In this talk I will discuss constructing the goals of the psychotherapy intervention, starting from my experience as a trainee in the second year of a specialization in psychoanalytical psychotherapy. I have been doing practical training for the last few months in an operative psychotherapy unit which is part of a clinical psychiatry department in a university polyclinic.

This operative unit was created in 1991 with the aim of starting a service that could offer clients the most suitable form of therapy for each pathology, in the hypothesis that for every diagnosis it would be possible to identify the intervention that research in the psychotherapy field showed to be the most successful for each single case. Due to the difficulty of putting this into practice, the initial idea was gradually abandoned (for instance it would have required staff trained in a great range of models of psychotherapy intervention), but the operative psychotherapy unit continued to exist in the Mental Health Center (CSM), ending up providing the service of mainly treating so-called “common mental disorders”.

The shift of the service from an approach focusing on the diagnosis and therefore on the illness to be treated with specific techniques, to one designed to accept the so-called “common mental disorders”, was certainly a great cultural leap. Moreover, a part of the original inspiration is still found in the new service provided, in particular, the lack of a time limit on the relationship between the operative unit and its clients: this is in fact due to the need to adjust the time and way of intervening according to the specific rules of the technique of the different psychotherapy approaches.

This service is at present the only one in the area that has the explicit mission of providing its clients with psychotherapy interventions and this function is also reflected in the relation between the facility and its trainees, who are required to be available for a long enough period – at least a year – considered necessary to achieve the aims of psychotherapy.

Access to this service is by referral from the GP, from hospital divisions or from the mental health center, of which it is part, and also by direct contact with clients. In the Wednesday morning meeting the cases are allocated to the different members of the team, all psychiatrists and psychologists, making up the service: from those in charge to the trainees, everyone has a specific psychotherapy training. In choosing the assignments, the “sick” clients, in whose demand there are obvious diagnosticable clinical elements, are assigned to the team’s two psychiatrists, or sent to the CSM.
 
When the patient-load is about to “saturate” the availability of the service, there re-emerges the idea – never put into effect but never totally ruled out – of placing time limits on the treatment of cases: the problem with introducing such a limit seems to be connected to the difficulty of justifying it in view of the therapeutic aims.

On the very question of the issue of time and therefore of resources in psychotherapy in the health services, I would like to present a recent case that I dealt with here: the result achieved in only five sessions with the patient can be interpreted through a psychotherapy approach of not seeking to correct a deficit in the patient, but to promote her growth by working on understanding the symbolic emotional aspects that had motivated her demand to the service and that organised her relational dynamics in the family context.

The case I am presenting concerns a girl of 18, who came to the service on the insistence of her mother and her cousin. During the first conversation, the patient describes her problem as the difficulty to forgive her father for divorcing her mother two years earlier. She specifically complains of the fact that instead of decreasing over time, her anger continues to increase so much that she still has not gone near her father despite his continual invitations. At home the girl speaks very little, she is often sad, and has great difficulty at school, in fact she failed the previous year due to her many absences.

At first, when I suggest exploring her expectations about the service and psychotherapy, the patient says she expects to find a space where she can finally start to talk about her problems, something that proves to be unusually hard because she is used to getting by on her own. Talking seems to increase the pain and anger about the situation, seen as having no way out. The patient offers her story by recounting the events that made her the victim of her father’s decisions, events that as such are not questioned, that cannot “be talked about”. Following her interpretation, adopting the perspective that she presents, makes me feel pushed into a corner with no way out: facts are facts, they cannot be changed but only accepted. At the same time I feel that from this corner the patient seems to suggest a way out when, with her demand for psychotherapy, she gives herself the opportunity to find a space with me where she can finally start thinking about her feelings.

“Betrayal” is a term that she often uses to describe her state of mind towards a father she is unable to forgive because she fears that trusting him again will mean the risk of another let-down. On many occasions she puts off the chance of meeting him, asking for more time to manage to forgive him, before approaching him. I say that listening to her tale of how she keeps her father dangling, refusing every attempt at reconciliation, reminds me of the famous story of Pope Gregory and Henry IV at Canossa1. The patient immediately shows interest in the possibility of thinking about the position she has in the relationship and feels that this helps her to understand her feelings better. She smiles when thinking of the story of Canossa, in which she no longer finds a place for the image of the poor victim that she had previously assigned to herself.

