Ever since the first steps were taken in the field of clinical psychology and in training as psychotherapists, one sometimes encounters the concept of setting, a term which variously follows various adjectives: clinical, relational, therapeutic, etc etc .
Advertising message In principle, after many books read, many supervisions, intervisions, discussions, comparisons and more, we have the idea of the setting as a psychic and physical environment, a space that contains the construction of the relationship between a therapist and a patient, a giving and receiving care, in order to make it as effective and useful as possible for the patient himself. Effective and useful: how, for what and according to which lines of meaning are topics on which, precisely, you can talk for hours, especially with those psychologists and psychiatrists of the public service destined, given the not strictly analytical context of the clinics, to countless variations of the setting itself.
So when we imagine a setting, we certainly think of a physical environment, we think of contractual rules shared in the relationship between therapist and patient but, above all, we think about how that relationship is built and placed in the mind of both in the here and now of the meeting and, even more, in the short and long term memories. So the setting is the environment that protects the construction of the therapeutic relationship and a safe place for both. All these elements also vary according to the even larger space, outpatient clinic, private practice and more, in which therapist and patient play their game.
There is something, however, that remains unchanged and that, perhaps, puts everyone in agreement: the psychotherapeutic purpose, that is to accompany the patient towards the acquisition and increase of awareness of the personal meanings with which everyone transforms facts into experience, the history precipitates these meanings and the attempt to explore other possibilities. In order to carry out these functions of profound self-reflection, it was believed, in the pioneering years of psychotherapy, that a context free of “current or ongoing facts” was necessary, since they would have been a disturbance with respect to the concentration necessary to look within and to be able to attribute what happened to him, in the absence of any other stimulus.
Here, therefore, the efforts were oriented, ideally, towards the concept of neutrality of the therapeutic setting: an empty space, where the therapist is discreet, a little amorphous, not even seen, gives more freedom and the patient, finally free of worries even the smallest that any type of human relationship entails for the simple fact that one looks at and is looked at, speaks to itself, can take care of itself and can experience the beneficial relief of being listened to in a non-judgmental and altruistic way. Anyone who has experienced the transition from the chair of the analytical room, face to face with the therapist, to the famous sofa with the out-of-the-box analyst, knows that kind of relief.
Winnicott, who worked hard to specify the concept of setting, wrote:
In short, the environment must be as comfortable as possible from a physical point of view and a safe place, where you feel you can be as you are, without being judged or abandoned. For this reason, the therapy room should not be too much characterized by personal aspects of the therapist; it is not appropriate to keep a half-length portrait of Mussolini, or a poster of Che Guevara, political, religious symbols or objects that show important aspects of the therapist’s life. Self disclosure can be used, but as a therapeutic tool and for the exclusive use and benefit of the patient, at the appropriate time and for clear purposes in the therapist’s mind, not to show off or show the therapist’s skills, for example, as a certified tennis player certified by the parade of cups and bowls.
Advertising message However, it was later seen that it was a little illusory, even a little naive to think of eliminating any kind of disturbance, since the presence of the therapist in the patient’s mind, as the former was made to accommodate in the most intimate, deep interior of the second, it was a fact that, although devoid of concrete elements, drew the chiaroscuro of the relationship and direction in the patient’s openness to himself. Thus, in order to immunize from the presence of the therapist, two operations were carried out: on the one hand, the impossible attempt to make him impersonal, in no way connoted, colorless, odorless and tasteless voiceover; on the other, on these premises, to interpret the therapeutic relationship, more fantastic than real,
With this, therapy, especially analytically oriented, has become for the most part the analysis of the transference: the discovery of the meaning that the person attributes to reality does not only take place through the analysis of the facts, external events of the patient’s life, by him narrated but, first of all, with the analysis of dreams together with the analysis of his way of building the relationship with the therapist himself.
