positive transference from the student to the educator which happens, for example, in the penal establishments (Note 8).
My work as a psychoanalyst psychiatrist in the penal establishments has allowed me to identify three clinical figures whose structuring is brought about by the combination of trauma and inappropriate sense of guilt:
the compulsive sufferer or ‘escentra'
In characterizing these figures we find aggressive drives which emerge without the epiphenomenon of delusions. Even though these drives manifest themselves in a "mute" way, using Lacan's expression (Note 9), they reveal a specific anomaly correlated to "an evolutionary arrest of the personality at the genetic stage of the super-ego" (Note 10). The childhood history shows "the pathogenic specificity of the trauma" (Note 11), which leads to a formation of the moral consciousness in antithesisto the figures which are invested with the regulating function. It leads, in fact, to the development of a paradoxical super-ego, and to the formation of an inappropriate sense of guilt. And since the moral principle comes after the principle of reality, these patients of course show difficulty in adjusting to a correct examination of reality (reality testing).
As the following sequence shows, a guiding thread runs through the psychoanalytic and psychiatric literature and intersects this prospective. It is a passage that shows that the theoretical indifference to the topic of transgression is like the ashes which lay atop burning coals.
From Janet at DSM IV, by way of Kretschmer, Freud, Abraham, Lacan.
Janet's Psychoasthenic Character
Kretschmer's Sensitive character
Freud's Criminals from a sense of guilt (Note 12) Freud's Exceptions (Note 13)
Freud's Those wrecked by success (Note 14)
Abraham's Impostor (Note 15)
Lacan's Paranoia of self-punishment (Note 16) Lacan's Paranoia of revendication
Cluster C + B Cluster B Cluster A + B
(Personality disorders, DSM IV)
Victim Compulsive sufferer Cynic
We find here that there are two structurally opposing categories and a third category of passage between the two. These categories seem to emerge from the unexplored boundaries of the forest where Freud's and Rank's theoretical attempts stopped, and beyond which Ferenczi and Lacan dared to look, without, however, proceeding into the labyrinth where we find the coexistence of heroism and crime, creative transgression and transgressive illness, adolescence and self punishing needs, horror and fable. They are categories that tend to be complementary. This was made clear to me a few months ago by a clever police officer in Florence: "The cynic", he observed, "is often coupled with the victim…". He then went on to illustrate this perspective with appropriate examples taken from his experience. Movies give us the same idea (I could cite many films that are extremely significant in this regard) and I sense the same message in the news reports of the bloody acts of recent years.
I shall try to illustrate my point of view by utilizing a few clinical cases.
Carmen is a young woman who suffers from AIDS and who also suffers from dependent personality disorder (DPD) with traits of avoidance personality disorder (APD) and antisocial personality disorder (APD). She was assigned to me upon her arrival in prison, when her physical condition was so run down that she had to be admitted to the hospital. I saw her again after a couple months, when her physical state had returned to a level that allowed her to return to prison. I shall report those parts of her story that serve to introduce the theme of the victim, of the oppressed personality.
The victim maintains the secret of the mortification that lies at the origin of his tendency to self procure pain, even though he is conscious of this mortification. The victim is completely dominated. He allows himself to be manipulated. The victim minimizes this situation. He has a grotesque calling to be the martyr. The therapist must be able to help the victim in laying aside the mask. To do so, the therapist must reveal to the victim the concealed tragic element that creeps through the clownlike surface. The victim suffers from an inappropriate sense of guilt, a sense of guilt that is borrowed, and that must be reallocated, returned to its owner. This psychic pattern develops when the perpetrator of abuse is a person affectively significant to the child and one who represents an authoritative figure in the child's eyes. Through the words spoken by this person, the sensation of being guilty is instilled in the child who suffers the trauma. The moral conscience then will lead the future victim to search for an impossible punishment for a guilt that is inextinguishable, as it is one that does not belong to the victim in the first place.
Carmen came into the room slowly, showing her pain. She said that she had asked to talk to me because she felt a bit restless. I curtly said to her that I knew the seriousness of her situation and that many other people were worried about it. However, I also emphasized how much better she looked than the last time I had seen her. Then I asked her, out of the blue: "Who was it that hurt you so badly? What happened that was so terrible in your life?". She cried and began to talk of the violence she had suffered in her family and how impossible it had been, until that moment, to talk about it with anyone.
The progress she made in treatment from the moment she was able to give to each his own was extraordinary. Today her autonomy from a cynical husband and from an apparently hyperprotective family is a reality. Her physical condition is satisfactory and she has a good relationship with the community that hosts her.
Katia is a young woman who found out while in prison that she was HIV-positive. She suffers from borderline personality disorder (BPD), with traits of narcissistic personality disorder (NPD) and antisocial personality disorder (APD). I saw her during her repeated re-entries to prison. The most important therapeutic gains went back to the time when she learned of her asymptomatic HIV-positive state. I shall tell the parts of her story which serve to introduce the figure of the compulsive suffereror "escentra", intending by this last term one who is constantly in and out of prison.
