While reading the book by Thodoris Megalooikonomou I felt a connection to it, having acted in my various capacities: as a medical resident in Leros and later in the Psychiatric Hospital of Attica, under the direction of Thodoris, as a relative of people with experience of mental health problems, as a political subject. When I met with the book, I was taking part in a parallel dialogue (Kleisoura & Karatzaferis, 2022). Back then, Alexia and I were saying to each other: "We are more than just educators. We are people who at some point in our lives went through experiences that we would rather describe, using a term that is more familiar to us, as modified or rather extreme states of consciousness. We have, in our immediate environment, people who committed suicide, who flirt constantly with addictions, who have been in and out of psychiatric hospitals, who are systematically abused and experience extremely difficult situations. We live in a world where violence is being fetishized, where journalism concerning what is vicious claims space in our senses, which are in turn stimulated by various crises. We were trained as psychiatrists in a time that is characterized by the narrow combination of a multiplication of remedies and the emergence of new intervention, imaging and classification technologies, when psychiatric theories have come to adopt an idealized perception of neutrality. We are working in an environment where mental health professionals tend to take on a more prominent role in the conduct of public affairs, often commenting on every aspect of the human existence and, not infrequently, planning relevant policies. We realise that many of the questions we pose are at risk of being obscured in view of the so called scientific and/or technological psychology and psychiatry, where priority is given to the process of providing explanations with the use of deterministic scientific models regarding subjects with mental disorders, rather than the meaning itself, and where the context is being disregarded, resulting in answers that derive from technological interventions based on (often dubious) scientific data. Within this framework I frequently feel distressed.
At this point, I shall pause and return to the book. The book is marked cover to cover by the consistency by which Deinstitutionalisation is approached on a practical, scientific, theoretical and political level. Theory and practice, epistemology and politics meet to remind us that, from an activist perspective, great theories are insufficient unless they respond to the needs of the people for whom they were originally developed, as is activism unless itis built on a theoretical basis establishing a connection of the parts to the whole. Moreover, these needs are formed on a material basis. Because, as a member of the "Hearing Voices" Network once commented during a presentation of mine on the value of "togetherness", "having someone close, an ‘active ear to listen to me’ is not enough when I live in constant precarity, when I am homeless and having to deal with the fear of losing an already insufficient benefit". This remark, as obvious as it might sound, is up for negotiation and public debate only in the context of funded, short-lived projects, tailor-made for the principles of a modernization policy, or the encouragement of individual "good practices", which, often enough, represent an attempt to address haphazardly certain needs, such as the need for professional training or housing, in the words of Thodoris.
I discuss Deinstitutionalisation and I need to make clear that the entire book also deals with the clarification of this much-abused term. In short, I understand that we are discussing Deinstitutionalisation here "as an ongoing process" (Megalooikonomou, 2022: 102) that "is not a simple process of structural change, but rather an inherently therapeutic one", (ibid: 93) aiming to "transform the existing culture" (ibid: 102) so as "to not deal with an abstract disease as a set of symptoms and behaviours" (ibid: 102), but through a "practical-critical process, which will produce this ‘margin of freedom’ that allows for the creation of possibilities, opportunities and relationships" (ibid: 189-190). "It refers to a set of activities, which tend to establish the patient as a socially acting subject through the engagement of social agents, the production of meaning, the protection of rights" (ibid: 101). Deinstitutionalisation is, therefore, an "ongoing process of transcendence that relates to all the therapeutic and social institutions and relationships that consolidate the answers in a mental distress/illness setting" (ibid: 224). It is "a process of calling into question every (institutional/ scientific/ therapeutic/social) limitation of the full emergence of the suffering subject’s needs, desires and potentials that will help them recover, express and fulfil their real self, their freedom and their relationship with the world" (ibid: 224). Ultimately, Deinstitutionalisation is an activist process which has been founded on a material basis and "requires the deployment of treatment teams, the preservation of jobs and the provision of material incentives" (ibid: 117-118).
However, the main question of "how to restore the complexity of the suffering subject" is not articulated within the boundaries of everyday clinical practice and the "complexity of the ‘social being who suffers’" (ibid: 18) is not addressed. Thodoris makes it clear that a person’s being represents their full potential. And there is no limit to the emergence and development of such potentials, since it is never known in advance what they are, which of them can be awoken, which can emerge for the first time, and which can be cultivated while already activated. (ibid: 229). This reflects an approach based on the entirety of the person, not on specific skills or individual functions.
