Introduction

I found the clinical case of Filippo interesting in that it offers opportunities for reflection about contexts, in particular those based on the tasks model1.
The organizational aspect that grounds relations on the tasks model is an organization that guarantees membership and is based on the symbolization of a power that dominates and prescribes “what to do” in a repetitive, predictable way. Performing the task therefore entails knowing the rules of the organization one belongs to well enough to correspond as closely as possible to its expectations. The one who lays down the law, moreover, also exercises control over procedures and their outcomes, a control that cannot be questioned and which does not envisage the checking of objectives attained.
Admittedly, this inclusion of an external power, which discourages the acquiring of competences in the constructing of the product and entails giving up the power to make decisions, has something reassuring about it: it avoids confronting the unknown, the foreign that is frightening2. Its effect is to produce repetitive behaviours that are quick to perform, predefined procedures that free one from the dilemma of choosing, from the tension of risk and from the effort required in pursuing a goal.
These aspects can be found in a great many contexts: in the family, when it acts as the guarantor of exclusive membership; in the school, when learning involves studying in order to learn what the teacher expects and what the curricula lay down, in Health Services, when one encounters situations that force one to face one’s own impotence.

The events

Filippo is a boy of nearly 18, attending the fourth year of Scientific high school. He has always been a brilliant pupil  with very high marks. Last year, in third year, he had an average of nine out of ten (lowest mark: eight in English).
In October Filippo took part in the Maths and Latin Olympics, a contest open to all the pupils in the school (the competition is therefore between all the classes, from the first to the fifth), and made up of tests established at a national level. The boy won the Maths contest but did not do so well in Latin: this is where the decline started. He lost interest in studying and began to feel ill when it was time to go to school, so he decided to stop going. He became more and more untalkative, constantly repeating that he was ill and could not do anything.

The referral

A teacher recognized, in Filippo’s situation, signs of psychic suffering and urged the parents to go to a psychologist. After several interviews with the boy, the school psychologist saw that the situation was quite serious and therefore required a psychiatrist. He therefore sent him to the psychiatrist of the Mental Health Centre where he works.
After two interviews with Filippo and one with his mother, the psychiatrist diagnosed a “depressive state” and prescribed a pharmacological therapy, being alarmed above all by some utterances such as I’ve got no interest in anything any more or when I feel like this I would like to disappear off the face of the earth  and by the boy’s worrying attraction towards his policeman uncle’s pistol. She therefore decided to send him to the psychologist.

The Mental Health Centre

The organization of the CSM (Mental Health Centre) envisages the following procedure for cases referred: whoever does the initial registration of a new patient, whether it be a psychiatrist, psychologist or social worker, decides, after an assessment, which other professional figures to involve in the case. At this point s/he contacts the one who seems best suited and reports on the problem that has been found. If it is a psychologist that is to be involved, the choice is between me and a colleague and is made on the referring person’s own criteria, not codified by the Health Service. The same thing happens in the opposite direction, when it is one of the psychologists that decides to offer a case to other operators.  This criterion is not explicitly written down but is supported by all the operators and has never been a source of conflict. 
In Filippo’s case, the psychiatrist suggests that I get involved as a psychologist. She describes him as depressed, although she does not see a very clear diagnostic picture, and hypothesizes a bipolar disorder. The main concern is about the boy’s withdrawal which makes her think there are the first signs of a psychotic disorder. Moreover, in the detailed case history she has compiled, she has identified some characteristics of the family showing entangling bonds and lack of confines. She asks the psychologist for a psychological assessment and a consultancy.
During the first psychological interview, the boy showed a certain ability to think about his experiences within a therapeutic relationship, which would be highly unlikely in the case of a psychotic crisis,  but the air of diagnostic uncertainty makes me agree to the psychiatrist’s suggestion of bringing the case before the team meeting. 