The compulsive sufferer puts into play the pretence of regret and shows a sceptical pessimism. He does no more than recall the wonders of a golden age lost "by pure chance". He lists the large number of success stories that went to pieces "in spite of himself". And he presents himself as entertaining chivalrous intentions. It is clear how his need for expiation keeps him from enjoying any kind of success and that his psychic blindness leads him to project the responsibility of the suffering which he alone is self-inflicting. He needs help in understanding that role which a paradoxical internal frustration has in maintaining anexternal frustration. In this clinical figure, what blocks the satisfaction of desire is the force of a moral conscience formed in antithesis to the indifferent neglect of the authority figure, facing what the child felt was his own illicit behaviour. A self-punishing super-ego replaces the permissive and distracted parents and since the action that originally structured this pattern was without consequences, the subject will never cease his search for an impossible punishment.
Katie entered the room angry and defiant, manifesting her worries in her diagnosed physical state. Alluding to her drug addict behaviour, she said of herself: "I hurt myself so that I won't bring harm to others...". My response was: "I'm sorry, but I don't buy that! Who could believe in the fact that someone who doesn't love himself would be able to spare anyone else? It would be incredibly presumptuous on my part to rely on the possibility of being spared by someone who is not even able to spare himself!". This observation broke her pessimistic scepticism, shattered her altruistic sham and helped promote not only an interest in herself but also a reflective and coherent attitude that allowed her to cure herself, also in a physical sense, and to accept the comfort that she had before "inexplicably" renounced.
Atena is a very young woman who is HIV positive and suffers from antisocial personality disorder (APD), with traits of paranoid personality disorder (PPD) and histrionic personality disorder (HPD). I saw her during her first period in prison. From the time she arrived in prison, she showed serious problems in conduct, manifesting aggressive behaviour and a striking intelligence which served a worrisome inclination towards destruction. I shall tell as much of her story as serves to present the figure of thecynic.
The cynic (literally, he who lives as a dog) is, at times, a tragic actor, and other times, a hieratic presence. Whether he unconsciously dramatizes the horror of his own premature disability or he raises himself to a priestly level of privilege which he shamelessly claims, he impudently denies his responsibility and projects, without reserve, the guilt of any reprehensible actions. He is characterized by a missing sense of guilt, a hostile envy and an arrogant pride. Just as with the "exceptions" that Freud talks of, the cynic seems to feel he has the right to be spared from further demands in that he feels he has already suffered them. He needs help in reconstructing his missing moral conscience. In building the cynic's structure, we usually find the following passage: an authority figure, showing himself to be inopportune and cruel, punishes a child for something he is not guilty of and a paradoxical super-ego is therefore formed in the child, permissive in terms of himself and ruthless in regard to others. It is my opinion that a similar psychic pattern is traceable in many serial killers.
With Atena I used the only instrument that pays off in these cases: with disconcerting irony I avoided her attempts of catastrophic involvement and, through grotesque exasperation of deformed material that she brought me, I allowed theridiculous, which was nestled behind the tragic, to come through. That is, I moved in a direction which is diametrically opposite in respect to the one I followed with the victim, thereby finally provoking in her a liberating and self ironic laugh (I don't believe that serial killers know how to laugh); a laugh that was the first step in the task of restoring a self critical conscience. I also unmasked how gratuitous were the aggressions which many innocent people had paid dearly for; I thereby acted upon her ethical sense, which was concealed behind a declared hyper-moralism and an amoral appearance.
What do these clinical observations suggest?
A state of confusion which happened in the genetic stage of the moral conscience lays the basis for the development, by way of trauma, of an improper sense of guilt, which is disorienting from an ethical profile.
Expiation and the countertraumatic cure (Note 18) represent the couple that guarantees the individual's right to therapy and to reparation as well as the responsibilities of the entire society. This is the reason why, applying surveillance and authentic treatment in prison, we should admit for these patients, in place of an illusory protective health situation, the potentially therapeutic value of a penitentiary sanction, made up of expiation and of countertraumatic opportunities.
On the other hand, it is because the subject punishes, avenges and cures himself through an aggressive lifestyle played out first against himself and, only secondly, against others, that we need to treat respectfully and mindfully the options of life of these patients; options which are unpopular and yet allow them an existence. To be a therapist means to be authentically available for the patient, especially in those moments where his faith in his disastrous existential style wavers (which does not happen rarely in the course of one's life) in such a way as to offer a hint, a trace, a sign of fraternal interest, the hope of change.We can really talk of a countertraumatic therapeutic relationship when a traumatic experience, as a penalty is by definition, is administered as a therapy instead of as a punishment, to truly help the subject who, in his early bonds of trust, experienced the trauma in a place of expected support.
With regard to the therapeutic relationship, some time ago, while I was talking with a surgeon and a biological research scientist, I observed how the loss of a joint vision can be attributed to the decomposition of medical knowledge; the joint vision that the doctor-patient relationship permits and to which the good luck of the medical world owes a great deal. Later on, I happened onto a book by Dumezil (Note 19), where medicine is presented as a third term in a trifunctional structure which is capable of self-reproduction. The first of the other two branches has to do with sacredness and sovereignty, and the second with strength and violence. The third term, medicine, reproducing within itself this functional three-party structure, subdivides in three procedures. The first procedure is based on the magical-religious treatment, the second on violence, and the third on the virtues of plants. I then read the beautiful and touching letter that a young man suffering from Hodgkin's disease sent to a newspaper. He demanded, also for the treatment of cancer patients, the psychological attention which has therapeutic results. He placed this attention on the hand of love and taking care. The young patient is right, he who is aware of the value of self-help, if one thinks of the fact that he took a nurse's course in the centre for tumour therapy where he himself had been treated. He is right to ask that the incision which cuts away his cluster of infected glands, the unguents, the potions and all other physical therapies that transmit their enlivening virtues to his sick body be supported by tools which are able to mobilize submerged yet potent energies, energies necessary for the "reprogramming" of an existence, necessary for the battle which a similar challenge brings.
