The strategic health management of a CAUP: a project for a psychiatry with a human face

About a year ago I took over the health management of a CAUP (psychiatric housing community). Initially I did it out of sympathy for the managers, serious people with whom I have been collaborating for years. I had some reservations on a professional level, as the CAUP is a psychiatric institution and therefore distant from the mentality of us strategists. In fact, these are also long-term hospitalizations in communities, which, although open and preparatory to an independent life, are extraneous to people's life contexts. Users are patients of public services, with troubled psychiatric histories, dotted with hospitalizations and Mandatory Health Treatments, diagnoses that leave little room for hope: psychosis, schizoid personality disorder ... Heavy labels, also communicated to family members, who look to the future of their own children with bitterness and resignation without any more educational investments. The therapies practiced are mainly based on drugs, neuroleptics and antidepressants in the first place.

I also took on this job with the motivation of the challenge. Once, in a seminar held in a public service, a psychiatrist colleague had challenged me saying that she would have liked to see me work with people who, due to economic and social conditions, could not have afforded psychotherapy or would not have tolerated its effects. Instead, I believe that it is possible to be strategic even with patients who are “objectively” less gifted due to their social and health history. On the other hand, the fathers of the strategic approach had worked mainly, if not exclusively, with institutionalized patients. Don D. Jackson had founded the Mental Research Institute starting from the work on psychotics and their families. Milton Erickson had started his "uncommon therapies" in a psychiatric hospital. Having to deal with psychotic people and with personality disorders, I mainly used the maneuvers that are used in these cases, according to the Brief Strategic Therapy (Giorgio Nardone model): the counter-delirium, the conspiracy of silence and the ritual of the pulpit, the diary of the delirium and paranoia, but above all the charismatic relationship.

Counterdelirium
The most rapid example of counter-delusion that I remember is the case described by Don D. Jackson of the patient who enters the room for the psychotherapy session, sits down and says: "Doctor, doctor, you know that here in this room there are bugs. ? " And the doctor said, “Oh yeah? Let's look for them! " They started looking for the bugs together for a while, until the patient stopped and said: "Doctor, here one of us is crazy!" According to the logic of contradiction, the limit of a delusion is a greater delusion, so the strategy used with patients in these cases is either to indulge the delusion, sharing it with the patient, or to devise one similar in structure, but larger in terms of structure. context. A doctor or a psychologist, simply indulging in a delusion, creates a therapeutic double bond in place of the pathogenic double bonds to which patients have been subjected in their contexts. Similarly, in the community, suitable counter-delays were created from time to time. A religious delirium was answered with a religious counter-delusion. A technological-based delirium (they spy on me through the computer) was answered with a technological counter-delusion.

The conspiracy of silence
It is necessary to avoid what everyone does about psychosis, based on common sense and that is the rationalizations, reassurances, dialogue, which I have seen done even by eminent psychiatrists, all things that do not work, because bringing delirium to reason always makes it root. more. Therefore, the directive was given to educators and community workers to avoid reassurance or dialogue about symptoms during the day. Each day, however, each patient had the right to half an hour, negotiated in time and space, to listen to the symptoms. The operator gave the stage during the session, that is, he listened in religious silence to the delusional or paranoid river of the person. In addition or alternatively, the diary of delirium was used. The patient is prescribed "all the delusional content that you have or that you feel, write it down and bring it to me so we can analyze it".

Charismatic relationship
The evidence that most comes to attention in working with these people are the attempted solutions of even the most qualified operators: o avoiding contact because they are too demanding (it is no coincidence that career advancement in health facilities coincides with estrangement from patients. Sometimes the resident has more contact with the patient than the director); o become complementary with respect to pathologies with attitudes of “friendly” availability which in fact contribute to making the patient chronic. Instead, we favored a relationship that gave availability, but also directivity, acceptance with respect to symptoms and distorted views, but systematic in pursuing therapeutic objectives. In particular, in patients with borderline personality disorder, the techniques are not so important as the charisma of the operator, who must act as a good model. For this reason, great importance has been given, in the training of the community worker, to the use of non-verbal communication: the smile, the gaze, the posture, the management of the proxemic space and their use in the conversation with people, i.e. all those aspects that contribute to making the operator a model to follow.

The effect of the strategic approach to users that have always been treated in a traditional way has been striking. Like the patients described by the neurologist Oliver sacks in the book Awakenings, they seemed to awaken in the face of such a different communication. No more psychiatric diagnoses and drug therapies, but therapeutic communications with the possibility of solutions. No more hand tremors, a side effect of neuroleptics, but the possibility of reducing drugs in a controlled way. After a year of work it is still early to compile statistics, but I must say that judging by unexpected returns to school and work, the first results are encouraging and lead to further experimentation.

Dr. Andrea Vallarino (Psychiatrist, Official Psychologist-Psychotherapist of the Strategic Therapy Center)

BIBLIOGRAPHY

• Haley, J., Uncommon Therapy, The psychiatric techniques of M. Erickson MD, WW Norton and Co., New York; tr. it., Uncommon Therapies, Astrolabio, Rome, 1976;
• G. Nardone, P. Watzlawick, The art of change, Ponte alle Grazie, Florence, 1990;
• E. Sluzki, DC Ransom, Double bind, the foundation of the communicational approach to the family, Grune & Stratton, 1976, New York; tr. it., The double bond, Astrolabe, 1979, Rome;
• Watzlawick, P., Weakland, JH, Fish, R., Chamge: principles of problem formation and problem solution, WW Norton Co., New York; tr. it., Change: training and problem solving, Astrolabe, Rome.
• Sacks, O., Awakenings; tr. it., Risvegli, Adelphi, Milan, 1995.