Peripatetic Group Therapy Phenomenology and Psychopathology

COMITÊ CIENTÍFICO DA COLEÇÃO MULTIDISCIPLINARIDADES EM SAÚDE E HUMANIDADES

In memory of my friends Norberto and Ganges

Thanks

To the professors Andrés and Jean-Marie.

To the therapist team that supported the activity.

To the director of the Instituto de Saúde Mental (Mental Health Institute) and its associates.

To Wilson Theodoro and Wilson Theodoro Filho.

To my brothers.

To Maria and Maria.

People do not die,

They remain enchanted.¹

Guimarães Rosa

Preface

This book attempts to apply the phenomenological insights of one of the greatest psychiatrists of the 20th Century – Eugène Minkowski – to a new form of group therapy – peripatetic group therapy.

To understand the project we need to know what these phenomenological insights were, what was so exceptional about Minkowski, and what is meant by peripatetic group therapy.

1. Phenomenological insight

In the 1920s four psychiatrists met at a conference and formulated a joint method for investigating psychiatric disorders. Their names were Eugène Minkowski (a naturalised Frenchman), Ludwig Binswanger (a Swiss), and Victor von Gebsattel and Erwin Straus (Germans). Their programme was antipsychological and antibiological, and essentially was a first venture into philosophical psychopathology – applying the philosophical thoughts of a number of philosophers, not just the school of pnenomenology – see below. Minkowski was most influenced by Bergson, Binswanger swung between Husserl and Heidegger, Von Gebsattel was indebted to Scheler, and Straus to Aristotle.

The phenomenological school of philosophy was a product of three philosophers at the turn of the 20th Century – Edmund Husserl, Max Scheler and Martin Heidegger (all German). Their key views about the nature of human beings and the world are so disparate that it is barely credible that they have been subsumed under the same school of philosophy. Heidegger inverted Husserl’s philosophy – which was an extreme form of Cartesianism – and proclaimed that man primarily inhabited a pre-reflective, pre-conscious form of being – barely separable from that of an animal. Scheler harshly criticised both his colleagues and opined that man was both animal and spirit, and was neither a solipsist nor an animal.

The phenomenological insight that França writes about is therefore underivable from any of the philosophers just mentioned, nor from any other 20th Century philosopher deemed to have been ‘phenomenological’ in his or her writings – e.g. Maurice Merleau-Ponty, Jean-Paul Sartre, and numerous others. It is rather an over-charged term for what is nothing more than the practice of intuition on the part of the psychologist, psychiatrist or therapist – not to be under-estimated, but not to be linked with a philosophical school which was at loggerheads with itself and whose supposed ‘fathers’ regularly denied that they were phenomenologists, and not to be linked with a group of psychiatrists whose philosophical mentors were sometimes non-phenomenologists.

2. Minkowski’s exceptional status

Minkowski was a Polish émigré who settled in France after the First World War and wrote a handful of papers and books between the 1920s and 1950s. His main focus was on schizophrenia and depression, his mentor being Bergson and not any of the three supposed fathers of the phenomenological philosophy school – Husserl, Scheler, Heidegger. His method was to seek out blatant anomalies in what I call the ‘philosophical inventory’ – e.g. time, space, personhood, objectivity, subjectivity – all those frameworks which determine what we experience and how we experience it. For Minkowski the psychiatric patient was he or she whose self and world were distorted vis-à-vis the ‘normal’ because their space, time, personhood, subjectivity and objectivity were different from the ‘sane’.

Not only did he formulate psychosis in such hitherto unheard of frameworks, but he realized, as no psychiatrist (and no philosopher either) had seen before, that the schizophrenic, and the depressive in a different and inverse way, were living examples of false philosophical positions about the ‘normal’ human being : schizophrenia being an in vivo idealism, depression being an in vivo materialism.

3. Peripatetic group therapy

If one wants to understand and treat psychiatric disorders then the closer one can get to their essential lives the better. Artificial settings, such as sitting in a bare hospital room with mental health staff must be deemed as distant as possible from everyday life. Accompanying the patient to meals, theatre, art exhibitions and the like are much better. The therapy is ‘phenomenologically- derived’ in the sense that it is based on intuition and everydayness. The phenomenological school of philosophy and the phenomenological school of psychiatry, both of which were anyway heterogeneous, are only tangentially involved in the matter discussed, whose validity must be assessed on the usual scientific parameters of whether something works or not.

