In this paper we reflect on the role of psychology in the hospital, seen as an organisational competence based on clinical psychology models. We will suggest that between organisational competence based on clinical psychology and psychotherapeutic praxis there is a close connection, following this line of thought: from the setting identified with the psychologist’s room, who protects the psychotherapeutic praxis from the actions of the organization by closing the door, to the setting of the psychologist who operates in hospital divisions promoting emotionally competent organisational relations and therefore psychotherapeutic.
Clinical psychology tells us that all organisational practice is based on emotionally organised relations. These are relations marked by a symbolic meaning, which allow the organisation to achieve its aims. Every organization has its symbolic models for this purpose. Thinking of the hospital, two of these come to mind, both based on strongly individualistic premises, ignoring relations. This ignoring produces critical events, in which we think psychology can intervene. The first of these models, tendentially hegemonic, is the economic model which hypothesises a social relation involving rational individuals; it ignores the emotionality experienced in relating. The second relational model that comes to mind when thinking of the hospital is the medical model, which also tends to be hegemonic. In the medical model, the emotional symbolisation of the relation is envisaged in a precise rituality, described well by Fornari as the split into the sick part and the healthy part of the patient, with the consequent aggression by the sick part, seen as “other than self” and the enemy, while the healthy part forms an alliance with the doctor. This alliance sees a strong technical expert confronting a weak client, who accepts an acritical dependency because it is reversible and guaranteed by the medical competence. We hypothesise that in cases where in a hospital, these organisational models of the relation prove to be inadequate, failing to achieve their purpose, then they are offered to the psychology units.

We are finishing the second year of practical training at two different hospitals. We have used a single case to talk about the experience in the psychology units because, although the two units are organised differently, the issues they have to deal with are similar. We have also decided to present a case that is not an example of what should be done, but that allows us to explore the difficulties encountered when the attempt is made to promote emotionally competent relations in a hospital. In this way we use the position of trainees as a resource: as in those who can explore and discuss the limits of their own competence. We will talk about the request made by an oncology division that the psychology unit has been working with for many years. The collaboration started when the Division Head wanted to have a psychologist as a member of the multidisciplinary team. The request was due to difficulty in reducing relations with oncological patients and their family to the customary level of the medical intervention. The emotions that are difficult to treat are related to the anguish about death aroused by an illness where it is considered probable that the medical intervention will fail.

Let us look at the case. Dr. M. from the oncology division phones the psychology unit and asks to speak to the trainee that in recent months has worked with them most frequently. She asks her to urgently meet Francesco, an 18-year-old patient who is undergoing chemotherapy at the day hospital; she adds that he is depressed. The request arrives during a meeting in the psychology unit of the team that works in the oncology division. In spite of the fact that in the meeting it is mentioned that the urgency may be a collusive pressure that needs to be interpreted, it is treated as a fact and the trainee is immediately sent to oncology.
It is worth remembering that going into the division to meet a patient is very different from receiving him in the room devoted to interviews in the psychology unit. While identifying who the patient is in one’s own room is relatively easy, identifying him in a division is far more difficult. The psychologist enters the division and looks for Dr. M hoping to obtain some more information. She finds out from a nurse however that the doctor has already left. The nurse knows Francesco and points out the boy’s mother, who is in the waiting room, waiting for her son to finish his therapy. The waiting room is almost empty. The psychologist introduces herself to the woman, saying that the oncologist has asked her to meet Francesco and she gets the impression that the woman was expecting her. The mother says that it was herself and her husband that asked for a psychological consultation for their son, after talking various times to the oncologist about their concerns. The woman talks about Francesco, giving a long list of behaviors that she finds inappropriate and underlines the powerlessness she and her husband feel as parents. Their attempts to intervene are constantly thwarted by their son, who rejects both of them. Francesco has been successfully operated on, and now has to do chemotherapy. In spite of the chemotherapy, Francesco continues to eat at McDonalds and to smoke like before. The boy’s father arrives in the waiting room and the wife introduces him to the psychologist. From then on he is the one that talks, continuing what his wife was saying about their son’s behavior, which he finds inappropriate for a seriously ill person. He adds that he would prefer the oncologist to be stricter and to forbid certain things. He says that Francesco rejects his suggestion of cutting his hair, which in the father’s view would make it less traumatic when his hair actually falls out. When the psychologist asks the father how he thinks his son is feeling in this period, he answers that Francesco is fine, as if nothing happened. He spends almost all the time with his friends while at home he is silent and uncommunicative. In short, he behaves exactly as he did before the illness. The psychologist senses that the parents, due to the feeling of impotence they have expressed, are trying to get back the initiative by infantilising their son; they want to regain their power over him, since they have no power over the illness. She however does not express this insight to the parents, confining herself to mentioning that the process of separation between them and Francesco, who is becoming an adult, seems to have been made more difficult by the onset of the illness. The father at this point says perhaps it is he himself that needs a psychologist. Talking about his son, he has realised that he is continuing to live despite the tumour, while the parents are not. He asks the psychologist if she can receive him, she gives him the phone number of the psychology unit and they part. Although this conversation indicates to the psychologist that she has met her clients, the trainee also decides to go to Francesco. He tells her the chemotherapy is “a drip like any other”. He clarifies that for him his friends are more of a reference point than his parents. He says he has a girlfriend. He conveys to the psychologist that he already has a relational context that supports him, with a cheerful attitude that seems to be a way of asking to be left in peace, which is after all the same thing that he asks of his parents.   

It is only after this conversation that the psychologist rediscovers the feeling of embarrassment she had felt before meeting Francesco. This feeling finally enables her to realise that he is not her patient, and to take a step back and to start thinking about what is happening. Why did the oncologist call the psychology unit? What failed in the relations between the division, the patient and his parents? After a few days the trainee and the oncologist meet in the division. They stop in the doctors’ room and the psychologist talks about Francesco, asking Dr. M. the reason for the referral. The latter says the boy’s parents are a torment. During visits, the father often talks down the son to ask questions and express doubts, bewilderment and fears. He expects her to use her medical authority to force Francesco to behave as he thinks a sick person should. The oncologist says that while the parents are extremely difficult, Francesco is a calm patient and is easy to manage. His treatment has a 90% probability of a positive outcome. The patient has reacted well to the illness, the parents have not. “But was Francesco depressed or not, then?”, finally asks the psychologist. No, answers the doctor. The psychologist is stunned into silence and can only suppose that the doctor had defined him that way to ensure that the psychology unit would get involved in the case and intervene.

We think this case is full of interesting indicators of the complexity of entangled relations, and of the need to stop acting them out and to start thinking about them in order to identify a possible therapeutic process. There is the relationship between the oncologist and the trainee. When she finally devotes a bit of time to her, it is revealed that the problem lies in the relationship between her and Francesco’s parents. There is the relation between the psychology unit and the division. If the oncologist indicated that the intervention was urgently required, adding the lure of the diagnosis of depression, perhaps she feared she would not be listened to by the unit. In fact, in meetings between the psychology unit and the division, the psychologists had recently been absent on several occasions. This was due to the team’s experience of not being useful to the division. This was caused, we think, by the tendency to take urgent action without analysing it, which was evident also in Francesco’s case. There is the relation between the trainee and Francesco’s parents, where the trainee realises, with some difficulty, that they are actually her clients. When the reconstruction is made and the relations through which the event is acted out are seen as a whole, various avenues of intervention open up: with the oncologist, with Francesco’s parents, and with the team.