And next to the therapeutic relationship, in favouring the abandonment of the victimizing and claiming positions of those who tend to project guilt instead of moving on to their own repair, we need a general evolution of the common sense regarding the responsibility of the wicked. We need to see the wicked more as losers than as vanquished, more as promoters of a not impossible cure than as a passive receptacle for miraculous remedies.
The first step in this emancipatory journey consists in renouncing any prejudices one may have in relation to stigma. Defining a person's weakness is essential if someone wants to help him. Trying to be objective about someone's happiness or expecting to know in advance what works for another can rather be seen as offensive. In my opinion, every structural orientation that contains a more or less elevated degree of self-injuring, be it lived by the subject in a projective way, meaning the consequence of bad luck or other people's animosity, or in an introjective way, as a derivative of his own incorrigible defects, can be defined as psychopathological, whether that orientation is expressed through behaviour, ideas, perceptions, affections, or emotions. I am not able to consider necessarily mad the life of street people, while I notice the psychopathological importance of "jail-addicts" who complain each time they return to prison but do not avoid the warpath that continues to lead them back there. Psychic suffering is a function of the distance that separates the subject's sense of self (his person) from the performance he gives of himself (the character he plays). Projecting the cause of suffering does not serve he who is suffering. Nor is the sufferer helped by those who support him in his inclination to project, since what could the poor character, unhappy in this role, do against the "big, bad" society? Instead, he could do a lot by using his tools differently; by learning to recognize those parts of himself that have managed, in this perverse game, to transform his true person into the character he is interpreting. Given that we can look beyond the error that many commit in exchanging the madman for the idiot, we see that the sick person is, in general, "too tender and sensitive, and, consequently, susceptible" (Note 20), not only vulnerable. From this it becomes clear that it is in transforming his own sensitivity to susceptibility, taking refuge in the projective-claiming system which is at the root of the transgressive illness, that the subject deviates from a creative use of tenderness and sensitivity. A creative use in which our subject does not cease to be an amateur (he writes, paints, dresses up, etc.) being able only exceptionally to establish a profession from that. What we can usefully work with is the uncritical susceptibility of the patient and the claiming consolations which sustain his falsehood and his patent aggressiveness.
It is true, furthermore, how the weakest of the weak subjects are those who, not being strong, become defined as such. Our patient proves to be undermined by a latent structural weakness which is badly concealed behind the evident unproductive aggressiveness. We are dealing with a losing weakness, that is to say far from the strength of weak thought which Gianni Vattimo speaks of: the strength of a thought of weakening which relinquishes strong ontologies while it glimpses, beyond the loss, a developmental direction, which, thanks to the depotentialization of rationality, can come closer with "pietas" to the tradition and can hypothesize meetings on terrain that differs from the normative and disciplinary ones (Note 21). Paolo Cendon's attention towards "weaknessology" (Note 22), as long as he is able to not fall into the trap of prejudice, has the strength and the originality to respond, on a different front, to this delivering secularization of thought. On the other hand, it was the weakness of people without masters (gens sans aveu) that induced Bronislaw Geremek's interest in them (Note 23). A philosopher, a jurist, and a historian, therefore, have approached weakness in these past years. This renewed theoretical interest has a practical consequence that only a bigoted populism could oppose in the name of a false democracy which is fated to leave the weak person to his own destiny of rejection. The advantage consists in the emancipatory chance inherent in the fact that someone recognizes his own weakness, a fact which opens to the utilization of a disability, instead of giving in. All of us have a weak point, but if we learn to use it this weak point may become our fortune. All of us have almost a weakness, an inclination towards something, which is able to condition an original line of development. Hiding himself, hiding his own weakness, his own disability, his own inclinations, from himself and from others: this is the way for the subject to lose himself.
On the other hand, wasn't it Costantin Brancusi, an artist therefore, who sustained that "the sage transforms his inner poison into a remedy for himself and into a tool to cure other people"? I found a way, a few years ago, to capture this idea. I was working in psychiatric emergency service when a woman, who for some time had been a patient in the city mental hospital where I had met her before, looked to me, the doctor on call, and manifested a sudden discomfort which had come on while she had been strolling about the streets of Florence. She had one of those names, out-dated for the times, that combine devotion and vague misogyny, to be diminutive to the feminine of common names of saints rather noted. We shall call her Antonietta.
Antonietta had characterized herself in the past for examples of intriguing and hazardous behaviour which gave testimony to an exceptional quickness of wit and to a subtle insight. I liked her from the beginning and, even given her habitual shyness and her documented inclination to take on an opposing attitude, I believed that she showed me if not some cordiality, at least some feeling. I proved it that day. I remember asking her to sit down and to talk, and then I listened to her for a long time. She, almost to repay my kindness, set me aside from her opinion regarding therapy: "To seriously carry out your work, you will need to follow my advice: stick with your patients, live next to them as the nurses do, don't lose contact with the madmen, listen to them, take up their complaints, their worries, their bizarreness. But then, you need to leave the mental hospital and find someone on whom you can pour out everything that you have gathered, so that you can dilute the concentration of discomfort you have taken up, to then be able to return again to the hospital. Only in this way can you be a psychiatrist. This ishomeopathic therapy.". I remember the tone of the speech which I have written here with sufficient accuracy: she had expressed herself in a whisper, even though we were alone in the room. I believe by whispering she intended to emphasize the importance and the secrecy of what she was saying and also to indicate the gratuitous privilege that I, therefore, enjoyed. The sense of her recommendation became ever more clear to me in the years that followed, although in part it is still a mystery.