Mental Health Centre team meeting

The team meetings are an essential principle in the organizational model of the Mental Health Centre in question. All the operators, as well as the trainees, take part. Two are held (or celebrated) every week: one is clinical and sets out to deal with a case presenting particular difficulties, the other is organizational and discusses the strategies to adopt to deal with the problems that emerge day by day. The atmosphere in these meetings is very relaxed and, although the operators present a range of professional and cultural differences which often stimulate heated discussions, the differences are overcome in order to achieve the objective. One way of guaranteeing the centrality of the patient is for the Director to call for interpretations from the different points of view representing the different professional approaches.
Meeting as a team also has the role of strengthening the cohesion of the working group and providing mutual reassurance on the sense of belonging.
This atmosphere changes drastically when the issue of medical responsibility arises and this mainly happens in three situations: when there is the presumed risk of suicide, when the onset of schizophrenia is suspected, or when it has to be decided whether to undertake a TSO (Compulsory Health Treatment); in these cases in fact there are difficult decisions to be made and it is a doctor who must take them. There is therefore an atmosphere that encourages acting.
Filippo’s case presented several elements that triggered this responsibility (suicide risk, psychotic onset). The team had recently had the opportunity to notice that, before the onset of psychosis, many of the patients treated by the CSM had been “the top of the class”.
The team meeting’s discussion of Filippo’s case proceeded, arousing growing anxiety among the operators, and leading the team towards a management choice that would “avoid the worst case scenario”. This expression indicates the doctor taking a stance and prescribing the intervention considered best, with or without the consensus of the patient.  There is the tendency to use standardized procedures that serve to transform the operator’s feeling of impotence deriving from the not known, into certainty about “what to do”. This involves a devaluation of thinking and reflecting in favour of actions, and among the escalating interventions there is always somebody who says: “That’s enough talking, we’ve got to do something here!”.
Using these procedures in Filippo’s case, however, meant accepting a reading of the boy’s problems that was becoming more and more remote from what the psychiatrist and I had described. Only when the focus was on this gap, thus reintroducing thought instead of action, was it possible to redefine the case, eliminating the alarmism that had developed in the meanwhile.
At this point, with the psychiatrist with whom I was following the boy, we decided to take a risk and work on an individualized project designed for him, which would include individual psychotherapy, the continuation of the current pharmacological treatment, the involvement of the other CSM psychologist to handle the parents, and the exclusion of urgent interventions.
The two possibilities of intervention proposed respond to two types of fantasies activated by the context: one of task performance and the other more oriented towards knowledge (working by objectives).
In the first case (medical responsibility) there is fear of the unknown and of the uncontrollable nature of events: this preoccupation makes a third element emerge, i.e. the power behind the law, in this case represented by a hypothetical court before which, if “something bad” happened, one would have to explain why one had not been able to anticipate the feared event. In this way one gives up the path of development and the testing of reality through the product, obtaining however peace of mind in not having to make the “wrong” decisions.
Triggering a process aimed at knowledge and at the client (constructing a project) instead, means, as in the second alternative, accepting the risk entailed in giving up an omnipotent control, on the one hand, and on the other, the decision to valorize skills that enable the intervention to be tailored to the problem posed.

Filippo’s family

Filippo lives in a small town in Puglia, in a farmhouse. He lives with his parents, a 14-year-old bother and his grandparents. He has never had a girlfriend and goes out very little because he feels like a fish out of water in his peer-group.
Filippo’s grandparents are the owners of the farm and the land where his parents work, often along with Filippo. The grandparents are actually Filippo’s father Antonio’s adoptive parents.
Antonio’s natural parents were very poor, with numerous children that they had difficulty supporting. The father was an alcoholic with some psychiatric disorders. When Antonio was about 12 years old, Filippo’s present grandfather, a well-off farmer and landowner with no children, decided to take in one of these children and later adopt it. Of all the children, he chose Antonio, who was considered “miraculously saved” because as well as solving the problem of survival with this radical change in his life, he would become his adoptive father’s sole heir. Shortly after the adoption, almost all of Antonio’s family moved to Germany (probably using the money received from Filippo’s grandfather).
In the farmhouse where the whole family live, the grandparents have a parental role: the grandfather takes all the important decisions both about organizing the work, running the household and educating the children.
The grandfather repeatedly makes utterances idealizing his decisions at the expense of those of Filippo’s mother’s family. He often says to his grandson: “Your mother is worthless, she’s a loser and lazy like her family”,and goes on with a long list of all the faults committed by these people over the years, even blaming the mother for the fact that she has never been given a piece of land promised in dowry at the time of the wedding. The only good thing she has done is to have given him grandchildren. The grandmother reinforces this (although she herself suffers from her husband’s authoritarianism) and takes every chance to remind Filippo that she is the one who really works and worries for him, cooking and looking after the house, not his mother.   The mother is actually told to look after the farm and the animals. When she comes in for meals she finds everything already prepared by the grandmother, who considers the kitchen her territory. This woman has been asking for more autonomy in living conditions for years but her request is classed as an ungrateful insult to the parents-in-law. The father tacitly supports this situation as does Filippo who is constantly asked to confirm his agreement. The phrase that is often repeated is: “You are intelligent and capable, like us”. The younger brother is trying to create a neutral position (neither in nor out) channelling his interests outside the family. The mother is silently resigned.

