The Residents

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“...Hi Vicky, sorry I couldn't get back to you earlier, I was out in the country. I'll send you my answers as voice messages, since that's easier for me; you can always speed them up.

About what you asked me, yes, it's impressive—you see so, so much loneliness in my work. Both in my private practice and, especially, at the psychiatric hospital. It's what people suffer from most, honestly: loneliness.

Let me tell you about a few cases. The way I see it, as a psychologist who only recently graduated, hospitalization for mental health reasons is a pause, you know? A “time-out” in the lives of the people who end up hospitalized. That comes at a cost for everyone. Beyond the fact that hospitalization helps adjust medication and stabilize severe conditions, it also helps put some things in people's lives back in order. And in the best cases, what gets put back in order is their social ties: the patient can reestablish a connection, find some support where before there was a total void. There's a lot written about this, but, to put it very briefly, what you see is that people don't suffer so much from the loneliness of “I'm alone at home,” but from a deeper, more basic kind of psychological loneliness, as if there were no one, inside or out.

I remember a patient who's 43. He's spent his whole life alone, using cocaine. He decompensates, starts hearing more and more voices, and ends up at the Borda. Besides the medication, which obviously did him a lot of good, being hospitalized helped him start talking to his family again. Now he's out in the country with his mom and sends me photos of them celebrating birthdays. From my end, being able to contribute to that is really lovely, really rewarding.

Another case: a patient with a visual disability, going blind, hospitalized after a suicide attempt. He found friends during his stay. He wasn't alone anymore. A group formed on the ward; they went here and there, and since he was blind, they accompanied him everywhere. When there was no longer a clear and imminent clinical risk and he was supposed to be discharged, he said, “I don't want to leave.” He said he'd found a home there. That was incredibly hard, because that's when you realize that often all you'd managed to do was move the loneliness somewhere else.

I have mixed feelings about the Mental Health Law. On the one hand, it opened up some really important debates and brought a lot of things into order. On the other, day to day, it's very hard to apply exactly as it's written. For example, “clear and imminent risk” sounds clear in the law, but in practice “risk” doesn't mean the same thing everywhere. What counts as an absolute emergency in a general hospital is almost routine at the Borda.

And then there's the idea that a hospital stay can't be extended for social reasons, which makes sense in the abstract, but the reality is that often there's no support network, no residential care facilities, no home to go back to. The real alternative is the street. So we end up applying stopgaps; hospital stays get extended because the patient has nowhere to go, even though, in theory, the risk has passed. And the other way around, general hospitals send “urgent” patients to the Borda with a little note, in a taxi or with a family member, when in theory they should be able to admit them themselves, too.

Sorry, I got carried away here because I'm really interested in the law, obviously, but the feeling I have is that the letter of the law goes one way and people's material loneliness goes another.

I told you earlier about the “nice” cases, relatively speaking. But there are others, too. I think of a 23-year-old guy from a very poor family, with lots of siblings. He comes in with catatonia, no drugs involved, a psychosis. One day his mom comes in and says she won't be coming anymore, that she can't take care of him. He's rigid in bed. He's on a ton of antipsychotics, but when I go see him, he asks me to put on a cumbia song, and his body loosens up. He asks his fellow patients to buy him coffee, and we buy him coffee every day.

There's no social worker on the unit, so there's no way to arrange a place in a care home; and a public care home is unlikely to accept someone who doesn't eat, doesn't drink water, and could medically decompensate at any moment. He's a very young guy who's incredibly alone. No one visits him. All he has is us, who've known him for a year, and his fellow patients on the ward, who come and go. He can't manage to make a friend. It's not that he says, “Nobody loves me, I'm alone.” His way of responding to that was to become rigid, stop walking, stop drinking. It's terrible, but it's also his way of dealing with something he doesn't know how to process any other way.

In psychosis, you can see very clearly how loneliness and symptoms get mixed up. Especially when there are voices and delusions. Delusions generally don't go away with medication; what gets switched off is the voices. And something that happens more often than you'd think is that those voices act as company. When you turn down the voices for a patient, their loneliness often intensifies. What you see are the negative symptoms: avolition, depression, lying in bed all day.

In a first episode, especially among young people, what families typically tell you is, “They shut themselves in their room and won't come out.” It's not just sadness or “nothing is fun anymore”; it's a total withdrawal from life into oneself, a kind of autistic retreat into the inner world. The problem is that there's no miracle medication for these negative symptoms. Depression in schizophrenia is the harshest face of the illness. You can turn down the voices, even with strong antipsychotics in treatment-resistant cases. But when they go away, sometimes you're left with someone who doesn't even have those voices for company anymore. That's when you start coming up with things—music if they like music, some kind of sport if they get into it, anything that can get a little of that completely stagnant energy moving. Deep down, what you're trying to do is keep them from being left alone facing an absolute void.