I knew already at the time how necessary it was to dedicate time to those who suffer, as if every rushed and impatient move were detrimental to the cure. Illness needs time, both to impose itself and to be defeated. I had felt the formative effect of a curious and careful stay in the places of madness, therefore I didn't find it to be depauperating to stay for long periods of time with madmen. Rather, I asked myself if, while I was there, I was really carrying out a therapeutic function; I repeated to myself that I was probably receiving more from the patients than I was able to give to them. Antonietta explained to me how this simple staying next to someone could be therapeutic, if the obtuseness of ignorance hadn't withered the interest: we needed a fusion of theory and clinical work to be able to gain the therapeutic goal. Only later would I understand the value of supervision of one's own activity and the prolific character of an elective professional exchange. The dilution which the patient spoke of consists in this: a third person, outside the therapeutic setting, has to control what the clinical work brings to the surface. It is an extremely fertile condition, which therefore allows a responsible sharing. I believe that an analogous need provoked the birth and the development of the first form of psychoanalytic society, which then degenerated in the actual scholastic organization of the various groups of analysts, together in the name of different leaders. The patient, though, did not mention psychoanalysis, of which she was amply informed, something that I noticed in various circumstances. I believe that she did not talk about it because she had lucidly intuited how psychoanalysis had lost contact with madness. She turned therefore to psychiatry calling it to perform a role certainly not immune from a psychoanalytical training: she knew how to speak with a ‘psychoanalyst psychiatrist'.
The homeopathic therapy which Antonietta spoke about was not a misunderstanding, nor a sign of her disturbance. It was, rather, a bright intuition. Homeopathy: "a therapeutic method that presumes to cure diseases through the artificial development of similar diseases in the body by administrating, without mingling of quality, minute doses of drugs which would induce, in a healthy person, a symptomatic state similar to the one we have to cure" (Note 24). Similia similibus curantur, as the Romans said (Note 25). The Greek term "omoiopàtheia" (Note 26) means, however, "agreement of sentiments and of feelings, homogeneity, equal conditions". Well, I believe that Antonietta intended to show me the importance of affinity between the one who is healing and the one who is being healed. We need to accept this assimilating community and to recognize a non-casual contiguity, if we want to avoid contamination and to become the vehicle for the cure. The risk of this contamination sustains the jokes about psychiatrists, who are "closer than other people, not only in a physical way, to madmen" (Note 27). The same risk also sustains, rather less comically, the burn out of psychiatric operators. We need to not be afraid of the little bells (Note 28) if we want to transform ourselves into medication to be administrated with skill. This operation is nevertheless insufficient, otherwise the nurse's work would be enough, that work which my patient points at as a model of an obtuse and uncultured homogeneity. The psychoanalyst psychiatrist who, for his own reasons, comes to the places of madness, is asked to cure himself by diluting to a minimum the psychic toxins assimilated in large doses through contact with ill people. In this way, the toxins become therapeutic for the psychoanalyst psychiatrist, in that he was not "healthy" before, and they become now, through him, potentially utilizable by the patient. The concept of reciprocity, that which bothered Ferenczi so in the psychoanalytic society, makes sense even in this direction.
I maintain, on the other hand, that we have not given enough attention to the reasons which induce someone to choose to study medicine and, therefore, to specialize in psychiatry. We don't work by chance in the places of cure and of punishment. It would take an undoubtedly qualitative evolution in the health system to further evaluate this issue and to really help the young student to orient himself in his choice. Often, those who decide to go into the healing arts, prematurely have to take on the role of therapist of the social constellation in which he has seen the light. This does not necessarily correspond to a clearly painful familiar situation and, at times, feels the effects of a genealogical compression which, no less than the "neurotic tradition" (Note 29), passes from generation to generation. Not ignoring the authentic primum movens (Note 30) of the choice made, usually very different from the heroic or banal reasons produced by the medical student, would represent for him a tool of rational selection and would make the future therapist responsible in respect to his own needs, a step without which he could never make himself useful to others. Each time I have heard speak of the psychological training of a doctor, I have thought that the search for the reasons of the choice should constitute the premonitory sign. It does not help, anymore than a newly learned notion helps, to know the stages of psychic development. It does not help to use a refined diagnostic network. It is necessary, on the contrary, to understand the importance of the "gnòthi sautòn" (Note 31) -know thyself. It is with his personality, which is weak or strong, outgoing or shy, generous or stingy, that the doctor will heal, given that "the drug most used in general medicine is the doctor himself. It is not only the bottle of medicine or the box of pills that count, but also the way in which the doctor offers them to the patient. Actually it is the whole atmosphere in which the medicine is given and taken that counts, even if no pharmacology yet exists for this important medicine" (Note 32). In fact, when the doctor prescribes himself, we cannot find any indication about the suitable posology of this "medicine", about the side effects of this kind of administration, or about the eventual related intolerance. At the beginning of The Book of Es, analysing the reasons why he embraced the medical profession, Groddeck writes: "Here is the essential quality of the doctor: a tendency to cruelty, repressed to the point that it allows this tendency to become useful, and dominated by anguish to be dangerous. Further exploration would be worthwhile in this well-devised game of contraries which is played between cruelty and anguish, because this game has a great importance in life." (Note 33).