All right to the point where, over the years and in certain clinical environments, there has been a reversal between means and purposes and the orthodox ritual of the setting has become more important than the psychotherapeutic function of which the setting is the main protection factor; to put it in evangelical terms, the Sabbath has become more important than the man for whom it was created. Freud, in fact, did not dedicate many theoretical writings on the subject, limiting himself to setting the example with his clinical practice to which, in the Vienna of the belle epoque, he devoted thirty hours a week to his home, or five patients each to five weekly sessions from Monday to Friday.
It was his collaborators and colleagues who subsequently formalized rules which, in fact, became more important than the pioneering spirit that had produced them, if not actually contrary to it. Think of Ernst Lanzer, better known as the rat man, to whom Freud offered tea and herring during the sessions, and all is well as long as the therapeutic space is used by those patients whom, in our stringed and somewhat reductive shared language, we call neurotics or “good functioning”. Those people, that is, who despite having aspects of suffering that compromise or limit some times of daily existence, even with difficulties, manage to have emotional ties or to work, study, belong to a social group, have fun etc.
A little different speech for those people whose functioning is seriously compromised, personality disorders, mood, or completely shattered, psychosis. These patients, so-called difficult, if not incurable, and who also represent the heart of our profession, especially when our work is linked to public service clinics, while accepting, more willingly than we think, the time of individual interview, they seem to start over every time. And there is no point in lengthening the duration of the individual encounters or multiplying them, which (???) is somewhat fragile as the ability to remain intimate, aware and present in a dual relationship. It is as if the gap we see at the end of the hour has no way of stabilizing in the mind as a passage towards new self-knowledge.
This consideration alone gives us an idea of how ancient and deep-rooted are the beliefs about oneself, and about others, that generate the patient’s suffering. It looks like a canvas by Penelope, what the patient and the therapist embroiders during the interview are undone in the days and nights between one interview and another. Even the homework, although useful, does not seem to prolong the therapeutic context beyond the hour of the session. It is not enough, it does not seem sufficient. Empathy and patience, that patience of the therapist who, time after time, repeats and repeats and contextualizes the same problematic meaning within the different life experiences, past and present, of the patient is not enough. The availability of the patient and his suffering is not enough that, even if the engine of change, at the same time it nourishes the rigidity and impermeability of the mental state: in the face of a painful experience, he anchors himself more in the convictions, in the feelings and in the prejudicial affections that in a distant time were useful and perhaps life-saving. Some emotions, more than intense, of this type of patient are impotence and fear, anger and despair. The clinical state is a depression as an immense void. On a cognitive level, deeply rooted and unsolvable metaconvinitions: nothing will ever change, I have no hope, I am unlucky, it’s all my fault, it’s all the fault of others anger and despair. The clinical state is a depression as an immense void. On a cognitive level, deeply rooted and unsolvable metaconvinitions: nothing will ever change, I have no hope, I am unlucky, it’s all my fault, it’s all the fault of others anger and despair. The clinical state is a depression as an immense void. On a cognitive level, deeply rooted and unsolvable metaconvinitions: nothing will ever change, I have no hope, I am unlucky, it’s all my fault, it’s all the fault of others
The attempt at neutrality, in which everything can be interpreted as the attribution of meanings to the patient is, in these cases, a way of simplifying the treatment, reducing disturbing disturbances and silencing that information which, if the borders are widened, transforms from noise basically in essential, evolutionary and very significant elements. Exercising the psychological and psychotherapeutic function in an articulated context such as daily life, in which the patient’s world of meanings is represented in every gesture, in every interaction, in every word or silence is very complex, but also very enriching for everyone; needs curious therapists, who must surround themselves with authority, while eating or drawing with the patient, who must continually seek points of balance between protecting their privacy and telling themselves,
I have been a psychologist and psychotherapist in the Mental Health Department for many years, I started in 1989, I have known different services, different ways of working and met dozens of patients. I have a solid education and, above all, the attitude of never wanting to stop learning, therefore I have always read and studied and are looking for answers to the questions that I have asked myself through time or that others, patients, family members have asked me. I have always appreciated the comfortable individual setting of psychotherapy, with particular attention to the characteristics of a care relationship, and in this setting I have always moved with all patients, even and especially those defined as serious, an important word and with multifaceted meanings.
