Introduction

Our report is based on practical training carried out in two centers in Rome, the first dealing with social rehabilitation, the second with therapy1
The rehabilitation center houses ten patients with a diagnosis of schizophrenia. They are cared for by a multidisciplinary team.
The therapeutic center houses 12 patients and the staff is formed entirely of psychologists. In this center the therapeutic-rehabilitative intervention is based on the concept of therapeutic trust, that is, on the privileged relationship that is established between the patient and the staff-member he is entrusted to.
What is common to the two centers is the fact that they are both residential: the patients live together for a limited time and experience daily life with other patients and with the staff.
The practical training prompted us to ask several questions, for instance, what makes a family or a Mental Health Center send a patient to a Center? And how can a psychiatric diagnosis be integrated with the goal of rehabilitation or of a return to society?
In the practical training we tried to construct some hypotheses on these questions. We will make some comments on a critical event: a patient’s leaving the center without prior arrangement with the staff. This event allows us to deal with some of the aspects of the relation between patients, the family and the center.
We will examine this event through the story of Angela, a resident in the social-rehabilitation center. Our goal is to give the event of “going away” a meaning, by linking it to the patients’ history and to the demand they make of the center.

Let’s talk about Angela

On our arrival at the center early in the morning, we are warned by the staff on duty that Angela has left the center. The staff talks about this event almost as if it were a “running away”. To the team it seems important and urgent to prevent other episodes of this kind. They therefore ask us to personally accompany the patients every time they go to the cafe or go to buy something. We suggest discussing the episode directly with the patients. To do this, we decide to use the patient discussion that we have recently set up.
We agreed with our tutor to set up patient discussion groups in which to link actions and rules in the center, with the patients’ experiences. The aim is to explore the relation between patients and staff, identify the developments (the here and now) and understand how the experience of the center is related to the personal history of the patients (the there and then).
Therefore from the point of view of our position as trainees, we have dealt with the relationships that the patients experience. Later we will see the elements we can identify as being peculiar to the figure of a trainee in the center.
In the group meeting that morning, one patient rebelled against the use of the term “run away”, saying, “Criminals run away, I Angela went home ”. This made it clear that for the patients, Angela’s episode of going away was represented as an attempt to get nearer her family: they did not blame Angela for breaking the rules, but recognised her desire to go home.
The word “run away” makes us think of places of confinement where one is forced to stay, situations where people are kept against their will. In our work it is important to understand that we are talking about experiences: staff and patients seem to act “as if” being in the center were a constraint. However, there is no formal obligation for them to remain in the center.
Let us go on, to try to find points that help us understand how the patient arrives and stays in the center.
Angela tells us she went out to go and visit her aunt who lives in Rome; she is very fond of this aunt and had been wanting to see her for some time. She says that the day before leaving the center, she had been scolded by a staff member for making a coffee, in breach of a shared rule. She says that in the meanwhile she had not been able to talk to the staff member about it.
Angela talks to us about desires that need to be fulfilled. The way she talks about it makes us think of a demanding position, which prevents her from talking either to the staff or to her aunt. Her attitude may make it impossible for the other person to understand what her request is.
Angela’s leaving the center evokes in us the child’s running away from home, from the family seen as an obstacle to independence. Leaving home is the chance to look for another image of herself.
During the group session with the patients, one of them, Silvia, says that “you go out to look for your friends; the problem is, your friends can’t be found”. Silvia is talking about the experience of loneliness and her difficulty in initiating and maintaining relationships. These same emotions seem to organise the life of the center. The initial, confronting experience that we had in our traineeship, was having to keep the patients under surveillance, to prevent them getting into dangerous situations. We feel that these experiences involve us in an asymmetrical relationship, that of an adult in charge of an unpredictable child.
Angela is cosseted by all the patients in the center: she is “little Angela”. She is 37, and right from the start she seems to be the adolescent of the group, spending most of her money on teenage magazines, covering the walls in her room with posters of actors and singers. She often says of herself: “Angela is rubbish” smiling and looking straight at the interlocutor, as if seeking confirmation. When this happens, we feel called upon to give her back a less negative image.
What strikes us, about Angela, is the contrast between her apparent weakness and fragility and her ability to involve us in doing things for her and not with her.