Trying to study in depth the issue of the doctor-patient relationship, I shall come back to Antonietta. Although I never followed her case in a continuous manner, I understand that the fortuitous character of our meetings concealed a community of more or less realized purposes and of perspectives. If we were to look at a doctor's therapeutic successes, the pearls of his working life, it would be interesting to investigate, through the anthropological tool, just what it is that holds these pearls together in a single string. Maybe we shall find a culturological base corresponding to the community I speak of. Personally, I observed a "similarity" between my patients, especially between the most severe cases; a similarity that was diagnostic, but not only.
Is it useful, however, for a psychiatrist to occupy himself with the recognition of the awkward material which runs along this uneasy ridge, aiming at connecting the monomania of the late Esquirol, the gratuitous act of Gide and the "natural born killers" of the overly criticized film by Oliver Stone?
A borderline familiarity links the acting out with other forms of suffering such as anorexia, bulimia and drug addiction, forms to which greater clinical attention is given, forms which express themselves through disorderly behaviour that pivots on the squeaky hinges of humanity at the end of this millennium; these hinges are represented by the arrogance and immediacy of the image, a fairly self-punishing vein, and the supremacy of acting on thought.
We see in the world today a trend in the younger generation, one which is found not only in economically advanced countries (people kill themselves because of boredom in the desperate tent cities of Rwanda!): the boys, and therefore the men, of the year 2000 increasingly tend to manifest their psychic troubles through disturbing behaviour. It is no longer appropriate to label this opinion as an anachronistic alarm, a prophetic speculation, or avant-garde surrealism. Such judgement is, these days, sustained by an overwhelming objectivity.
If anything has happened in these last decades in the evolution of clinical forms, anything highly evident but nonetheless neglected, it is the great increase of illnesses which translate into a symptomatic acting out the structural disorder which is at the base of them. And the symptomatic acting out is always aggressive. It is pre-eminently self-punishing in the case of adolescent suicide and in the anorexic-bulimic forms, beyond the tragedy that it provokes in the family environment. It enters into the balance between cruel self-annihilation and the destruction of others in drug addiction. And it is predominantly harmful to others in the case of gratuitous and unbearably thoughtless disintegration of the life of someone who casually passes, in that unlucky moment, near the killer: I refer to the parricides which are on the rise, to the stones dropped upon moving cars, to the deadly games that teenagers play, and even more.
The transgressive character of madness is taken for granted: the madmen break the rules, don't keep their word, forget the commandments. The aggressive inclination of madness, on the contrary, is not taken for granted. If the eventual mix of aggressiveness and transgression makes the disorder explosive and difficult to treat, the clinical denial of this disorder scientifically ratifies the renewed tendency to expel the dangerous members of society without providing them with treatment. After the initial psychiatric interest in monomaniac disorders (such as anorexia or obsession with thinness, drug addiction, and the mania of victimizing other people) there came a misinterpretation, due to impotence, which favoured the spreading of the disorder without name which here we call transgressive illness. The denial of the psychopathological character of such behaviour caused, at least in Italy, the exclusion of these subjects from the special penitentiary treatment reserved to the mentally-ill offenders. The Italian prisons are overflowing with unrecognized madmen who are unable to take advantage of the simple punishment. Nor is useful the sporadic recognition of this psychopathological character useful by some psychiatrist with good intentions, especially when his clinical work is isolated from the scientific context. We have to consider that it is often the patient himself who tries to avoid the diagnosis and the "therapeutic grip" by resorting to the strategy of symptomatic acting out. It seems that psychiatry, somewhat by impotence, somewhat by laziness, has fallen into the trap laid by madness.
Only by means of shrewd experience can we notice the prominent clinical position of the borderline illnesses which constitute the part of the psychopathology most difficult to treat; the part which is denied, refused by public psychiatry, at least in Italy, and expelled from the society of the just men. The subjects we speak of tend to increase the army of the "men without masters", therefore laying the bases of a "mass-transgression". The first element one can appreciate in these patients is the resistance to therapy. This apparent impenetrability is the same that we find in psychosomatic diseases, and also in tics, stuttering, left-handedness. Psychosomatic diseases, especially under the forms of generalized physical anxiety and of transitory indispositions, are highly diffused in the population we are examining, which is afflicted in significant measure also by the second symptomatic series. There seems to be a close relationship between the resistance to therapy and the necessity to conceal the traumatic genesis of the disorder. This genesis gives room for a disastrous and primitive hatred to flourish, one which is emotionally so intense that it favours, together with guilt, a self-punishing and aggressive orientation. The antisocial patient acts this orientation through transgression, the psychosomatic patient embodies it through self-mortification, the tic-sufferer and the stuttering man openly manifest this orientation at the cost of being ridiculous and, finally, the left-hander makes it by daring a highly precocious opposition.