I contemplate that such entirety can be tormenting. The competitive, simplified and univocal narrative adopted by the classification systems can let one off too easily. As Thodoris says, by quoting Franco Basaglia, "when the patient is tied up (with straps, diagnoses, univocal interpretations) the psychiatrist is free. When the patient is free, then the psychiatrist is tied up" (ibid: 124). The psychiatrist’s tying up refers, among other things, to the realization that there is something connecting him to the suffering person with whom he is sharing the room. I personally recognize this connection in the following lines (ibid: 89): "When we started working on the Deinstitutionalisation of the Psychiatric Hospital of Leros, before anything else the intervention team considered it necessary to pose itself the question: what is our purpose?" In other words, the question was how to restore the complexity of the suffering subject.
The question itself puts me in a position of responsibility and creates dilemmas. Such dilemmas prompt me to change my level of thinking, to look for a meta-level, at the same time when I also have to remain on the level of needs and desires of the here and now, instead of an abstract moment in space and time. This grounding on the needs of the suffering subject represents a form of resistance to what Thodoris, elsewhere in the book, calls an "’abolitionist policy, all grist to the mill of neoliberalism" (ibid: 222). Shutting down the psychiatric hospitals will not be enough if thousands of people are to end up homeless, as was the case in the early 1980s, in the USA. Founding new facilities in the community is of limited value if they are to reproduce an asylum-type operation with locked doors, discipline, sedative drugs. A simple change of space or way of running things is not sufficient. Let us also remember an old motto "Leros: Not a place but a way of operation". Eventually, one cannot help but wonder: "is being outside of the asylum walls enough to achieve a good, different from the previous therapeutic practice?" (ibid: 224). The answer is no, it is not.
And then, I wonder, what is the point of posing such a question today, when asylum-type terms and operations have become characteristics of the community itself? We recently experienced the construction of a terrorizing campaign of discipline, compulsion, constraint, curfew etc. that reminded many of us of the conditions inside a psychiatric hospital. The issue of danger transcended the asylum walls and reached the community. Perhaps a book could follow entitled "Leros – Dromokaition – Dafni – community: wall after wall".
Back to the dilemmas and contradictions, the first thing to be felt is shortness of breath. How am I to respond to the homelessness of a person, a member of the Hearing Voices Network who, having fought drug addiction for years, is now adopting an oppositional behaviour? Opposition is a point of criticism and at the same time a position of self-exile. Is this a convenient continuation of the scapegoat game? What role do I play in this tragedy? Am I the Abuser? Am I the Saviour? Or am I another victim?
These are not questions to be answered through reason. Besides, reason in our time lacks optimism. My shortness of breath subsides, becomes lighter, and is even turned into joy when I recall this short phrase that invites me "to oppose to the pessimism of reason, to raise the optimism of the acting"1. Slogans can sometimes be a condensed form of accumulated collective knowledge and I do not believe that they only express the person who originally came up with them… just like songs forge a path of their own, independent of their creator…
At one level, for me action is all about keeping dilemmas open. What I seek is to be aware of the dilemmas and contradictions, to look for ways to prevent them from being covered up, ways of letting them open up and unfold, become social and political issues at stake. The main narrative offers me certain starting points, while at the same time it asks of me and occasionally forces me to sweep them under the rug to protect my own interests from a position of neutrality. Having read the book, I keep the following:
- The value of seeking to move beyond the univocal reading of individual resilience towards collective resilience (reference) and include resistance with a positive sign. It is usually said that "the patient resists treatment", which suggests a moral responsibility behind any lack of improvement. Therefore, my aim is to include in the therapeutic case, be it directly or indirectly, an intersubjective condition where two subjects are able to resist jointly to a change threatening their autonomy.
- The value of accepting the other person as a reliable being, able to take responsibility of their own recovery, thus assigning a political overtone to their pain of resistance. The collective experience of pain, especially within a group, introduces a new possibility that goes beyond the neoliberal call to happiness, which mandates to nip it in the bud. Byung-Chul Han says (2021:27): "The society of consolation strips pain of its political significance, turning it into an individual and medical matter". In search of answers, Han (2021:44) turns to Benjamin, who wonders "could it be that every disease would find its cure if it could only roll away to the estuary of the narrative’s stream" and to the Hearing Voices Network (2021) which refers to a "coalition of pain". In the book there is a direct or indirect denial of "positive psychology", yet this is done through a dialectical encounter with the "positive" that "already exists", that has been achieved, the healthy part in its dialectical relation to illness as a personal and social contradiction.