The symbolization of the figure of the psychologist

In the first interview I realise that the process of “psychiatrization” being directed at the boy finds himsubstantially resigned. The first tack taken is that of acquiesence. Filippo adopts the attitude of the obedient pupil willing to patiently listen to the lesson to find an explanation of his illness. He probably sees me as one of the many who have passed through recently (he has not been back to school since the Christmas holidays), he hopes to obtain help but he does not know what sort. So there is no rebellious, antagonistic behaviour, and his attitude to the pharmacological therapy has also been compliant.  Filippo has ready-made opinions which allow him to interpret reality according to a dogmatic criterion, and what he is no longer able to do, such as study, talk to friends or go to school, is justified by his deep malaise which does not seem to be linked to his emotional sphere, which he experiences in a very confused way.  He is able only to represent himself as follows: either I go back to school or I’m finished, but I can’t go back to school…Maybe I’m like my mother’s family (in the mother’s family there is a 30-year-old uncle who in the past has had to have psychiatric treatment).
Initially Filippo asked me for explanations, or rather, lessons that could make him feel better. He felt oppressed by the expectations of everyone around him who saw his return to school as the only aim that could eliminate the unexpressed fear: that there would be no cure. In particular he felt his family members breathing down his neck, as they took turns to accompany him and constantly asked, “But will he be able to go back to school?” But also the teachers and the headmaster continually urged Filippo on.
The rumour that spread among the students was that Filippo had gone out of his mind due to too much study.

Critical event

The model underlying the relationships in Filippo’s family organization are based on the emotional categorization friend/enemy or in/out where those who are in are like us and those who are out are like the natural relatives (the mother’s family or the father’s unmentionable relatives). In this way the grandfather views his bond with the family as being of greater value than the blood ties (Filippo avoided going to visit his maternal grandparents because, though there was no explicit ban on it, he knew his grandfather would be displeased). Whoever has the privilege of being in must however feel obliged to unconditionally accept all the dogmas that one has to abide by, like in a sect where the followers accept as gospel truth the orders given by the leader, who gives an interpretation of the world and of the way to relate to it. It is only by acquiescing that one is sure of receiving affection and that one shows affection. The dominant emotional dimension is dutifulness3 which Filippo implements to protect himself from the risk of having to make decisions that might be contrary to his grandfather’s expectations. In this collusive situation there can be no conflict, no protest, no criticism, since they are seen to threaten the sense of belonging.
In this context Filippo has a specific role: he is the chosen one. All the idealized roles are projected onto him: good boy, brilliant student, excellent worker (he never refuses to work on the farm in his out-of-school time), model son/grandson.
Filippo has also taken the acquiescent relational model into scholastic contexts. Here the collusion is based yet again on a task-performance type of functioning. 
This means that for the student who aims for excellent results, it becomes top priority to be involved with the teachers and their expectations, to “do one’s homework” conforming and learning what the teacher wants to hear during oral tests. The teacher is therefore reassured that the interlocutor is under his/her control (s/he can control the class), and therefore that his/her teaching methods are effective. In this situation it is difficult to valorize knowledge.
At school Filippo always responded to the teacher’s expectations, which was highly gratifying for the teachers (he listened to them as he were hanging on their words just as he does with the psychologist and the psychiatrist). In spite of this, there was not the usual triggering of the teacher’s pet dynamic on the part of his classmates. Filippo managed to establish himself as an idealized object among them as well: in fact he was always willing to give help or advice, to do homework for others and to avoid conflictual situations. His willingness allowed him to exert a check on the envy or other negative feelings which he could have aroused in his classmates. 
The proposed interpretation of the crisis is that the failure at the Olympics represented the first time in society when Filippo felt he was competing in a contest, of which he had always managed to avoid the risk. Feeling “destabilized” as he said (a term Filippo uses very often with reference to himself) created a break in the collusive  situation, casting doubt on the idealizing model underlying his relationships and consequently, on the entire structure supporting him (in particular his dogmatism). At this point there was a kind of blockage: the feeling of being unable to see things as they were before but at the same time feeling the impossibility of “thinking about”  and triggering critical thoughts.