The inclination to act out is a necessary condition for diagnosing this disorder. Classic psychiatry, on the other hand, clearly indicates the existence of a behavioural pathology and the clinical value of the symptomatic acting out. It refers to the acting out which is caused by the union between aggressiveness and transgression, due to the fundamental dysphoria and to the drastic fall in the capacity of the subject to correctly judge, to censure and to resolve himself. And it all happens in the absence of a true, utilitarian justification, while we can easily recognize the immediate or secondary self-punishing effects, some high aspirations, the magnetic attraction exerted by the image, a paradoxical exhibitionism and the abortive ambition of an identity which is already structuring itself.
These elements explain, albeit not completely, the diffusion of the problem among the very young. There are other two elements that justify the antisocial option in adolescence. First, such a choice protects our patient from the clinical symptoms which are less advantageous under the relational profile, in that they are immediately branded as pathological to the point of inhibiting a sufficient social integration, even a borderline one. Furthermore, on the borders of society, a collective body of marginal subjects develops, which, though it is ridiculed, excluded, and feared just as a gang might be, is a recognized group and is regulated from the inside by a code which is more or less stable. This group is paradoxically "inviting". Our subject needs to quench his thirst for original heterodoxy, for expressive liberty, and for supremacy. He is not able to provide, for this thirst, the same solution achieved by the artist, thanks to particular effects of style, nor the solution of the delinquent, who earns by strength the internal leadership of his own acolytes; and so our subject loses himself in the group, unless he finds a self-punishing tool to gain his individualization. This disastrous effect allows us to not confuse the psychopathological option with the physiological transgressive inclination of the adolescence.
The adolescent, escaping from the whirling vortex of the primary social order -the family order- is also a marginal subject. By now emerged from the childish unconditional adhesion to the family constellation, but not yet set in his original position as regards other people, and therefore excluded from the adult universe, he lives on the border, on the frontier which is always at the risk of becoming a trench. Adolescence takes shape as a human structural model of marginality and of transgression, as an indispensable passage for the subject who is searching for confirmations of his identity, also in a sexual sense, and who is wishing to go beyond the pre-established limits. This phase implicates the unconditional adhesion to the group of friends, adhesion that is necessary for the recovery of a fertile originality. This last purpose is really different from that of self-punishing, although it intersects the pathway of the transgressive illness, whose messages today's experts of the sector continue to listen to absent-mindedly. There was a different attention in the past.
Psychiatry was born of the marriage of medicine and justice, a marriage produced by the need to confront, in a modern way, a social problem which, well beyond every cultural and social relativism, had remained unchanged through time. The social problem I allude to is transgressive illness. At the time, the therapeutic responsibility that inspired the moral treatment was not separate from a theoretical interest in the mind's passions. The pioneers of this science lived together with the madmen, in close community with them, wishful to describe and also to cure the recognized disorders. Gradually the descriptive interest got the better of the therapeutic will, allowing for the excessive descriptive growth that reached its peak in the predominance of the phenomenological school and therefore in the birth of criminal anthropology. Anthropometric measurements and predictions were the bricks of such a construction. This progressive degeneration, which prepared the way for the sociological decadence of the present century, caused the lost of any hope of curing the madness, in that the psychic disease was interpreted as a constitutional given, destined to develop without ever turning back. Since there is no theory without clinical experience and viceversa (with "clinical experience" we mean every therapeutic experience we can undertake with man in his totality and not just the result of observation, however indirect, of the case through the described symptoms), the construction of psychiatric thought became feeble and useless.
The great discovery of psychoanalysis was not, in my mind, that of the unconscious, but rather the affirmation of the necessity for a fusion between clinical experience and theory, starting from the doctor's training, which passes through the therapy of himself. It was evident that proceeding in this manner, psychoanalysis would have generated useful forms of thought and an extraordinary intellectual dynamism.
Unfortunately, the effects of this contribution were not sufficient to determine the rebirth of psychiatry. We can recognize various reasons for this failure: the limits that psychoanalysis set for its interventions, its fear of exposing itself and of failing and then its progressive ineptness, excluding sporadic exceptions, of taking advantage of the mutual pursuance of theory and clinical work. Furthermore, to sanction the separation of theoretical and clinical moments, was the advent of the psychopharmacological era and of diagnostic networks with evermore close meshes. The psychiatrist, thereafter, became only devoted to research new substances for the cure of the organ of the mind and to distinguish the responsiveness of the different pathological forms to different drugs. He seemed to be satisfied by this field of research and intervention. The diffusion of the social justifications for psychiatric disorders was very dangerous in that it caused a "political-psychiatric" involution, which pushed psychiatry towards the general systems, thus reducing its ability to observe and to cure man as a single subject participating in a collectivity.
Too many strong prejudices and evident, even if denied, limits are at the basis of the faith in drugs and of the idea of a social genesis of psychiatric disorders. The impotence of these positions in dealing with the forms of disease that determined the birth of psychiatry, forms that maintain a close relationship with transgression, brought the gradual denial of these types of suffering, which are frequently left to the mercy of those who continue to barrenly describe them without proposing their treatment. I allude to criminologists, to forensic psychiatrists, to legal medical doctors, to sociologists and, lastly, to journalists. The fruit of this disinterest has brought an increment in the psychopathological forms that express themselves, especially but not exclusively, in the new generations, through antisocial, sometimes very serious behaviour, which are also sustained by the tendency of the madness to dissimulate and mask itself.