That's why you hear the idea “better to feel persecuted than to be alone” so often. Not because it's good to have delusions that people are after you, obviously, but for some patients, paranoid delusions give them a kind of Other: someone who looks at them, thinks about them, wants them, even if it's to hurt them. It's horrible and it makes them suffer, but it's not the same as the total void of thinking there's no one there.

And underneath all of that is what we call structural loneliness. It's not the nicest term, but I think it can be explained simply. As kids, what saves us from feeling like we disappear every time our mom or whoever looks after us leaves the room is gradually building an “image” of that person inside us, an inner presence that remains even when we can't see them. That's called object constancy, but in concrete terms, it's knowing from a very young age that I can't see her, but she exists; she didn't stop loving me because she went to work. In adulthood, that means being able to feel that someone's there for you even when they aren't physically there in that moment. Some people were never able to build that properly. They don't have that inner sense of someone is there, even if I can't see them right now. So loneliness isn't just being without company in the present; it's having no one inside you who can be a source of support. That's what I call psychological loneliness. It's not just an empty house; it's an empty inside, without any pictures.

Then there's our own way of not being alone inside the hospital. I find there are things I can only talk about with my fellow residents. If I tell them about something that happened with a patient and want to vent about it, I know only they will understand. There's something impossible to convey about working on an inpatient unit—the scenes, the decisions, the mistakes, the small achievements. You tell other people and it sounds like a strange anecdote; with them, it's something you've experienced together.

The same thing happens, on a different scale, between patients. We're doing a lot of therapy groups at the hospital now, and it's great. Seeing someone say out loud, “I heard a voice telling me to cut off my leg, and I went and did it,” and someone else reply, “Something similar happens to me,” is intense, but it's also a relief. Madness is profoundly isolating; it leaves you feeling that what happens to you only happens to you. Sharing it in a group breaks that bubble a little. There, in that small scene on a Tuesday afternoon, moments come up when they're not so alone.

You see it most in the groups. When someone lets out something they're ashamed of and someone else says, “Something similar happens to me,” something comes together almost without anyone trying. There's no need to pretend. It's pure honesty, and it hurts, but it hurts in a different way. And what comes out of it is compassion. An I believe you, an I see you. It's one of the most powerful things that happens in here, and I wish it happened more outside the hospital. But it takes a lot of honesty and a lot of courage to face that pain so it doesn't become just performative, but truly open-hearted, and give rise to connections that can be really intense and lasting.

About what you asked me regarding the levels of depression and exhaustion so many people seem to be experiencing, I think depressive symptoms and anxiety are part of everyone's life; they're part of the human condition. They have adaptive functions, so to speak. Stress puts you on alert so you can act—the adrenaline—and depression does too... your body tells you when you need to stop for a bit. But generally, instead of listening to that alarm, we treat it like creaking noises we need to cover up, like a flaw telling us that we, personally, aren't up to what's being demanded of us, that something's wrong with us, that I haven't been able to read the Lacan book on my nightstand for three months because I'm lazy and not doing things right. And what gets covered up is that the signal isn't a failure on our part, but a failure of the social, economic, political, and even emotional conditions we're trying to live in right now, with difficult circumstances, communities that have been dissolving, and constant pressure and urgency.

I think thinking this way changes your patience. It's not so much about putting up with someone as understanding that they're fighting a battle you can't see. Their struggle makes sense. That's why what we were talking about a few days ago—being able to step outside ourselves, to de-self, —seems key to me. Because once you understand that the problem isn't just his, or just yours, but something bigger, the question stops being Why can't you? You start to understand it differently: I mean, it makes sense that someone would struggle to function given certain circumstances. And from there, outside the hospital, I'd say the kind thing to do is to think, well, we're all part of someone else's surroundings, and ask ourselves what we can do to make the battles of the people around us a little easier or less lonely. I think that's what we were talking about: being honest about our own pain and other people's, too, and about how we can help. And I see it work; it's really moving, even in small ways.

I see it in concrete gestures here at the hospital: the person who brings a glass of water to a fellow patient who's having a harder time getting up, the one who makes room at the table for the new person, the one who notices a fellow patient is feeling lower and offers them a piece of candy, the one who plays their friend's favorite song before their own. They're ways of saying, “I'm here, and you're there,” without asking for anything. Because it means admitting that someone else's loneliness is our concern, too, that our well-being is entangled with everyone else's, and vice versa. And that can lead from little gestures like the ones I mentioned to broader efforts to improve social conditions, not just the specific distress of individuals.

Well, what do I know—at least that's my position, both as a professional and as a person.

Sorry if I got carried away.

Let's meet up.

Hope some of this helps...”