“This great evil… where does it come from? How did it steal into the world? What seed, what root did it grow from? Who’s doing this? Who’s killing us? Robbing us of life and light. Mocking us with the sight of what we might’ve known. Does our ruin benefit the earth? Does it help the grass to grow, the sun to shine? Is this darkness in you, too? Have you passed through this night?”
The Thin Red Line (Terrence Malick)
Dear young colleague currently specializing in psychiatry,
Having rounded the cape of my years, my life now spans twice the length of yours. This means that I, as a veteran, can endure almost anything. You cannot. I am currently on the ward, and the night itself bows its head. At this hour, before dawn, the peace is perfect even here. Were it not for the muffled background hum of the air conditioners, I would hear the lapping of waves upon the shore.
Why write to you? Why the need to place these matters that concern us into a bottle and entrust them to the tide of the web? These are things I have distilled and juxtaposed, like pearls on a string, from great men—from Masters whom I, unlike you, was still in time to meet. And thus, I feel the ethical duty to pass these things on to you. Then, of course, you will make of them what use you will. Or what use you can.
Perhaps not now, but one day, these few things will prove useful to you. I do not know if you chose to become a psychiatrist out of an irrepressible vocation, as it was for me in my time, or by chance, having lost the national lottery of residency spots for the schools you preferred.
In any case, you are in now. You have embarked. If you are attending your final year, you are like one of those soldiers crammed into Allied landing craft heading straight for the beaches of Normandy in ’44, or Guadalcanal in ’42-’43. If you haven’t seen it, watch the mystical film “The Thin Red Line” by Terrence Malick. Watch it for the moment when the pounding of the Marines’ hearts, tight together on the barges, drowned out the sound of the engines and the waves with sheer fear.
In any event, you are about to define yourself as a “medical specialist in the cure of mental illnesses.” This is for common sense—the logic of the layperson—and, naturally, for the Law, psychiatry being a “regular” branch of medicine.
What I am writing to you in this message, however, has nothing to do with common sense, nor with the Law. Let us say it has to do with epistemology, with the history of psychiatry, with the very notion of madness. With what it means to be human.
You will find, my young friend, upon your imminent landing on the “Omaha Beach” of the Territory, a world you do not know, a very difficult world indeed. A world where diagnoses are made by rule of thumb, without any rating scales, or often are not made at all; for one is worth as much as the other, and ultimately, in the psychotic night, all cows are black. A world where drugs are used as fire extinguishers, where therapies sooner or later all become the same, and one uses the drugs that are available, not those one would wish to use; where psychotherapy is an ideology of the past, and rehabilitation a chimera; where colleagues are tired, elderly, unmotivated, and understaffed; where nurses will tell you what is right for you to do, and what is not; where, often, you will have the impression that everyone and everything is against you.
A world where those who taught you during these years generally never set foot (you will see them again at conferences, always perfect, smiling, without dark circles under their eyes, self-satisfied and surrounded by young residents who will take your place).1
In the current situation, the impact produced by this biological-reductionist homogenization and by th2e monotony of bureaucratic-managerial language upon the ideals and practices of the most cultivated and literate part of society concerns you very closely. For psychiatry is the direct expression (unlike cardiology, nephrology, orthopedics, or other medical-surgical branches) of the society in which it is inscribed. The grammar of mediocrity holds the chair everywhere today, marching in step with the sterile, uniform emptiness of the technical jargon of Western media and markets. Uniformity, monotony, and emptiness—reductive and sterile qualities—characterize the current way of teaching (and, alas, sometimes practicing) psychiatry, triumphing over complexity, subtlety, refinement, and variety of content.
It is sad to see, more than two hundred years later—that is, since 1793, when Pinel, breaking the chains of the mad at the Salpêtrière, aggregated psychiatry to medicine—the humiliating, dishonorable, and wretched condition into which that very psychiatry has fallen, is about to fall, or is destined to fall. It is an abyss that opens before you: one of uniformity, standardization, and flattening. All lies. Everything you see, everything you hear. Lies so big they make you want to vomit.
Soon you will find yourself in a cage with invisible, elastic bars. They call it the “Terricomio” (Territorial Asylum). They will soon want you burnt-out… or part of their lie. I would like, instead, for you to be ready to wage a war to the last drop of blood, to save the richness of difference and suffering which characterizes, beyond psychiatry, everything that is important in human culture. Because, even though you are young, there is little time to do so.
I was “enlisted” by my Captain when I was your age, with the appellation of “fresh recruit for a long battle.” I would have followed him anywhere. It was for him that I returned from Germany, where today I would be Chefarzt at the Klinik für Psychiatrie und Psychotherapie Charité in Berlin. “Fresh recruit for a long battle”—that is how I would like to address you today. Unfortunately, my dear friend, some battles undertaken in this direction, even by men of great worth, have been lost. It is not only that the force of linguistic and cultural vulgarity, equipped with the latest media technology and sponsored by immense resources maneuvered by consumerist markets, has become overwhelming; it is also that the elite—that elite which once took a stand against this cultural mediocrity—has now been erased, and upon what were once its banners, the capacity for medical foundation has been abandoned by official or mainstream psychiatry, entirely preoccupied only with receiving legitimation from medicine.