In the following sessions she already seems more relieved. The work done with her seems to have created the possibility of reconsidering some of her fixed positions in the relationship with her father. Rethinking the “facts” in terms of fantasies and emotions, as a way of symbolising the relations, has enabled the patient to talk about her problems, pulling apart the premises that seemed to make them un-negotiable.

Various times the patient expresses the desire to go back to her old home as the only chance to solve the problem of her anger. I suggest that the question seems to indicate the desire to take up a previous relationship more than a real solution that can dissolve all distress.

Starting to think about the symbolic dimensions of betrayal, as an experience related to fantasies constructed around the relationship with her father, has enabled the patient to recognise her own feelings. The person betrayed in his heart yearns for a situation, often idealised, existing before the betrayal itself, just as the patient’s yearning expressed her desire for a return to the situation prior to her parents’ separation, the period of her life marked by the fantasy of a single, exclusive relationship with her father. What was betrayed was therefore not the relationship she actually had with her father, described by her as being absent and uninterested in family relationships, but her desire, her fantasy about that relationship, a fantasy that the separation had made untenable.

After this proposed reading of the dynamics acted out in the relations, the patient understands the surprise shown by all her family at her inexplicable excesses of anger, especially because her sister, emotionally organised in very different ways, had not reacted like her to the separation and had immediately started to see their father. 

Later, in the fifth session, the patient reports that she and her sister have been to dinner with her father: she is still angry with him about his mistakes, but she says she is willing to forgive him, because, she comments, “after all, we can all make mistakes”. The possibility of forgiveness exists only now that the patient has recognised that there was no pact betrayed by her father and that in fact she can get involved in building an entire relationship with him. At home things are going better, she talks to her mother more, she already has other meetings with her father planned and she is trying hard not to fail in the current school year, something she now finds very important.  

What does this case tell us on the question of the use of psychotherapy in the health services? In the area of the so-called “common emotional disorders”, constructing the goal of the psychotherapy cannot be done using a procedure like diagnosis and treatment of a disorder. In the case of the young patient reported here, the demand for treatment in the space of couple of sessions developed into a demand for the possibility of thinking about one’s feelings. I took this possibility as being part of the development and therefore of the organisational provisions of the service which, calling itself psychotherapeutic and being devoted to “common emotional disorders”, has moved away from the treatment of pathologies, to turn its attention to the problems experienced by people in their contexts, often the reason they ask the mental health services for help.

What was the goal agreed on therefore in the case of this patient? Not the ”corrective” goal of bringing her closer to her father or of calming her anger, but instead that of experiencing in the therapeutic relationship the possibility of getting back in touch with her fantasies about the relationship with her father, those that made him unapproachable for her. As a trainee, by recuperating the history of the service and its meaning in the overall working of the department, I felt I was interpreting the innovative aspect that the service is trying to develop, moving towards a variability that does not lie in the techniques of psychotherapy, as it did at the time of its inception, but in the demand of its “common” rather than pathological clients.

The interest in promoting development by working on the awareness of the symbolic emotional dimensions that motivate the patient’s demand to the mental health services, may therefore, as in this case, offer a chance for the psychotherapy services to rethink their possible goals in the perspective of limited resources, a condition which has now become necessary for the very survival of psychotherapy in the provisions of the National Health Service.

Notes

1. Canossa is the name of a village in Italy,. Its castle is famous because the Holy Roman emperor Henry IV sought pardon before Pope Gregory VII in 1077. For three days (25-27 January) he stood constantly before the castle gate, in the dress of a penitent, beseeching with many tears the pope's forgiveness. Since then the place represents a place of humiliation or penance. Mostly used in the form "go to Canossa": to humble or humiliate oneself, to eat humble pie. Top