L’“inganno” dell’empatia in ambito sanitario. Dall’empatia all’exotopia: dicotomia del senso attraverso l’uso riflessivo dei film

The article intends to propose a critical re-reading of the term “empathy”. The educational point of view on the relationship of care concerns, in fact, a dialogic tension dominated by continuous replenish the other as a bearer of an autonomous perspective, equally sensible of our own and not reducible to ours. We must therefore build models of medical education in which it is fundamental the practitioner’s ability to de-concentrate from his own models of social-cognitive construction of reality without, however, vanish from the perspective of the patient. This is defined by Bakhtin “exotopia”. In empathy, in fact, the operator de-contextualizes and isolates some parts of the experience of others to understand it, according to his own experience, so keeping a valid context. He simulates, somehow, to “put himself in the shoes of the other”, but in fact, at the last moment, “put the other one in his shoes.” In exotopia, however, the search begins when, having tried to put himself in the shoes of the other, you find that it does not go well. But to realize this, we must “expose” and questioning ourselves and we may not use either questionnaires or interviews rigidly structured. We must, that is, activate a reflexive attitude in relation to our professional epistemology and in relation to our implicit knowledge, that determines powerfully the care practices. The decision to use the two movies (in this case a short film and a documentary) wants to be a help to develop the reflection on the link empathy-extopia, as it stimulates the processes of experience development – marked by the transformative and interactive values – in which the subject is, or becomes, player in his own learning and existential process.Il contributo intende proporre una rilettura critica del termine “empatia”. Il punto di vista educativo sulla relazione di cura concentra, infatti, la propria attenzione sulla tensione dialogica dominata dal continuo ricostituire l’altro come portatore di una prospettiva autonoma, altrettanto sensata della nostra e non riducibile alla nostra. Si tratta, dunque, di costruire modelli di formazione medica e sanitaria nei quali è fondamentale la capacità del professionista di decentrarsi dai propri modelli di costruzione socio-cognitiva della realtà senza, però, annullarsi nella prospettiva del paziente. È quello che viene definito da Bachtin “exotopia”. Nell’empatia, infatti, l’operatore isola e decontestualizza alcuni tratti dell’esperienza dell’altro per comprenderla in base alla propria esperienza, quindi mantenendo valido il proprio contesto. Simula, in qualche modo, di “mettersi nelle scarpe dell’altro”, ma in realtà, all’ultimo momento, “mette l’altro nelle proprie scarpe”. Nell’exotopia, invece, la ricerca inizia quando, avendo cercato di mettersi nelle scarpe dell’altro, ci si accorge che non gli vanno bene. Ma per accorgersi di questo bisogna «esporsi», mettersi in discussione, non ci si può avvalere né di questionari, né di interviste rigidamente strutturate. Bisogna, cioè, attivare un atteggiamento riflessivo rispetto alla propria epistemologia professionale ed al proprio sapere implicito che determina potentemente le pratiche di cura. La scelta di utilizzare i due filmati (nella fattispecie un cortometraggio ed un reportage) vuole costituire un ausilio per sviluppare la riflessione attorno al nesso empatia-extopia, poichè stimola i processi di sviluppo dell’esperienza – dal marcato valore trasformativo e interattivo – in cui il soggetto è, o diviene, attore del proprio processo formativo ed esistenziale

La pratica riflessiva nella formazione alle Medical Humanities. Teorie, metodi, strumenti e valutazione

Il lavoro si colloca all’interno del dibattito scientifico internazionale sulla Medical Education, l’ambito di studi e di ricerche che si occupa della formazione dei professionisti della salute e della cura nei tre cicli della formazione: universitaria, post–universitaria e continua. Il volume intende evidenziare il ruolo della pratica riflessiva nell’insegnamento delle Medical Humanities, per sviluppare professionisti consapevoli e responsabili. Vengono presentate le teorie, i metodi e gli strumenti, con un focus sulla valutazione delle pratiche riflessive, avvalendosi anche degli elaborati scritti di alcuni studenti dei corsi di laurea sanitari dell’Università di Firenze. Il testo comprende, infine, una bibliografia tematica internazionale e si rivolge agli studenti dei corsi di laurea sanitari, ai professionisti in formazione, ai docenti/formatori e a tutti coloro si interessano di queste tematiche