Working in a DSM is a very engaging experience that can disturb any type of solid training over time. Especially if you work with an open and curious mind, fortunately, you doubt a certain rigidity that accompanies every excellent training path which sometimes translates into the statement “we are right only”. The DSM has a complex organization made up of very different services for clinical purposes and activities, now so well known in their functions as to make it further unnecessary to specify them further here. Just remember that there are clinics, therapeutic communities, day centers, residential and semi-residential structures and dedicated hospital departments. And we also consider the variety of professional figures who make up a team. therefore, every single therapist / patient interaction brings with it, not even too much in the background, the interactions that the patient has and has had with other operators or with other structures; think of the patient discharged from the SPDC department or from the community, what he brings with him in the clinical interview with the psychologist.
Each psychotherapy, in DSM, is benevolently affected by everything that revolves around it and that is why the very concept of setting and the possibility of making it an in-depth analysis and an object of careful supervision acquires a fundamental meaning in the treatment of serious patients.
A couple of years ago, within the Department of Mental Health where I work, I took on the responsibility of opening and managing a new Day Center for young people, the age of which is between 18 and 25 years old. The Day Center is a semi-residential facility with morning / evening opening that welcomes complex patients, by diagnosis, number of hospitalizations, life history, etc., offering therapeutic and rehabilitative activities. So, in a matter of months I find myself moving from the most comfortable and easiest individual setting to a perpetually group care dimension: the Day Center is the group place par excellence, the young people live in the group and for the group which connotes and defines them even when, or especially when, they are afraid of them or are on the margins.
We can already glimpse here a first scenario in action, social relations.
In addition, myself, assuming a role of responsibility, I have a professional duty to manage a small, variable group of operators, and me, within this mini team: each of us is benevolent and curious, the motivation is strong and, although we are often stunned by bureaucracy, “I bend but I don’t break” seems to circulate in the air of the Center. We break our heads to start from some sustainable activity, since, having in general scarce material and economic resources, little can be put into practice of what was grandly planned at the beginning; we must appeal exclusively to our professional skills and start from there, what each of us can offer, we study and re-study a lot, we read, we confront each other, we take care of each other’s anxiety and we form various types of groups.
Second scenario, interactions in the operator subgroup
We realize that, although oriented in a different way, the group activity, whether it is skill training, psychotherapy, psychoeducation, laboratories etc. converges in a harmonious and natural way towards a goal: to help our young patients get to know each other a little more, stimulating a curiosity towards themselves that favors new, non-prejudicial words, broadening awareness, promoting reflection and knowledge, do not be afraid of emotions and interiority and, last but not least, discover the meaning of the disorder that accompanies them which, for our young but already very disorganized users, is not only an isolated symptom in a person who is still functioning, it is a group of symptoms in a creaking psychic structure, although unknown and therefore fragile. It occurs to us how these patients self-describe or better, how they can’t do it: to tell a multi-faceted experience with infinite nuances they almost always use a single broad and polarized concept of “I’m fine” / “I’m sick”. Those who listen to their life history, if attentive, catch clichés, preliminary ideas, phrases taken from who knows which figure of reference, a parent, a teacher, cheap diagnosis borrowed from a medical consultation or from the internet. While they speak, in the silence of a real listening, they are bored, frightened at best, neglected and superficial, they are sure that nobody cares because they don’t even care about themselves and there is no time to waste on chatting. Those who listen to their life history, if attentive, catch clichés, preliminary ideas, phrases taken from who knows which figure of reference, a parent, a teacher, cheap diagnosis borrowed from a medical consultation or from the internet. While they speak, in the silence of a real listening, they are bored, frightened at best, neglected and superficial, they are sure that nobody cares because they don’t even care about themselves and there is no time to waste on chatting. Those who listen to their life history, if attentive, catch clichés, preliminary ideas, phrases taken from who knows which figure of reference, a parent, a teacher, cheap diagnosis borrowed from a medical consultation or from the internet. While they speak, in the silence of a real listening, they are bored, frightened at best, neglected and superficial, they are sure that nobody cares because they don’t even care about themselves and there is no time to waste on chatting.
