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The “Piacentino” Context In Which We Work As Aspiring CAT Practitioners In Italy

Fiorani, C., Poggioli, M., Provenzano, A., Romanelli, S., Sogni, A., 2010. The “Piacentino” Context In Which We Work As Aspiring CAT Practitioners In Italy. Reformulation, Winter, pp.6-11.

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This is the experience of a small group of PsIchologi Psicoterapeuti, six in total, who have been learning to practice CAT in Piacenza in Emilia-Romagna. This is a brief attempt at describing our own reciprocal roles within Italian culture. We are therefore participant observers, this article is subjective, it reflects our views and opinions and experiences and not those of the whole of Italy.

This region is apparently a happy island as far as Mental Health services go - services can vary tremendously from one region to the next or even within a region.

As far as I can see there seems to be no formal debate amongst and between professionals as to the problems with the diagnostic approaches that are used as a basis for making decisions about treatment to understanding psychological difficulties. There appears however to be individually a recognition of the need for an exit from the medical model and there is a perceived need within some individual clinicians to link a person’s social and material world to their distress. In my limited experience some clinicians appear disappointed with a psychoanalytic model that does not really give them tools for their everyday practice with patients.

In general I have found the lay public to be relatively psychologically uninformed, but very informed medically. Government directives on mental health are not available to psychological therapists and definitely not available to the public. There are national directives on the provision of medical care, but very little is said about mental health. Details are decided regionally and standards and services can vary enormously between regions and within regions. The medical model is very strong, and the diagnostic categories are taken very seriously.

There tends to be no debate as to the reliability of psychiatric diagnosis, which places one very much in the in the realm of the expert, a knowledge form that can only be used by a skilled few. There is no involvement by service users equivalent to e.g. the Hearing Voices Network in the UK.

Figure 1

Social changes which have happened over two hundred years since the Industrial Revolution in the UK have happened in Italy in the last 70 years. There has been a relatively rapid change from a society mainly reliant on agricultural subsistence farming with many emigrating in order to survive, to an industrialised modern, though very socially unequal, nation. There are some very privileged groups. Who you know counts. Italy’s very liberal labour laws do not protect everyone. There is a large black economy. There is a big north-south division. It is quite common in Italy to find grandparents to be hardly able to read and write, son or daughter to be educated to senior school standard, who left school maybe at 14 and went on to have their own small business or have been employed, and grandchild is at University. Everyone goes to University now but not everyone completes the course.

There are still exorcisms held in Churches and a lot of the population goes to see a “maga”, a sorceress, although not the younger generation who have gone to University. From this stems the cultural divide between those that are educated and those that are not.

Figure 2

The family unit is still very strong in Italy. There are many small family-run firms and it can be economically difficult for younger people to leave home, or if they do they are funded by the family. There is a tendency to have smaller families and for the younger member of the family to be given everything money can buy. There is a price to pay. You are judged by what you have rather than who you are. You are what you wear “La bella figura”

Figure 3

A theme in some of my patients has been one of individuation from the family. Strong family bonds can be wonderful. When it’s dysfunctional however, and the economic reality is one of dependence without the possibility of escape, it leads to many unexpressed and unmanageable emotions. It is no accident that family therapy began in Italy. The importance of friendship can be overshadowed by the role of the family which is the most important social, economic, and organisational unit.Even politically the Italian family can be a highly sophisticated network of patronage and power held together by the exchange of favours.

The cultural habit is somatisation and, I would add, hypochondria is also a national pastime. The tendency is for someone with psychological problems to keep quiet about them, it tends to be seen as an illness, hence the somatisation. There is still stigma attached to it being known that one has seen a psychologist. There is also a cultural pressure to keep everything within the family (“do not wash your dirty linen in public”, keep the family secret). If people do see a psychologist, they tend to do so privately. People can be very reluctant in discussing their families.

Patients can be reserved and diffident, polite but resistant, it reflects the culture, “lavare I panni sporchi a casa”( wash the dirty clothes at home). They can be provocative and challenge you, become exhibitionists, a bit of a bully, but underneath be very fragile and frightened. Very contemptuous, looking down on you because they fear criticism. Reflecting cultural roles. Being black and white, all or nothing,extreme also reflects cultural norms.

Within adult mental health there is psychiatric provision for psychotics and severe depression. The interventions are often medical rather than psychological. Complex mental health problems are sometimes seen by a Sert (drug and alcohol service) and often in casualty.

For adults the is no state provision other than psychiatric care for problems ranging from reaction to life events, all the way up from mild to moderate anxiety and depression, simple grief reactions, to moderate depression and anxiety, panic disorder, severe OCD, personality disorder, co-morbidity or history of abuse. A referral might be made but obviously it would go to the very back of the waiting list and remain there, so referrals tend not to be made. There is more psychological provision in child and adolescent services. In fact in the supervision group I have been running in Piacenza, three out of five members of the group work with adolescent services. In these services, although there is psychological input, the model is still strongly medical. Very few psychology departments exist in Italy.

There are few opportunities for psychologists to be employed by the state-run health system, and often psychiatrists are employed giving only drug therapy where perhaps a psychologist would be more useful in relapse prevention. A psychologist in Italy has to work hard to prove that they are useful. The medical lobby is very strong and doctors maintain a united front. A gynaecologist does not argue against a neurologist. Different schools of psychotherapy, however, fight against each other for who holds the monopoly on the truth. There is as yet no discussion about the common nonspecific aspects of the talking therapies, or an idea of integration. Traditionally, Italy has been Psychoanalytical and Freudian - a drive theory and concept which marries well with the biomedical model held here, with little emphasis on the relational, the cultural, the social.