- To seek alliances that will help me look for what Richard Day (2004:716), a Canadian anarchist theoretician, describes as "affinities", referring to instant connection points where we meet one another and something happens that is transformative and consistent with our collective ethics for granting justice; or in Thodoris’ words (ibid: 252) to seek the therapeutic and more widely political nature of my work and the social coalitions that I have to develop.
In the light of the above, the dilemmas remind me of an important question that is related to the issues of self-determination raised by Michel Foucault (1997: 87): «How could I participate in coalitions that allow me to act in solidarity and support of people (who are) in pursuit of self-determination through the performance of actions in the context of which the people themselves are the ones such actions are targeted to, the field of their application, the tools that are being used and the acting subjects?" I am thinking all of this and still realize that I am already discussing how the dilemmas themselves are emerging in a time when everyone is seeking for easy answers. When experiencing a crisis or feeling afraid, people often ask me for something "to get well", some "instruction to work through the pain" or a remedy, a diagnosis. The instruction, the remedy, the diagnosis are also not univocal. If I can offer a good piece of advice, I will do so should someone come asking for it. However, "focusing on the psychopathology, without regard of the entirety of the existence of a person as a whole, makes us unable to see that the mentally suffering subject, with all the fragmentation, the confusion, the delirium, the strange behaviour, is still a human being interacting with a historical and social context and, as such, cannot be reduced to just their psychopathology. Rather, the latter must be seen as part of the subject’s story/biography – that is of a subject that acts, has purposes and motives and whose behaviour is meaningful: this means that "their actions, being human actions, are attached to conscience, are purpose-driven, originate from the interpretation of specific situations and the assessment of values…" (ibid: 230).
I, therefore, believe it is consistent, from an emancipatory approach, to look for ways that will help us juxtapose the assessment, which frequently penetrates and fragments every concept of identity and personal consistency, with the assessment of the contexts these persons are included in, as well as my own assessment, one of a professional who attends (up to a point) on the road to recovery, the assessment of an institution with which I am each time interwoven. At a historic turning point in the field of mental health, Franco Basaglia (2008:39) underlines that "the therapeutic practice reveals itself as being entirely political, to the extent that it tends to recompose at a level of regression an assessment that is already taking place: that is, to recompose the assessment leading to a retreat to the acceptance of the causes that triggered it".
Naturally, the matter of immigration is discussed in the book, where it is clearly acknowledged that the "remedy" for mental suffering is specific (ibid: 382): the eradication of the conditions that led to a deprivation of hope and prospects for a future, for a safe life with recognized rights – the right to asylum, to equal pay work, to education, to health etc. I read this and I remember a refugee who had survived torture and gender-based violence. I go back to my notes from our encounter:
Even when I didn’t have therapy I used to talk with the physiotherapist and now I don’t have this anymore. When I was there, under the care of MSF, I knew where to go. Now I feel alone. Pressure… I’m not sure why things got complicated again lately. I feel frustrated. It’s like it used to be when I was thinking too much. Now I am trying but I can’t help it. I feel under pressure: I feel a weight on my heart. This is what I feel. I believe that thoughts are connected to such a feeling. Now that I’m not thinking too much, this pressure is still there. I feel blocked. I need to feel free and calm. I want to feel something. I don’t understand who I am. I was hoping to walk again but I don’t see it happening. I wanted to be like everyone else. My doctors said there is nothing else they can do. I try to stand on it but it hurts. I can’t seem to forget the pain. I feel the pressure piling up from the inside. I have so many questions about this.
What is going to happen now that it started?
Why does it come so often?
Why doesn’t it go away?
Why doesn’t it stop?
What has happened? It has only been a few days since the contracts of the entire team taking care of him at MSF were terminated, at the same time when his small benefit was discontinued, just when he was starting to become stronger, to walk a little, to feel less pain and live in a house waiting for his interview with the asylum service. Here he is receiving yet another blow that forces him back to a position with no alternatives but to live once again "with no other option" and "consent" to order, with no possibility of escape, captive of the field of psychiatry, in the same way as he had been a captive of the outside world, unable to confront its contradictions with dialogue. So how can anyone answer the question "why doesn’t it stop"?