Third pattern, shared words.
A group of operators facilitates the differentiation of the words necessary for a person to represent himself and others in a truer way; these words, regardless of their physical appearance, how they are dressed or how their social, school, family life has gone, are new, more specific words, a different possibility of approaching and making themselves known. We are reminded of that moment in life when we begin to speak: by imitation, through listening, through invented words that make us laugh or through experience, a vocabulary is born that broadens the cognitive horizons of a child and favors the exploration.
And finally, there is another therapeutic dimension in these structures: a daily space, made up of gestures, expressions, jokes, play, activities in common, chatter, an immense deposit of possibilities for treatment that opens up to the eyes of the careful operator. It is in particular through this manifold concreteness that, especially young people, open themselves to listening and observing the comments of others and, through this openness, they learn and experience directly aspects of the relationship such as acceptance, trust, possibility of pleasure or being heard because they say or do interesting things. It is this concrete mirroring that allows patients so laboriously receptive in individual contexts to question their leathery and gloomy beliefs about themselves and others and start thinking that perhaps there are more pleasant alternatives for their life and their future. . The concreteness of daily community life, gestures, actions, behaviors, impacts spontaneously and immediately on important psychic functions such as self-reflexivity, the theory of mind, empathy, understanding the point of view of others, distancing oneself from one’s point of view, differentiation, etc.
The sense of humor, which these young people are never without, is an essential coloring agent of the interactions between them and between patients and operators. We all have experience of how therapeutic laughter is, how much it can lighten a conflict, strengthen an alliance, establish a complicity, cheer up a day, make yourself known about other aspects of yourself that do not only concern your own problematic and your own disorder.
The precious experience that patients in semi-residence have is that some people, peers and non-peers, know and recognize them regardless of their pathology and see and confirm their qualities for too long secret. An interesting question to ask is: who are you apart from your ailment? How would you describe yourself? What are your strengths, your resources? We realized that the answer to these questions is completely ignored; if already in the description of the disorder one is laconic and vague, all the rest is unknown.
Understandable if we reflect, analyzing the anamnesis, on the strongly negative identity that has taken shape both in the school environment and, consequently with peers, and in the family. Almost all these patients have a diagnosis of ADHD, DSA, someone has had the support, certainly a rather low performance, serious and painful experiences of bullying, social exclusion, superficial, neglected or, on the contrary, strongly controlling family environments: what an opinion can they have themselves? What kind of self-esteem?
This is the fourth scenario, last but fundamental in our experience, precisely to assist the individual setting and reinforce the acceptance of oneself as a prelude to a change.
The limit, which has been described many times, is that the psychiatric operator risks becoming the friend of the heart and therefore losing authority, a risk also present in individual settings and directly connected to the therapist’s unconscious relational needs. In our experience, this is not the case, at least in this age group of the patients we are talking about here. This is not the case when the psychologist is careful to keep the dimension of care and nourishment active and clear in the therapeutic relationship, specifically I care / you receive, I give / you take, I teach / you learn, and in this sense there is no equal, there is a difference and it is this wonderful difference that allows those corrective experiences that these kids are hungry and need. The stimuli for change pass through a caring, realistically safe and constant dimension, where responsibility for care is shared, in the sense of compliance, but not knowledge. This fourth and final dimension, which we consider essential, is the one that must be more monitored by the psychologist who works in residential and semi-residential centers, in order not to incur misunderstandings, confusions or anything else.
The comparison within the working group and mutual support are very important, the humility of recognizing one’s own, intimate, need for help, without feeling less good, frequent supervision and self-observation and, above all, the ” mind of the beginner “. The beginner’s mind has to do with openness, curiosity and the absence of prejudices. It is when one observes something for the first time, in the beginner’s mind all the possibilities are present and the observation is accompanied by amazement, although certain experiences may be recognizable or known. It is observing without pretending to already know everything, without entering competitive mode, but leaving oneself receptive and available.