[Guidelines in psychiatry: clinical and forensic issues]

Treatment guidelines (GL) in psychiatry represent a useful and functional tool to be explored and enhanced in terms of the contribution of patient care and the promotion of scientific improvement. However, they show some limitations, both clinical and forensic. The objective of this paper is to examine the objectives, the clinical limitations and the applicability of the GL on professional liability (forensic aspects). From a clinical point of view, the GL have objectives that are functional to the promotion of physical and mental health, among which the constitutional observance of the right to health, the improvement of public health, the implementation of best clinical practices, the promotion of scientific research, the professional training of operators in the field of physical and mental health. However, GL cannot replace a contextualized clinical judgment. GL must be applied, in the single clinical case, in light of their multiple criticalities, including the limits of the methodology used for their formulation, the differences between the GL' recommendations, the difficulty of their application in daily clinical practice, the lack of specific treatment interventions. From a forensic psychiatric point of view, GL, as currently conceived, cannot be used in terms of professional liability without their interpretation on a legal basis with forensic psychiatric methodology, similarly to any other clinical and scientific information, with its qualifications and criticalities

[The psychiatrization and unpredictability of interpersonal violent behavior]

The relationship between mental illness and violent behavior is a complex phenomenon. Scientific literature indicates that the presence of a mental disorder, even severe, is not sufficient, alone, to predict or motivate violent behavior, which seems to be more associated with other intermediate variables. The phenomenon of psychiatrization of violent behavior can be defined, from a psychiatric-forensic point of view, as the prejudicial and erroneous attribution to mental illness as a causal factor in relation to violent behavior. This phenomenon has consequences in psychiatric clinical practice, but also at the level of social stigmatization, management of organizational and economic resources, and the judicial system. In this paper, clinical criticalities related to the psychiatrization of violent behavior will be analyzed, including the need to differentiate clinical etiology and legal causality, predictability and avoidability, protective clinical factors and clinical risk factors, the limits of categorical psychiatric diagnosis, the need for specific victimological information, the criticalities of pharmacotherapy. Some forensic criticalities will also be analyzed, including errors in clinical and forensic methodology (psychiatrization of the symptom, prejudicial contamination, diagnostic overshadowing, legal causalization of protective and risk factors, the use of categorical diagnosis in the forensic field, the psychiatrization of non-pathological human experiences, the criminalization of the subject with mental disorder). In conclusion, it is highlighted that an individual can have a psychic disorder, even severe, but this disorder is not necessarily in a causal relationship with violent behavior. The lack of a causal relationship makes predictability of violent behavior difficult, even impossible depending on the case, both in the general population and in individuals with psychiatric disorders

Osservazioni psichiatrico-forensi sulle imputazioni e condanne agli psichiatri per il comportamento violento del paziente = Charges and convictions of psychiatrists for the violent behavior of the patient: psychiatric-forensic remarks

Purpose of the present study is to point-out a number of psychiatric-forensic remarks about the management of violent behavior against the person (VBP) amongst psychiatric patients. The study is the authors' personal contribution based on clinical and forensic experience as experts in the management of psychiatric patients with VBP. Twelve psychiatric-forensic remarks have been highlighted in the present study: 1) VBP is a multifactorial event; 2) the risk of VBP against the person may change rapidly over time in quantity and quality; 3) there are no methods for reliable prediction of VBP in a single clinical-case; 4) there are no medications with an indication of "heal" the VBP; 5) there are no therapeutic measures that neutralize always, quickly and without recurrences VBP; 6) there exist clinical hypotheses to assess VBP; 7) there exist principles of victimology to assess VBP; 8) there are emotional reactions that can affect the evaluation and clinical and forensic management of VBP; 9) the responsibility of the psychiatrist has to be evaluated at the moment of the events; 10) the responsibility of the psychiatrist must be contextualized in the single clinical-case; 11) there is the need to clarify the individual professional responsibility of psychiatrists who treated a patient; 12) there is the need to clarify the criteria for the definition of the guarantee role. The above-mentioned twelve psychiatric-forensic remarks have implications in the assessment and management of psychiatric patients with violent behavior. They may constitute a basis for further discussion aiming to obtain consensus amongst psychiatrists about good clinical practice and forensic implication in the management of psychiatric patients with VBP and to avoid charges and convictions