In this talk we will report on a case dealt with during our practical training experience at the SPDC ‘Psychiatric Service for Diagnosis and Care” at the Carlo Forlanini Hospital in Rome. We will try to show the specificity of the goals and the methodological problems related to organising a clinical psychology-psychotherapy intervention in this specific context.
During our traineeship we developed the idea that the organisation of any psychotherapeutic initiative that is proposed as being useful in the department, poses a problem: knowledge of the structural and cultural constraints of the context.
We will talk about of an admission that we participated in as trainees and that in our training experience has assumed the role of “critical” case. It was a situation that was strongly at odds with our system of expectations and thus triggered an unexpected surge of discussions, of interest and of study in our work with the psychologists who were our practical training tutors at the SPDC, as well as with our teachers and fellow-students at the school.
An eighteen-year-old boy, Lorenzo is brought to the hospital. He arrives at Emergency accompanied by his family due to an episode of confusion that occurred at work, with auditive hallucinations and misperceptions. The psychiatrist at the SPDC, called by Emergency for a consultation, decides to admit him to hospital. Lorenzo has just turned eighteen, he studies, works as an actor, and lived with his parents in Australia until 2001, when he returned to Italy with his mother and sister with whom he currently lives. His parents are separated. This is the information in his clinical record.

We meet Lorenzo on the fourth day of his stay in hospital. One of the psychologists of the division, our tutor, suggests that we have some interviews with him and his family, to understand “the problem”. Talking to the tutor – who, remember, represents the mission of the Service as regards us – we get a better understanding of the kind of difficulty that is facing the division concerning the admission of this patient. The tutor tells us that he spoke that morning to the psychiatrist that dealt with Lorenzo’s admission; they discussed a possible diagnosis. The tutor expresses doubts about interpreting Lorenzo’s crisis as a sign of the onset of a psychotic episode or a mood disorder, possibly bipolar disorder. In any case, the psychiatrist plans to release Lorenzo as soon as possible, believing that keeping him in the ward next to other serious patients is potentially harmful for the boy. The psychologist, on the other hand, suggests keeping him in hospital for a few more days to carry out interviews and analyse the situation better; if it was an onset, in fact, it would be important to intervene at once. He also tells us that in the last few days the boy has been administered a sedative therapy to soften the impact of entering the ward.
The information the tutor gives us contains facts (like the boy’s age, the type of therapy he is on) but also emotions, emotional ways of symbolising the relation between the patient’s problems and the intervention of the division. The psychiatrist’s idea that Lorenzo’s stay may be harmful for him and that he should be released quickly, are processes of symbolisation typical of the SPDC context based on history and a long cultural process that since the 1970s has led to the closure of the psychiatric hospitals and the organisation of a system of local services.
Rereading law n° 833 and the later national objective projects of ’94 and ‘98 that establish the role and features of the various services that would make up the Mental Health Service, we find there is little about the SPDC, apart from the name of the service, Psychiatric Service for Diagnosis and Care. What is said clearly in the law is that the various local services, above all the Mental Health Centers, are called on to reduce as far as possible the number of admissions to the hospital division. Admissions to the SPDC are therefore represented culturally as corresponding to collusive failures of the new mental health system, created to achieve one main aim: to close the psychiatric hospitals.
In the discussion between the psychiatrist and our tutor, the experience of the harmfulness of admitting patients and the urgency of releasing them, consistent with the idea that the “custody” of the sick person must anyway be as brief as possible, seems to have been challenged; it has been agreed to wait in order to deal with the problem. Now the psychologist asks us to help him to deal with it, to support his hypothesis that keeping the patient in hospital could prove useful and that the division could take care of the patient. We arrange with him our first conversation with Lorenzo to explore the origin and meaning of the crisis.

We begin the meeting by suggesting that Lorenzo help us to know something about himself, of how the admission to hospital took place, how he felt then and now.
He tells us that he attended a state-run scientific high school until the final year, then he began working as an actor, and three years later he enrolled at a private cramming school, which however he is not pleased with. He is also an expert of computer security and after a period as a hacker he started working in this sector in outsourcing with large businesses. But his work as an actor is continuing: he is now making a film. He is very busy, he shows us his electronic diary full of appointments. With his work, he says, he helps to support his family. The crisis occurred on the set: as he was putting on his costume, he felt confused and anxious; then he started to hear voices in his head, some reassuring, some “bad”.
We start to make hypotheses about the meaning of the crisis that brought Lorenzo to the SPDC. The problem seems to be connected to relating, to the emotional ambivalence aroused by relating, and is connected to what Lorenzo is taking on, perhaps with seeking an identity and an integration of all the many levels and contexts of experience into which he is venturing. We conclude by suggesting more conversations with Lorenzo and also with his mother in the coming days. Lorenzo agrees.
We talk about this initial interview with our psychologist tutor, who tells us to work “intensively” on the case in the next few days.
The same morning Lorenzo’s mother and uncle, his mother’s brother, come into the division. We meet them while they are talking to the psychiatrist who dealt with the admission. The family ask the psychiatrist what sort of medication Lorenzo is taking and how long he will have to stay in hospital; the mother down everything in her notebook.
The psychiatrist reassures the mother, saying that Lorenzo will be out soon, no later than a week, just the time needed to adjust the pharmacological therapy. He also tells her the psychologists are administering tests, indicating us. At our suggestion, the woman agrees to an immediate interview.
Based on what we have reported so far, we will make some comments on the peculiarities of this case, which we have considered a “critical case” in terms of the working of the SPDC.
We think that Lorenzo’s admission made us, and the team, aware of the problematic position of the SPDC towards the therapeutic value of admission to hospital.
The team thinks that the crisis may be related to the onset of a disorder of the schizophrenic spectrum or a mood disorder. “Onset” in psychiatric hospital culture, evokes the desire for a cure, for the total remission of the illness. This expectation in psychiatry is always frustrated. But as regards the symbolisation of the SPDC as a place of custody, of containment of acute situations, the therapeutic aspect of admission seems to be marginalised and negated.
We are faced with two different ways of representing the hospital as a place of care for Lorenzo’s problem: on the one hand there is the representation of the service as an anti-therapeutic place, a place used when the situation is very critical, when there are no other contexts where the treatment can be carried out. As Lorenzo has a caring family that looks after him there seems to be no reason to keep him in hospital. The hospital implicitly serves in cases where the crisis cannot be contained by the social context.
In the second perspective, which seems to be adopted more by the psychologist our tutor, the hospital is represented as a place where the crisis is dealt with, even when there is a collaborative non-rejecting social context. When the family is present and participates in the problem, it can be included in the process of understanding. Consequently, the service can function not only as a substitute of the family, but can also integrate the family resources.
So on the one hand, hospitalisation is symbolised as an unpleasant, undesirable condition and therefore to be avoided as far as possible, while on the other, it is seen as good.