Figure 4

It is quite a long and arduous task to become a “Psicologo Psicoteraputa” which would be the equivalent of a UK Clinical/Counselling Psychologist /Pychotherapist. First there is a five year psychology degree, followed by a year doing a mandatory unpaid placement (which there is much competition for), followed by a state exam. If one stops here one becomes qualified to give “psychological support” and to administer tests, and many stop here. Most end up in posts allied to psychology, very few end up as psychological therapists. Some of them open private practices, always on the premise that they do testing and give psychological support, but not therapy. Approx 60% of psychologists stop here with no further training. 40% go on to do the four year training to become a Psicologo Psicoterapeuta which is an essential requirement to get into the few and rare Public Sector Health Jobs. The majority of psychologists and Psicologi Psicoterapeuti work in private practice, and sometimes get employed if a region has the money to arrange maternity or Illness cover.

Most of the Schools which offer courses to become a Psicologo Psicoterapeuta are privately owned. Only two are state-run and University-based. These are primarily aimed at doctors and if a psychologist manages to get into one then they have to repeat exams they have already taken as part of their psychology degree. There is no funding for psychologists, so all who train can look forward to approx 10 years of self-funding unlike doctors who earn a wage whilst training.

Figure 5

Bearing in mind the above here then are the reciprocal roles of a group of Italian Psicologi Psicoterapeuti who took part in a six month CAT supervision group which was held in Piacenza starting in March 2010.

I came to Italy having internalised the CAT ideal of cooperation, mutual respect and interdependence, which made perfect cultural and social sense to me as a desired standard by which to practice my profession. I found myself in quite a different social and cultural climate in Italy. I have found that in Italy cooperation can be viewed with suspicion and it is of interest to have investigated the reciprocal roles within the supervision group. Having said this, I have always carried on regardless and operated here within the context of my profession using a cooperative model and I have found colleagues who have reciprocated and cooperated, the supervision group being a case in point.
As an outsider, I have tended to look at anyone with a job as:

Figure 6

The following are the reflections and experiences of the group.

Psychology is a growing profession and psychologists are at the moment their own worst enemies. To quote one of my group members “rather than saying we are all in the same boat, let’s help each other, the rule is to push someone else out of the boat, because they are seen as competition” it was not a position that she liked, but one that she observed around her.

Everyone in the group described themselves as striving / performing.

Group Member

“Striving / Performing trying not to be seen. Keep out of sight, to Demanding / Critical. Her dilemma, ‘I want recognition but fear not being up to the mark, fear exposure in a critical conditional competitive setting’. The Critical Conditional was seen also as a self-to-self procedure.” The climate in the department where this individual works is medical, critical, competitive. The problem was that she tried and tended to work well and autonomously, but also needed some recognition. In another setting this psychologist felt more looked after and gave recognition but the psychologist in question was still striving performing, although here happier, there was more confirmation.

Figure 7

Group Member

“People in the department who do little are left to their own devices, “let sleeping dogs lie.” Those who work hard are given even more work, so the more you work the more you are given and it feels overwhelming.Trap: I want to be recognised, only recognition means being given even more work, feel overwhelmed and depressed, want to leave, there are no other jobs out there, striving performing again and ambivalent, my supervisor is also my line manager, they teach me but also they judge me, so I feel unable to voice concerns and insecurities. No time to think, overwhelmed by work, feel guilty if I do not do the work, so work even harder.”

Figure 8

Other Group Member

No collaboration with other psychologists who are seen as competition, feel isolated alone, if I ask for help it feels as if I am devalued, have to appear expert all the time, if I ask it is seen as “You do not know your job, you are not good enough”, so self esteem is very precarious; someone who looks for collaboration is limiting themselves.

Figure 9

Another group member describes her “boss” as passive aggressive so she avoids her, does not want to be exposed, but she is proud of her
profession, she tries to educate people. She finds the doctors quite open to her suggestions, so with doctors she is more relaxed.

Another group member, feeling that she had to be the expert, although now with the introduction of CAT it’s been easier, they have taken to it in the therapeutic community, “still feel judged and I am striving performing,” “there is more autonomy in (Council) as I am the only psychologist so less fear of judgement.”

Another group member felt her referrer to be paternalistic critical and intrusive, which left her striving precariously and feeling insecure of her abilities.

• Hide my professional competence
• Unexpressed anger, play ball as he might not refer
• Criticised and invaded
• Powerful
• Powerless

Figure 10

I am left with the feeling that in Italy one has to be very determined, seemingly without vulnerability, determined to be a psychologist and financially able to do it.

Nonetheless there is an oasis of CAT which with its contextual considerations has enabled us to meet as a group, to examine honestly our own reciprocal roles and behave in a trusting and cooperative manner towards each other, with much interest in a continued collaboration. So CAT has been our exit.

In Italy one becomes a master at “arrangiarsi” [coping; managing with what’s available] one gets on with it.

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Full Reference

Fiorani, C., Poggioli, M., Provenzano, A., Romanelli, S., Sogni, A., 2010. The “Piacentino” Context In Which We Work As Aspiring CAT Practitioners In Italy. Reformulation, Winter, pp.6-11.

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