Let us try to link Angela’s story with the image she tends to suggest in the center.
In the admission interview, her mother said that Angela’s problems started when at 16 she found a boyfriend; her mother intervened to break up the relationship. She thought her daughter was not fit to be in a couple. Angela responded violently against her mother who, to defend herself, called the police. Angela was admitted to an SPDC: that was the beginning of her psychiatric career.
A symbiotic relationship seems to be emerging between the two: in an endless game of love and hate, Angela tries to get away from her mother, but cannot do without her. 
Angela’s ambiguous relationship with her mother is shared, in the group discussions, with other patients that talk about their ambivalence towards their family members, symbolised as the cause of their problems and at the same time as “all I have”. They express feelings of boundless love and at the same time, in the stories the patients tell, the family members seem distant, as if they were dead.
In Angela’s case, the mother seems to be asking the center to be an extension of herself, in the sense of exerting a strong influence over Angela. The center is called upon to work out a strategy that can deal with the demand for differentiation between Angela and her mother, valorising the discontinuity between being a parent and being staff.

Conclusions

We have reported on relations, family relationships, and demands for intervention addressed to the local services. The center, as the link in the more complex chain of services for mental health, wants to act on issues connected to the problems of living together.
At the beginning of these comments, we posed some questions: what makes a family or a Center for Mental Health send a patient to a center? What problems are posed by the rehabilitation and return to society of these patients?
The case dealt with can be seen as a critical event.
The critical event can be seen as a symptom of an emotional situation in crisis and as a signal of possible lines of development. Think of the patient’s leaving the center, of her attempt to return home to a family member. There is the sign of a failure of collusion in her stay in the center, but also of a collusive failure in the family. She rejects the center, she is rejected by her family. She is at a half-way point, she is alone with her difficulties in socialising and living together with others. It is in this situation that her decision to stay temporarily in a center may take shape, with her demand addressed to the center and her process of development. Her leaving shows a failure to consciously accept the experience of living in the center, seen as an obligation she does not understand, and at the same time a step towards a family situation experienced emotionally in an ambiguous manner. The critical event calls for order to be established in the emotions associated with the center and with the family. In this sense the critical event is a resource for the goals of rehabilitation and therapy.
Patients often leave the center to go home, with a precise aim, to join up with their family members. The critical event does not seem to us to be the act of leaving the center, but the return to it.  We might say that going home is as if the patients were anticipating the day when they will return to society, the goal they are working towards in the center. The families seem to feel threatened by this attempt They have experienced the difficulty of living with their family member, and so see the center as a protective context.
In this perspective, the important function of the service can be understood: to create limits in ambivalent symbiotic relationships between patients and their families and at the same time to construct a social network around the patients, offering relationships that are less entangling.
We would like to add one last comment about the peculiarities of the role of trainee that we experienced.
In this position we thought of the center as a clinical case.
It seems to reproduce within itself issues linked to living together.
Also as far as its internal operations are concerned, there is the re-emergence of the problem of differentiation. The center is a service in which the residential aspect involves numerous situations of life and relating between staff and patients: having lunch together, making the shopping list, going on an excursion, events that tend to evoke family relations. The center can be seen as an extended setting2, where it is important, if one is to understand what happens every day, to understand who says what, to whom, in what situation.
In our experience, trainees, as a temporary presence not identifiable with the facility, can more easily prompt relationships that are unlike the familiar ones. We think the trainee working in a center can develop the psychotherapeutic competence to establish a setting, which enables situations and relationships to be distinguished and which can serve as a frame of reference to make sense of what happens.

References

Mazzone, R., Tedone, E., & Niuà, G. (1998). Il mandato delle comunità terapeutico – riabilitative [The mandate of the therapeutic and rehabilitation communities], Reverie - Rivista semestrale sulle strutture intermedie in psichiatria [Reverie, Semestral review on intermediate structures in psychiatry]. Retrieved on: http://www.psychomedia.it/index1.htm

Notes

1. Therapeutic centers are residential facilities mainly for therapeutic purposes and they house up to a maximum of 20 young individuals with psychiatric or general psychological issues. (Regulations of Lazio Region n. 9 of 27.6.85 and Lazio Region decision n. 11887 of 23.12.88).
Rehabilitation centers are residential facilities for the psychiatric care of a maximum of twenty medium to long term patients for therapy and rehabilitation (art. 1 Regional regulations 27June 1985 n. 8, Lazio Region Decision n. 11887 cit). Top

2. Mazzone, Tedone & Niuà (1998), Il mandato delle comunità terapeutico–riabilitative, Reverie - Rivista semestrale sulle strutture intermedie in psichiatria; consulted at: http://www.psychomedia.it/index1.htm.Top