The anthropologists are less present in this sector than other professional figures and so I did not cite them among the heirs of a curiosity about the transgressive "short stories" and among the managers of a supposed objective knowledge which focuses on the crime more than on the criminal. It is with a cultural anthropology, interested in the subject in his trans-individual dimension, that a psychoanalytical psychiatry can formulate a common thought, better than the one each of them, proceeding separately, could formulate. The psychiatry that I speak of would be aware of the therapies of the emerging clinical forms, would have deep roots in its social context, would aim towards a conceptual vision of man in his totality. Beyond cultural anthropology, this psychiatry can find other interlocutors in the scientists of that evolution, such as Richard Lewontin (Note 34), who demonstrate to be available to evaluate the reciprocal influence between genome and environment and who do not ignore the complexities introduced by the fact that man is a social animal.
While Michel Foucault worked around the concept of the "historical relativity" (Note 35) of the idea of madness, anthropological knowledge emphasizes "the cultural relativity of the psychiatric conceptions" (Note 36). To explore the "cultural psychology" (Note 37) of a certain human group, we need to "evaluate the reciprocal influence between the subject, the society and the culture that one belongs to" (Note 38). It seems to me that we are trying, from many different angles, to give life to an ambivalent, marginal and presumably prolific area of exchange between different trains of thought. This happens with the omen that the discovery of some adjacent areas may produce in each researcher a more acute perception of his own competence, bringing an end to the anti-scientific inclination which keep cultural relativity incompatible with psychological universalism. On the one hand, psychological universalism explains the persistence of problems which are independent from culture, but psychoanalytically understandable. On the other hand we cannot deny the influence of the cultural mind on the way symptoms manifest themselves, are lived by the subject and receive a treatment. Every therapeutic approach, which is therapeutic just owing to "the ethical principles of health and maturity" (Note 39), seizes relative and universal elements.
To conclude, I shall say that trans-disciplinary research represents the true resource for the therapy of transgressive pathology. What is important is to find ourselves on those abandoned and uncultivated lands that, once tilled, will show themselves more fertile than the scoured grounds. I speak of those borderline areas which are between soma and psyche, justice and psychiatry, physiology and pathology, childhood and adulthood. To proceed with cautious determination, giving up the usual disdainful withdrawals, is the intent that would arm this type of extreme research in which one involves other interested professional figures, not so much for an opportunistic necessity, as for the pleasure of awakening a common theoretical need that ties everyone's practice together.
I have the impression, on the other hand, that the lack of therapeutic strategies in this field echoes a sceptical pessimism - of the "too good to be true" (Note 40) type - around the possibility of redeeming the pathological transgressors; a pessimism that represents not only "a materialization of our conscience, of the severe super-ego within us, itself a residue of the punitive agency of our childhood" (Note 41), but also the punitive instance of humanity's infancy which caused the subsequent troubles of mankind.
1) The second section of this work will be published in the next number (16-17/2001) of ‘Il reo e il folle' (The Wicked and the Mad). A third section of the work was going to be written by Murray Cox, who suddenly died in June 1997, leaving a great void in his circle of friends and in the landscape of forensic psychotherapy.
2) Italian neologism (which means "someone who goes out and in") created by a young inmate to define the concept of the "revolving door" inmate.
3) I discovered recently that Sir Thomas Browne, English physician of the seventeenth century, spoke of "transgressive infirmities". Browne T., Pseudoxia Epidemica, Sir Thomas Browne's Works, Edited by Simon Wilkin F.L.S., William Pickering, London 1835, Book I, Chapter X, p. 248.
4) In Greek
5) Freud S., The Ego and the Id, in Standard Ed., The Hogarth Press, London 1963, Vol. 19, p. 50.
6) For the theory of gratuitous act, which associates heroism and crime, I refer to André Gide's novel, Les Caves du Vatican.
7) In Greek .
8) Aichorn A., Verwahrloste Jugend, (Ital. transl. Gioventù traviata, Bompiani, Milano 1950).
9) Lacan J., De la psychose paranoïaque dans ses rapports avec la personnalité (Ital. transl. Della psicosi paranoica nei suoi rapporti con la personalità, Einaudi, Torino 1980, p. 329).
10) Ivi, p. 328.
11) Ivi, p. 311.
12) Freud S., Some Character-Types met with in Psycho-Analytic Work, in Standard Ed., Vol. 14, p. 332.
13) Ivi, p. 311.
14) Ivi, p. 316.
15) Abraham K., Die Geschichte eines Hochstaplers im Lychte psychoanalytischer Erkenntis (Ital. transl. La storia di un impostore alla luce della conoscenza psicoanalitica, in Opere, Boringhieri, Torino, 1975, Vol. I, p. 156).
16) Lacan J., op. cit., p. 328.
18) Brandi G., Il sistema delle pene tra grazia e giustizia. Il reo: dall'innocenza al controtrauma, in Il reo e il folle (The Wicked and the Mad), 1, 1996, p.10-16.
19) Dumézil G., Le roman des jumeaux, Editions Gallimard, 1994, p. 209.
20) Hrabal B., Obsluhoval jsem anglického krále (Ital. transl. Ho servito il re d'Inghilterra, Edizioni e/o, Roma 1991, p. 86).
21) Vattimo G. - Rovatti P.A., Premessa to AA.VV., Il pensiero debole, Feltrinelli, Milano 1983.
22) Cendon P., Quali sono i soggetti deboli? Appunti per un incontro di studi, in Politica del diritto, XXVII year, n° 3 Sept. 1996, p. 485).
