What happens in the mind of someone who has undergone a high-tech medical or surgical procedure? This is a question that more and more doctors in top positions, specialists in Rehabilitation Medicine and others, are asking themselves. The first to do so was Augusto Iossa Fasano, a psychiatrist and founder of the Metandro association, who discussed this topic in a book titled “Fuori di sé. Da Freud all’analisi del cyborg” (ETS Editions).

VBRRII: Professor, how do we answer the question we started with?

Iossa Fasano: “Today we know that orthopedic prostheses, brain stimulators, cardiac devices such as pacemakers and defibrillators, and even insulin and dopamine pumps have the power to alter a person’s identity, with potentially significant consequences on the psyche”.

VBRRII: How is identity involved?

Iossa Fasano: “Identity is structurally ambivalent: it is shaped by something that remains constant over time and by something mutable that we ourselves foster as progress, advancements, corrections on a moral and concrete level, which manifest in the processes of maturation and aging. When we undergo an implant, in this changing part an artificial tool is inserted, perhaps technologically advanced, that man had never used before. This brings with it a great challenge that humanity has not yet fully understood: if before we were mind-body, today we are mind-prosthesis-body”.

VBRRII: Why can this passage be problematic?

Iossa Fasano: “Because the implantation of a prosthesis or a device is never merely a medical-surgical or technological procedure; it involves the spirituality of the individual, their relationships, and their life within a range of action that expands progressively. It is a true metamorphosis, as Ovid would say: a transformation of identity that must extend and encompass its own limits. The mind must pursue and accept this transformation, planning forms of physical and social adaptation”.

VBRRII: Doesn’t it always work for us?

Iossa Fasano: “No, because the prosthesis is an artificial element that joins natural parts, making us a hybrid subject: a cyborg, a term coined in the 1960s and popularized in the 1980s by the American philosopher Donna Haraway. Furthermore, beyond the fusion of artificial and organic elements, there is an element that both fascinates and slightly frightens us: the spark of electricity, electronics, and cybernetics, exemplified by artificial intelligence. Something that thinks inside of us, next to us, and together with us, or in the most frightening version, thinks and acts against us”.

VBRRII: How does one patient feel when overwhelmed by this metamorphosis?

Iossa Fasano: “They feel like many of the patients I saw in the ‘80s and ‘90s: anxious, impatient, confused, depressed, impulsive, and with insomnia problems. At that time, even though I was faced with symptoms that could fall into psychiatric categories, I investigated the medical history of those people and discovered that they shared an etiopathogenetic factor such as a traumatic event or an illness that required the implantation of a prosthesis, internal or external. Today the same thing happens”.

VBRRII: So it’s not a classic depression…

Iossa Fasano: “No, it is a real crisis of adaptation, which can slow down and hinder recovery. It does not allow a restitutio ad integram, that is, the restoration of the original health condition. In practice, the intervention works perfectly on a technical level, but the individual does not revert to their previous state. For this reason, all patients who receive an implant, specifically the insertion of an internal device, such as a brain stimulator, should undergo a preparatory phase and long-term follow-up. I have built a theoretical model and validated a test that addresses counseling and any clinical approach that does not necessarily follow a psychiatric framework. With doctor Franco Molteni, we have set up an initial ‘Psychiatric Engineering’ or ‘Psycho-dynamic Engineering’”.

VBRRII: How many people suffer from this lack of adaptation?

Iossa Fasano: “It’s difficult to make an estimate, but I would say it concerns up to 15 percent of people who have undergone a high-tech procedure”.

VBRRII: Is it possible to help these patients?

Iossa Fasano: “Certainly. It can be achieved with psychotropic drugs, which are now effective with minimal side effects. These drugs are also prescribed by general practitioners, orthopedists, physiatrists, and gynecologists. But these medications should be used with greater caution. In addition to psychiatric intervention, the support of a psychologist and a psychotherapist is needed. The person should be welcomed with their own drama. In the past, it was often said, ‘You have undergone an amputation, now you have a prosthesis. What are you complaining about? You have been treated!’. Instead, it is necessary to recognize the traumas that individuals carry with them—traumas that, at times, paradoxically stem from being given a second chance”.

VBRRII: What do you mean?

Iossa Fasano: “In the past, when confronted with a tumor or other serious illnesses, patients had no option but to surrender, acknowledging disability and even death. Today, however, more and more often, the bet can be restarted, and individuals find themselves with a life expectancy they never imagined. But at this point, they must adapt to living with the body they have left, and it is not always easy to invest personal energy to relaunch existence, perhaps living with a disability, a prosthesis, or a device that is not visible but is there. Often it is easier to resign”.

VBRRII: The deeper the device is implanted, the greater the potential discomfort, right?

Iossa Fasano: “That’s right. A large part of the population accepts external prostheses and even showcases them as if they were designer objects. In these cases, aesthetic ostentation becomes a form of identity enhancement. Internal prostheses cause more issues because they are not visible. You can’t control, remove, or turn them off, so obsession kicks in: ‘Will it hurt me?’. ‘Is it working?’. ‘Can I deactivate it?’. Even if implanted for a good cause, an internal device pierces the person, forcing them into a coercive action. I always think of a 20-year-old with Brugada syndrome, a very frightening condition due to its unpredictability and lethality, who used to turn off the pacemaker with a magnet because he was terrified of feeling the defibrillating shock”.

VBRRII: What is the turning point?

Iossa Fasano: “Taking examples from those who have succeeded. Often, these individuals have equipped themselves with an external prosthesis, something that helped them externalize their internal condition. I’ll give you an example: some people, after undergoing surgery to correct their myopia, decide to wear non-prescription lenses, maybe with a stylish frame. It’s the useless that compensates the useful. The external prosthesis is, therefore, a tool to facilitate the dialogue between our inner self and the external world, revealing what is concealed within us”.

VBRRII: You have developed a protocol to help those who are suffering.

Iossa Fasano: Exactly. It’s called the Bionic Prosthetic Paradigm (PBP) and involves the exploration of four areas of socio-familial life and one of possible symptom development, through the completion of a questionnaire that investigates 26 post-implant aspects. We have opened up a new field where an increasing number of doctors in top positions are requesting to integrate psychoanalytic-oriented counseling support with surgical and prosthetic techniques. Not only that. The Ministry of University and Research has agreed to include two new subjects in the four-year specialty school for future psychotherapists: ‘Theory and Practice of the Bionic Prosthetic Paradigm’ and ‘Theory and Practice of ISGs, Integrated Health Groups’. The cyborg condition, that is, the understanding of how we are and how we will be made according to a multidisciplinary model and a network approach, is becoming increasingly relevant”.