4. In conclusion

What is the best approach to mental illness is an issue that has challenged doctors and interested laymen since the Greeks. The most effective have been serendipitous – antidepressants, antipsychotics, electroconvulsive therapy. But this has always seemed to me unsatisfactory. What França does here is to take the best theoretical account of psychiatric disorders – Minkowski’s – and see if it can buttress a particular sort of therapy.

Maio de 2020

Dr. J. Cutting

British psychiatrist and author of books on psychiatry, he was an honorary professor at Kings College Hospital - London and Institute of Psychiatry – London.

Presentation

This book, initially, demands a previous contextualization, however small, about the mental health history in the world, in Brazil, and, more specifically, in its capital, Brasília, where the therapeutic intervention that I describe here was performed. This contextualization is necessary because the perception of what is health and sickness in the mental health field is not uniform around the world, and has direct perception with the ethical, cultural, and economic contexts of different populations and countries. And, of course, these specificities also are subject to the variation of the historical evolution through time.

Proposed initially by Bleuler in 1908, the diagnosis of schizophrenia in its origin referred to distinct causalities and possible evolutions. In this perspective, the delirium was a sign of the affective and associative loss by the sick person. This diagnosis represented important progress for the so-called Kraepelin’s early dementia, which did not distinguish from conventional dementia regarding causality and treatment. The diagnosis of schizophrenia represents, therefore, an active effort of comprehension and care with people in psychic suffering.

Even that less known nowadays, Eugène Minkowski is represented as a pioneer and a historical reference inside mental health. While an ex-Bleuler’s assistant, Minkowski had a major role in the popularization of the diagnosis of schizophrenia in France. Maybe the higher Minkowski’s mark is his proposal to change the therapist’s position, who leaves the place of simply asking questions and listing symptoms and goes to a place where he/she aims to understand the patient’s lived experience, using as reference his/her own conscience. Not by chance, Lacan writes about the importance of Minkowski’s works.

Unfortunately (or not), the mental health field did not evolve totally increasing and linear, neither uniform. No matter how the reader comprehends, nowadays, the importance of the good care in mental health, the examples of the consequences of the ethical, cultural and economic movements in the offer of services in mental health are many. In the XX century, there was the rise of the social hygiene movement in Europe and the Americas, which started to define the public policies. This way, most of the services in mental health developed based on an asylum and hygienist model. Such ideology motivated the presumed that sick people, less capable and/or less suited, should be isolated apart from society, under formal or informal eugenic excuses.

This thought made know all around the world. For instance, we can bring the French case that even articulating, formally, the speech of liberty, equality and fraternity allowed that psychiatric asylums kept functioning in Algeria in 1953 as real deposits of humans, where the psychiatric aisles where divided between different ethnic groups². It may not sound reasonable, but the white French had an exclusive aisle, distinct from the one that sheltered Arabic and Berber people – apparently, the French citizenship were a mere formality for these people, treated as selvages by the psychiatric perspective at the time. 

In Brazil, the same hygienist isolation policy was present. The example more extreme is in Barbacena, Minas Gerais. The largest hospital in this city had a majority of black people, reflecting the eugenics ideals of the social hygiene movement. Curiously, 70% of the patients who stayed at the hospital did not receive psychiatric diagnosis. Unemployed, homosexuals, epileptics, children with enuresis and even single mothers were routed to this asylum built to the maladjusted. Without the permission to leave, estimates accuse the death of at least 60 thousand people in this mournful institution, that, nevertheless the degradable environment, also used to sell corpses illegally to medical schools, for example.

This death policy was prevented by individual efforts of various professionals, also receiving the collective name of antipsychiatry, a name created by David Cooper. This movement fought the indiscriminate use of eletroconvulsotherapy and lobotomy, demanded a human treatment for everybody and proposed therapeutic alternatives, in freedom, for people in psychic affliction.

Between the pioneers of the antipsychiatry movement, we can highlight Franz Fanon, who eliminated the racial distinctions in an Algerian hospital that he worked as a principal in 1953. In the Fanon case, it is important to add that he did not limit himself to improve mental health, but also fought against the French imperialism and still serves as a reference to the contemporary decolonial thought.