The critical event as an opportunity for growth

The goal of returning to school for Filippo can be seen as a reinstatement of “normality” which takes on the meaning of a reconfirmation of the previous situation. By means of his symptom, Filippo managed to bring the family context and that of the school into question. His scholastic “failure” represented a revelation of the critical points in given organizations4.
I suggest that Filippo think of our encounters with a different purpose from that of going back to school and that he make hypotheses about what is happening. In this way I try to offer him a new model of relating that envisages his involvement and not a situation where he sits and diligently listens to me
The intervention strategy was oriented towards development and evolved in the following steps:
- the proposal of agreeing on a therapeutic aim apart from that of returning to school was the first step in starting to think about what happened;
- this enabled the focus to be shifted and a “thought about” the family situation to be formulated, in particular about the dynamics of belittling the mother
- a process was triggered whereby these emotional aspects were interpreted using Filippo’s personal criteria, therefore not using the collusive dynamics of the idealized adult who is listened open-mouthed, but a relation where it is Filippo himself who sets his own goal, using his competence;
- through the awareness deriving from the here and now of the therapeutic relationship, there emerged his way of relating to the other and responding to  expectations, which serve as a check on the aggressive feelings of the other towards him.

Later developments

In April his return to school was agreed upon, this time accepting the possibility of getting a mark below eight (previously he had said that in this case he would feel destabilized).
The school responded to the initial difficulties by placing less emphasis on marks and valorizing the person, thus easing his re-entry to the class.
Filippo passed the year, but in his opinion he was helped by the teachers who gave him higher marks than he deserved (average: eight).
The psychotherapy is still underway.  At present the goal is still the interpretation of contexts according to criteria that Filippo sees as his own and that he is trying out in the therapeutic relationship. It is a difficult task because it entails bringing into play points of view that are almost always in contrast with the family and that create “moderate discussions” (the grandfather avoids confrontation on risky subjects).
Some examples of the changes in Filippo:
-he has been out more than once with his maternal aunt, who had suffered from depression, during the period of absence from school (she is the only one who understands me);
-this summer he went to Germany with his uncle to the wedding of his natural uncle, and met his cousins;
-he has had an ‘adventure’ with a girl;
-he enjoys going to the disco;
-he often refuses to go and help on the farm in out-of-school hours, but prefers to enjoy  
  himself;
- his school marks have dropped to an average of between seven and eight.

The psychotherapy enters its final phase.

The last interviews refer to relations with the teachers and to the experience of loss following his decision to no longer “respond to the teachers’ expectations” seeing that he is considered one of their star pupils and that this would bring into the relationship with them conflicts that never previously existed.
The issue of the Olympics is still present: in this new school year, after a lot of thought, Filippo decided not to register for the Latin contest but to participate, as the sole representative of his class, in the Maths contest, where he came second (he was not destabilized!).
In this final phase of the psychotherapy, attention is focused on the boy who won last year’s Latin Olympics, Gennaro, and who was also this year’s IT winner. Filippo has always  symbolized this boy as an enemy onto whom he has projected a series of intentions that make him feel as if he is constantly competing against him (even about the seats occupied at the stadium). Obviously the boy knows nothing about all this. Lately Filippo has decided to get to know Gennaro better and is discovering that he is a completely different person from what he believed. He no longer seems to be afraid of acknowledging that the other boy might be smarter than he is. The relationship with the other symbolized as the enemy is being transformed into competence in dealing with the outsider to get to know.
At the end of the session I notice that the boy in question (from the same town as Filippo) is waiting for him in the MHC waiting room to go home together.
I think the psychotherapy can enter its final stage.

References

Carli, R., & Paniccia, R.M. (2002). L’analisi emozionale del testo: Uno strumento psicologico per leggere testi e discorsi. Milano: FrancoAngeli.

Carli, R., & Paniccia, R.M. (2005). Casi clinici: Il resoconto in psicologia clinica. Bologna: il Mulino.

Notes

* Head psychologist at the CSM, Centro di Salute Mentale (Mental Health Centre) of the ASREM (Molise Regional Health Service), for the Termoli area. Top

1. One of the grounding models of social relations is the tasks model, oriented not by criteria of competence but of performance of the task: the characteristics of the task are defined by a power that comes into the relationship as a third element. See Carli & Paniccia, 2002. Top

2. Relating to the other is a mode of relating that enables one to accept the risk of symbolizing what one does not know as a friend. It therefore involves overcoming the relationship limited to maintaining systems of membership, in favour of acquiring and exchanging information facilitating reciprocal cultural enrichment and growth. See Carli & Paniccia, 2005. Top

3. Dutifulness refers to the neo-emotion of obliging. Taking on duties, obligations, implies excluding the risk represented by asking oneself what one wants. Covering oneself with duties, and obligations entails excluding the risk represented by asking oneself what one wants and by making an effort to obtain it and always includes an other, or others, who oblige or are obliged. See Carli & Paniccia, 2002. Top

4. The “given organization” is a collusive model offering membership of an organization existing independently of the actions or of the aims of those who operate in it. Those in the “given organization” feel reassured by the fact that their a-critical membership of the organization is taken for granted. See Carli & Paniccia, 2002. Top