But let us get back to the process of intervention. In the conversation with the mother and the uncle we begin to formulate a possible interpretation of the meaning of the crisis and to see with the family that the meaning of the crisis might be connected to the history of their family relations.
The mother describes Lorenzo as a highly intelligent boy. He was precocious in everything, she says, and even as a child he took part in conferences on maths and IT.
Lorenzo’s life changed greatly when he was given a job as an actor. The commitment was so great, with school, IT consultancies and film-making, that Lorenzo was always very tired. As a result he decided to give up state school and enrol in a private course of preparation for the school-leaving exams.
Once inside the cinema world, and after a disappointing meeting with his father, who he had not seen for many years, Lorenzo started to smoke hashish, though without hiding this fact  at home, and seemingly aware of the risks connected to it. But there was a problem. Just a week before the crisis, when he had just turned 18, Lorenzo was arrested by the police for possessing a larger quantity of hashish than the law allows.
The experience of the arrest was very traumatic, especially as it came straight after a major argument with his mother about the boy’s economic independence, and a bitter telephone conversation with his father, accused by Lorenzo of always having neglected him.
From what the mother says we begin to understand how much the mother idealises her son, and sets great expectations on him. These expectations have always been confirmed by Lorenzo with his prodigious success and talent. The mother seems to have invested Lorenzo with an emotional role that is difficult for the boy to sustain, that of the companion who makes up for the disappointments and abandonment that the mother suffered in her relationship with her husband. The theme of having to trust each other, of forming an alliance to protect themselves from a persecutor, seems to be important in the relationship between mother and son. We think about another aspect. In the mother’s representation, Lorenzo is a precocious child. On the symbolic plane a precocious child is a prodigious child, born despite natural laws, mature before the natural time, but at the same time an immature child, more fragile and more at risk in life than a child born on time.
Now, Lorenzo’s turning 18 seems to have been the event that triggered the crisis in the family system. In the space of a few weeks Lorenzo seems to have been through a series of serious disillusionments which together cast him into anxiety. He felt betrayed by the friends who, unbeknown to him, had put the hashish in his bag, which had caused his arrest. He had had harsh clashes with his mother and his father, during which he showed profound indifference towards both his parents.
In the precocity of his involvement in the productive, adult world, we think the boy did not have the time, and therefore the space within himself, to understand the confused and ambivalent emotions aroused by this phase of his emotional life: the separation from his mother, the search for his own identity, for an autonomous way of making sense of the many and varied directions he was taking. We think the confusional crisis the boy had on the set was an expression of this set of problems. It is as if Lorenzo were calling for help in constructing inside himself a model for trusting relations not based on controlling the other person through idealisation or underestimation, but on knowledge and exchange. We hypothesise that, for Lorenzo, giving up school meant detaching himself from the world he knew, from a group of peers with whom he may have shared interests, and  from a system of rules that were reassuring in his venturing out into a personal emotional experience of building relations with his peers, apart from his mother.
The family members, especially the mother, do not seem aware of the strain involved on an emotional level, of the changes being faced by Lorenzo and by themselves. But with equal strain the mother tells us she needs help to bring order to these recent events that seem to have happened so quickly that they got out of her control.
In the following days we assist the psychologist tutor in further conversations with Lorenzo and his family designed to arrange a therapeutic plan with the family to follow at the Mental Health Center after his release from hospital. We feel that a central aspect of the case that we participated in, concerns involving the family in a process of understanding the meaning of the crisis, of the symbolic component of the crisis. We were acting in a borderline area of SPDC operativity, the importance of which we have understood during these years of practical training: the relation between patient, family and health service.
This operative domain goes beyond the goals of the psychiatric intervention, limited to containing the crisis and eliminating the symptoms, and brings into the treatment, categories of interpretation of the relational problem underlying the origin of the crisis that can serve to develop a psychotherapeutic role in the SPDC’s social mandate of custody.
In this sense the practical training-resource of SPDC psychologists can be seen as a task of interfacing between the inside and outside of the service: and therefore a specific resource for connecting the internal goals of getting through the critical phase of the symptomatology, with the external goals – typically concerning the family and the group of primary reference – in the perspective of re-integrating the patient into his daily life, in a network of social relations that, as far as possible, has been made more aware and more competent by the   clinical psychology intervention.