In the chair of psychiatry, throughout the entire second half of the twentieth century, not a single psychopathologist has ever set foot, and professors are too busy chasing the “publish or perish” logic on high-impact, fashionable journals subservient to the consensus to be able to dedicate themselves to psychopathology.
Psychopathology, besides being a medium between you and the patient, besides providing you with that structured language based on the patient’s lived experiences which opens the path to the interview, would also be a medium between you and the society that surrounds you. In the sense that psychopathology constitutes a paradigm sensitive to the cultural climate that society breathes. Without psychopathology, you, the future psychiatrist, are detached from culture and flattened solely onto a biological register.
Concretely, this means that you will have less and less say in the “management” of the patient, in his relationships with the environment, in his life history. Your task will increasingly be only that of an (illusory) receptor balancer. In reality, a tailor of “camisoles de force chimique” (chemical straitjackets) for situations to be kept under control when they explode. You will be the firefighter of madness. You will have to stabilize with drugs, without knowing much more. Settling for what they tell you or what you manage to grasp of the patient’s life to be able to prescribe a therapy. You are, at bottom, even if they don’t teach you much, a professional expensive to train; therefore, you must earn your salary in the Services or Private Clinics by seeing a great many patients, for very little time, no more than once a month, without dwelling on them too much. A prescriber. Not a clinician.
The rest of the patient’s life will be the prerogative of others. The patient and his relationships, as soon as you have more or less re-equilibrated him, will be handled by others. And this will be the end. The end of psychiatry and the mortification of you as a psychiatrist.
But, after all, even if you were to have a say, what would you speak of concerning that patient with the various rehabilitators, psychotherapists, or social workers? Would you speak of his receptors? Of his genes? Of his alleles? Of epidemiology? Of meta-analyses? Who do you think cares about these things, other than the editors of the journals where your professors publish? Obviously, these elements all represent probabilities of research, the subject matter of a psychiatry that seeks to accredit itself as a hard science, but they do not help you in the slightest to understand who that person before you is, and why he is there.
If you possess the compass of Psychopathology, however, you will know where you are and where the patient is. You will be able to speak of Wahnstimmung (Delusional Mood), of Trema, of Apophany, of the transformation of the structure of Dasein (Existence), of temporality and spatiality, of the trajectory of a life, of the profound modification of intersubjectivity. And you will see that they will listen to you. And how they will listen to you! Because these are things that have a grip on reality, on the flesh and blood of the person suffering. While the hypersensitivity of the post-synaptic receptor is a hypothesis that flies over the heads of us all.
No one will be able to take away from you the charm of having understood something profound about that man or that woman, and no one will be able to replace you, because you alone will know “what it is about.”
Do not think that this is philosophy. It is technique. It is the tool of the trade. If you must be a specialist, be a specialist in this, in the weirdness of the human, in its derailments, in its abysses.
Do not let yourself be reduced to a mere dispenser of pills. Defend your dignity. Study. Read Jaspers, Minkowski, Binswanger, Callieri, Borgna, Ballerini, Tatossian. Do not be content with the summaries of the guidelines. Seek a Master, if you can still find one hidden in some dusty office or some remote provincial ward. And seek your own personal analysis, interrogate yourself about your own shadows, for only if you know your own darkness will you be able to tolerate that of others.
The Territorial Asylum (Terricomio) will try to swallow you. It will try to make you a bureaucrat of hygiene, a filler of forms, a legal-medical defensive shield. Resist. Resist with the beauty of the clinical encounter. Resist with the dignity of the person who welcomes another person.
Remember that every time you look a patient in the eyes and try to understand his Erlebnis (lived experience), you are keeping psychiatry alive. Every time you reduce him to a symptom to be suppressed, you are killing it, and you are killing a part of yourself.
My dear young friend, I am telling you these things sine ira et studio (without anger and without bias). I gave up long ago on taking exams for higher-level positions because I would have stopped seeing patients. I did not become a doctor to concern myself with personnel management and budgets.
A man, in certain circumstances, to save himself, can do only one thing: find a situation that is his own, create an island around himself. I remained in the places where they sent me, without ever being relieved. If there is such a gap of years between us, it is because they hired no one after me.
If I never meet you in this life, at least let me feel your absence. If we had worked together, one glance from your eyes and my life would have been at your disposal.
I will leave the Public Service without rank and without awards, without regrets, with one hand in front and one behind, poor and naked as I entered, but happy to have been forgotten in a corner of the “Terricomio,” together with the patients with whom I tried, as best I could, simply as a clinical psychiatrist, as the last of the Mohicans, to share a destiny. What difference can one lone man make, in all this madness? My battle is lost; I am left only with the honor of having fought it day after day, and of having known men who put me on the trail of a clinical practice close to the absolute fascination that every existence, even the most torn, transmits.
Make what you can of this nautical chart, my friend. If you manage to make it your own, pass it on enriched with details.
And never stop asking yourself a crucial question, which has haunted me for all these years: “If a person you care about deeply, truly deeply, were to become ‘mentally ill’, what kind of psychiatrist would you want them to meet?”
I know there is no answer. Try to become, if you can, that psychiatrist yourself. The way to get there passes through suffering (including personal suffering), through humanity, and through culture.
Gilberto Di Petta, sempre unico e bravo. Ogni volta che il dott. Di Petta presenta l’abisso oscuro in cui si è trasformata la psichiatria attuale, nasce una nuova stella all’orizzonte di tutti noi, giovani e meno giovani.