As stated in the book, however, the core of this social problem is the transformation of an increasingly larger mass of people to the "waste of this world", to "people who are in excess" – and, all around them, a hazy mass of situations which are characterized by precarious working conditions and insecurity for tomorrow, thus confirming that millions of people live today in conditions of vulnerability (ibid: 237-238).
During my training, I learned about the epistemology of connection. And yet, as a political subject, I also learned that this connection cannot be achieved in conditions of freedom. "Men make their own History, but they do not make it as they please; they do not make it under self-selected circumstances, but under circumstances existing already, given and transmitted from the past" (Marx, 2010 83). Perhaps here there is some space for me to look for the connections that will allow the members of the community, through mutual confrontation and the dialectification of shared positions, to rebuild their own body. Such a connection creates the conditions for a therapeutic community.
In conclusion, I would like to say that it is important for me to recognize my role as part of the world of threat and abuse by which the "patient" feels oppressed, and that the assessment of the "patient" is my personal assessment. Back to Axelos (Liviakis, 2010): "There is no world without man or man without the world. One single and multidimensional game connects and disconnects them at the very same time. The interrogative dimension includes an erotic dimension. And this erotic dimension connects and disconnects. Love and death play together everywhere". Love and death, question and answer, process and purpose, chance and necessity. It is exactly this dialectic of dipoles that the technology-control-security complex threatens to wipe out, based on the pursuit of eternal life and sustainable development, the elimination of ambiguity and the inherent weakness to fully understand (algorithmization and artificial intelligence), the subjection of all to the need and purpose of production at the expense of dialogism and play. In that regard, every crack created by the therapeutic encounter is likely to let some light to be shed.
Basaglia Franco (2008) Ενάντια στην απαισιοδοξία τηςλογικής: Για την αισιοδοξία της πράξης. Εκδ. Καστανιώτη
Day, R. (2004). From Hegemony to Affinity: The political logic of the newest social movements. Cultural Studies, 18 (5), pp. 716–748.
Han Byung-Chul (2021). Η κοινωνία της παρηγοριάς Ο πόνοςσήμερα. Εκδόσεις Όπερα
Foucault, Michel. 1997. Ethics: Subjectivity and Truth. In Essential Works of Foucault, 1954–1984, ed. P. Rabinow, vol. 3. New York: The New Press.
Marx Karl (2010) Η 18η Μπρυμαίρ του Λουδοβίκου Βοναπάρτη, Εκδ. Θεμέλιο, 2010, σελ. 83.
Δίκτυο Ακούγοντας Φωνές (2021) Δίκτυα, Κινήματα, Συγκινήσεις και "η πρώτη ποίησι της ζωής μας". Περιοδικό Μετάλογος, τ 40 (Κεντρική ανακοίνωση στο 12ο Παγκόσμιο Συνέδριο Ακούγοντας Φωνές. Ιρλανδία 1-3 Σεπτεμβρίου 2021)
Κλεισούρα Αλεξία & Καρατζαφέρης Λυκούργος (2022) Αναζητώντας μετακινήσεις: μια διαλογική διεργασία με και για τον Πέτρο Πολυχρόνη Περιοδικό. Μετάλογος, τ 41
Μεγαλοοικονόμου Θοδωρής (2022) Δρομοκαΐτειο - Λέρος - Δαφνί. Ο ένας τοίχος μετά τον άλλο. Εκδόσεις των Συναδέρφων
Λυβιάκης Γιάννης (2010, Φεβρουάριος 10) Μια διάλεξη του Κώστα Αξελού στα Χανιά Χανιώτικα Νέα Ανακτήθηκε στις 1/11/2022 από https://www.haniotika-nea.gr/42273-mia-dialeksi-tou-kwsta-akselou-sta-xania/
Taken from the title of the book "Alternative psychiatry: Against the pessimism of the reason: For the optimism of the action" by Franco Basaglia, Kastaniotis Editions. The title is derived from the phrase "Pessimism of the intellect, optimism of the will", which is attributed to Romain Rolland and has become famous by Antonio Gramsci. ↩