«I felt like I had a monster. My child has been reborn now. I hated you because my son loved you more than me! Now you've given him back to me!» As she recalled the stirring words spoken to her over the phone by a mother, Piera Toschi's voice rose above the calm tone with which she recounts moments of a life dedicated to understanding, helping and treating psychotic children.
We are in Florence, via Lungo l'Affrico n. 246. Here there is a Specialised Centre for Psychotics; it appears to be a rarity, and so we have come to learn about it.
The conditions for an objective assessment are not lacking; it is raining persistently and the beautiful park surrounding the building appears grey and sodden; the slightly worn early-twentieth-century villa has the useless, awkward floor space typical of its kind; the director who welcomes us is not showy, and perhaps carries a trace of wariness. The showcase effect, the appearances, are absent: one can see the substance more clearly.
The human and professional substance of the «Il Salviatino» institute begins with Piera Toschi, a physician specialised in paediatrics and psychoanalysis. Her scientific training and a lifetime of experience with psychotic children have not stripped her of humility or mental flexibility: whenever she hears that a specialist or an institute is doing something new for psychotics, she immediately goes to learn about it, to study it, perhaps to copy a piece of equipment. She is often accompanied by the psychologist working at the Centre, Prof. Luigi Rima, an unusual figure of a reassuring grandfather.
Laura is 12 years old. She is very beautiful. In the music therapy room there is an electric organ. Laura presses two adjacent keys. She closes herself inside the continuous dissonant vibration, which sounds like something from another place outside of time. Her wonderful eyes gaze beyond our world. Every so often a slight smile, entirely inward — Laura remains within the endless sound. That was the first time I saw the mystery of being closed within oneself.
Laura is 12 years old. She is very beautiful. In the music therapy room there is an electric organ. Laura presses two adjacent keys. She closes herself inside the continuous dissonant vibration, which sounds like something from another place outside of time. Her wonderful eyes gaze beyond our world. Every so often a slight smile, entirely inward — Laura remains within the endless sound. That was the first time I saw the mystery of being closed within oneself.We see «grandpa Luigi» in the first laboratory we enter as we tour the institute. He is sitting with a boy in front of the «therapeutic projector», divided into cells in which images and written words appear on command. «We copied this from Philadelphia» he explains. «It would have cost several million, but a local technician built it for us for next to nothing».
As we listen to the director, what strikes us as the most important characteristic emerges: the scientific training has grown not so much behind preconceived ideas as through research and direct, affective experience of the real sufferings and problems of these children and their families. Without polemical overtones, but with the feeling of someone who has been personally involved, the topic of integration soon comes up.
Children — she says — must be taken on early, around the age of three. For these we achieve excellent recoveries. For those who arrive at 8 to 10 years of age, perhaps after 5 years of not speaking, we can do little. Parents, paediatricians, and nursery assistants must learn to recognise the first signs of severe psychoses, of autism. From the cradle, a child who does not return a smile, who does not make eye contact, must be observed carefully. Integration can be useless or worse.
The psychotic child lives in a state of anguish that originates precisely within his own environment. The relationship with parents tends to become distorted. Faced with a «different» child, the parents' behaviour inevitably becomes charged with tension and changes. The child is affected by this, his anguish increases, and so his «strangeness» intensifies. As a consequence, family tension grows. It is a vicious spiral that must be broken. When it begins, the child must enter a therapeutic community. Experience tells me that residential care — preferably semi-residential — is necessary in severe cases of autism and psychosis that manifest in striking ways: indifference to reality, withdrawal from external stimuli, mutism, refusal of food. In such cases, the family that provides care on its own faces enormous difficulties.
As for reintegration into school, aside from the preliminary analysis that allows one to judge fairly well whether it is appropriate or not, there is one reliable test. If the child learns at school, he should attend and come here only for psychoanalysis. If he is merely warming a bench, integration is pointless.
Nicola learned to write here. It is a pity he arrived at 10 years of age. Had he come at 6 or 7, instead of doing nothing at school, he would have learned much better.
The autistic child defends himself from reality, withdrawing into a shell. He does not want to see others, does not want to hear, does not want to eat. They all have feeding problems. I began to nourish anorexic children through psychotherapy, making sure each time to offer something I had understood they liked. I, as psychotherapist, was experienced as a feeding mother. These are the first steps of a long process that initially aims to make the children receptive, then, once it is understood that they are receiving, to make them communicative — primarily to awaken in them the will to communicate: the means does not matter, a reaction, a gesture is enough.
For every one of these things I say, I have faces, experiences, gestures in mind. When Luigi came here, his mother was convinced she had a monster, for whom doctors assured her nothing could be done: he played only with his own body and in a manner repugnant to us. Luigi stayed as a resident for 5 years, then attended the centre as a day patient from 9 to 5, passing through all the psychoanalytic stages from birth; he was gradually reintegrated. Today he is almost cured.
I often treat them physically, even though it is said that the psychoanalyst should not also act as physician; but I see psychotic children with such anguish and suffering, from whom it is impossible to know what they feel, that only those who truly know them can and must treat them.
In addition to the children, we try to intervene at the other pole of the tension: the family. The parents of a child who comes here commit to attending regularly (every 7 or 15 days) for psychotherapy, over a long period.
The families of the children are united in an association. We hold periodic meetings, celebrations, discussions, sometimes after viewing suitable films together (for example, The Miracle Worker, David and Lisa): these serve to better understand the illness, to free parents from guilt, and to encourage their participation.
When staff are absent, some parents come to fill in: here it is essential that working groups be very small and that the children be followed continuously and on an almost individual basis.
For the educators, though not without difficulty, I have managed to exercise a certain degree of selection. They hold a teaching diploma and a special education qualification. When they arrive here they undergo a period of apprenticeship alongside an experienced educator, during which they also learn to know the children. They also receive periodic in-service training here.
What makes this Centre particularly interesting, in addition to the expected range of workshops for various activities and therapies (music, dance, craft work, etc...), is also the particular care dedicated to the «surrounding elements» (let us call them that) of the child: the parents and the educators.
Its results, its limits, and its value as an example all depend on the fact that «Il Salviatino» appears to be very closely bound to the human and professional qualities of the person who directs it.
-by Nicole Schultes e Sergio Sciascia, 1984
The therapeutic community
The premises of a therapeutic community must be a welcoming and stimulating environment, with qualified staff.
The service users should not exceed twenty in number and must be organised into small educational groups of no more than 3 to 4 children. Therapeutic interventions consist of medical and pharmacological, psychotherapeutic and rehabilitative, psychological and pedagogical treatments.
Using appropriate psychotherapeutic techniques, the child is guided to receive external stimuli and to seek out messages. Integrative interventions in psychology and sensory perception are then carried out, and the work of educational groups is developed. In this environment of varied and appropriate stimuli, the child is led to give positive motor and behavioural responses. If the intervention is timely, recovery of language is also possible. The coordination of these interventions is the principal task of the Therapeutic Community. Through the practitioner, patients experience the environment in which they live.
The aim of the Therapeutic Community is to reintegrate the patient into the world, in the best way and at the best moment.
Therapeutic Communities should be distributed across the territory so as to allow easy connection with families, also because these must receive supportive treatment.
-edited by Nicole Schultes e Sergio Sciascia, 1984