23) Geremek B., Gens sans aveu, (Ital. transl. Uomini senza padrone, Einaudi, Torino 1992).
24) Translated from Battaglia S. (Edited by), Grande dizionario della lingua italiana, UTET, Torino 1981.
25) "Something alike is needed to cure something".
27) Finzi S., La sciarpa dimenticata, in Il cefalopodo, n° 1, 1995, p. 316.
28) Lepers and "monatti" had to signal their presence by using little bells, so that other people could avoid the contagion.
29) Balint M., The Doctor, his Patient and the Illness (Ital. transl. Medico, paziente e malattia, Feltrinelli, Milano 1977, p. 345.
30) The main and early cause of something.
32) Balint M., op. cit., p. 7.
33) Groddeck G., Das Buch von Es (Ital. transl. Il libro dell'Es, Bompiani, Milano 1987, p.5).
34) Lewontin R.C., Biology as Ideology. The Doctrine of DNA, Anansi Press Limited, Concord, Ontario, Canada 1991.
35) Kakar S., Shamans, Mystics and Doctors, Kopf, New York 1982 (Ital. transl. Sciamani, mistici e dottori, Pratiche Editrice, Parma 1993, p. 13.
39) Ivi, p. 361.
40) Freud S., An Experience on the Acropolis, in Standard Ed., Vol. 22, p. 242.
41) Ivi, p. 243.
- Abraham K. (1923), Die Geschichte eines Hochstaplers im Lychte psychoanalytischer Erkenntis, Publ. in Imago, Vol. 11, N. 4, 355-70 (1925) (Ital. transl. La storia di un impostore alla luce della conoscenza psicoanalitica, in Opere, Boringhieri, Torino, 1975, Vol. I).
- Balint M. (1957), The Doctor, his Patient and the Illness, Pitman Medical Publishing Co. Ltd., London (Ital. transl. Medico, paziente e malattia, Feltrinelli, Milan 1977).
- Brandi G. (1996), Il sistema delle pene tra grazia e giustizia. Il reo: dall'innocenza al controtrauma, in Il reo e il folle (The Wicked and the Mad), N. 1, 1996, 10-16.
- Browne T. (1646), Pseudoxia Epidemica, Sir Thomas Browne's Works, Edited by Simon Wilkin F.L.S., William Pickering, London 1835.
- Cendon P. (1996), Quali sono i soggetti deboli? Appunti per un incontro di studi, in Politica del diritto, XXVII, N. 3, Sept. 1996, 485-500.
- Dumézil G. (1994), Le roman des jumeaux, Editions Gallimard, Paris 1994.
- Finzi S. (1995), La sciarpa dimenticata, in Il cefalopodo, N. 1, 1995, 315-322.
- Freud S. (1895), Project for a Scientific Psychology, in Standard Edition, The Hogarth Press, London 1963, Vol. 1.
- Freud S. (1900), Interpretation of Dreams, in St. Ed. cit., Vol. 4-5.
- Freud S. (1901), Psychopathology of Everyday Life, in St. Ed. cit., Vol. 6.
- Freud S. (1916), Some Character-Types met with in Psycho-Analytic Work, in St. Ed. cit., Vol. 14.
- Freud S. (1921), Psycho-Analysis and Telepathy, in St. Ed. cit., Vol. 18.
- Freud S. (1922), The Ego and the Id, in St. Ed. cit., Vol. 19.
- Freud S. (1925), Preface to Aichhorn's Wayward Youth, in St. Ed. cit., Vol. 19.
- Freud S. (1932), New Introductory Lectures on Psycho-Analysis, Less. XXX, in St. Ed. cit., Vol. 22.
- Freud S. (1933), Sàndor Ferenczi, in St. Ed. cit., Vol. 22.
- Freud S. (1936), A Disturbance of Memory on the Acropolis, in St. Ed. cit., Vol. 22.
- Freud S. (1937), Analysis Terminable and Interminable, in St. Ed cit., Vol. 23.
- Geremek B. (1992), Uomini senza padrone, Einaudi, Turin 1992.
- Gide A. (1914), Les caves du Vatican, in Oeuvres complètes, N.R.F., Paris 1932-1939.
- Groddeck G. (1923), Das Buch von Es, Internat. Psycoanal. Verlag, Vienna 1923 (Ital. tarnsl. Il libro dell'Es, Bompiani, Milan 1987).
- Hrabal B. (1971), Obsluhoval jsem anglického krále (Ital. transl. Ho servito il re d'Inghilterra, Edizioni e/o, Rome 1991).
- Jannucci M. (1996), Al cuore della cura l'avventura della pena [At the Heart of the Cure Comes the Adventure of the Poena], in Il reo e il folle, N. 1, 1996,
- Kakar S. (1982), Shamans, Mystics and Doctors, Kopf, New York 1982 (Ital. transl. Sciamani, mistici e dottori, Pratiche Editrice, Parma 1993).
- Lacan J. (1932), De la psychose paranoïaque dans ses rapports avec la personnalité, Le François, Paris (Ital. transl. Della psicosi paranoica nei suoi rapporti con la personalità, Einaudi, Turin 1980).
- Lewontin R. C. (1991), Biology as Ideology. The Doctrine of DNA, Anansi Press Limited, Concord, Ontario, Canada 1991.
- Vattimo G., Rovatti P.A. (1983), Premessa, in Il pensiero debole, Vattimo et al. Ed., Feltrinelli, Milan 1983.