In Brazil, the Psychiatric Reform was inspired in Franco Basaglia’s works, converging to a public policy of ending asylums and opening Days Hospitals. However, the public policy, approved by pressures from the Human Rights’ supporters and the scandals of torture and mistreatments, do not necessarily change the prejudices and the culture of politicians and health professionals of a country that is historically racist and excluding: in the Brazilian case, it happened the gradual closing of asylums, but not a precise structural change regarding the importance of mental health, that follows underfinanced in Brazil. Concerning the health professionals, many of them keep acting guided by gender and race discriminations, among other hygienic elements that generate or justify the indifference and/or rejection of fragile patients, who cannot defend themselves or demand dignity.

It is in this context that this present work was developed. The asylum called Clínica Planalto, placed in Distrito Federal, Brasília (Brazil), was forced to end its activities only in 2003, due to accusations of crimes against humanity. Besides the mistreatments, it also happened the disappearance of some people who were prisoned in that place under justifications of receiving treatments and care. This specific case is important to me because, at the time, I was a student at the University of Brasília and I remember not only the celebration because the asylum was closed, but also the implications that demanded the organization of a host structure that would route these people in freedom, who kept needing cares after the closing of the institution.

These memories were lived again in 2014, eleven years later, during my doctoral program, when I met some of the survivors of the Clínica Planalto in the Mental Health Institute (Instituto de Saúde Mental - ISM), in Brasília – an institution where I wanted to develop my research. Besides that, the residents’ profiles changed over the years: the institution also started to include people who came from the prison system. Although the Brazilian legislation demands the offer of therapeutic homes to people who left an asylum, the different governors of Brasília completed 20 years in 2020 without obeying this law. This precarious condition only reinforced the ethical obligation to include these people in my therapeutic project. 

This brief synopsis shows how our professional experiences do not happen integrated into our life’s stories. Maybe one of the differentials of this book, that was born based on my doctoral dissertation defended in 2016 at the Graduated Program in Psychology of the University of São Paulo, is the search to demonstrate the growth that happened over the years not only through the reflection and appropriation of Minkowski’s works but also through the active exercise of applying these principles in the therapeutic work, developed with people who needed a professional dedicated to reaching them.

This process of reflection and growth follows a lived rhythm different from the chronological deadline of four years that is necessary to initiate and conclude a doctoral program. This book is about, therefore, the elaboration of diverse questionings that initiated during my doctoral program (or outside it), which I organized later to present to the reader in this book. Even though numbers do not reproduce the reality, this book counts with nearly ten thousand more words then the dissertation, becoming a very distinct work when compared with the project that initially generated it.

In this second book written by me entirely dedicated to the peripatetic group therapy, it is possible to identify and comprehend not only the maturation of one work to another but also the development of a distinct professional handling and the effort to understand the patients. The own narrative of the clinical process, fully described in this book, similar to a chronicle narrative, provides this work a different experience from most of the clinical publications available, that usually omit or resume parts of the process that may be considered less significant or uglies. However, these parts are, ultimately, essentials to transmit the gradual and organic evolution of the therapeutic process – a process in which nor the therapist nor the participants are ready for the great insights or the clinical punches.

For those interested in phenomenology, another element that makes this work attractive is the description and appropriation of Eugène and Françoise Minkowski’s works. Besides my appropriation happen adapted to the peripatetic group therapy, I believe that it is about an introduction to both Minkowski’s works in Portuguese. The lived psychopathology to lived people developed by Eugène Minkowski is each time more actual in a context that our professionals dedicate less time to comprehend people in suffering, under the pretext of using a rigid method and a crippling bureaucracy that recommend how a treatment should happen.

This present research was made in a specific time of fight for improvement in the mental health field, such as the increase in the quality of the services and, of course, the rise of the system of Day Hospitals. In 2020, on one hand, we face again certain budget restrictions that, in practice, turn unfeasible the offer of services in mental health. On the other hand, the Brazilian Federal Government (and also the state and municipal spheres) finances, again, private asylum entities, most of them religious. Even that the so-called therapeutic communities in Brazil have lots of registers of forced work, torture and other types of disrespects to human rights, they get stronger in face of the political alliance of the government with religious politic groups – that also pressure the eugenic idea of a supposed homosexuality reversion.  

In the face of these oscillations between backwards and forwards regarding the false dilemma about offering care or exclusion of maladjusted people, authors like Minkowski and Fanon keep current and necessary nowadays. Even that product of a specific context (Brasília – Brazil – Earth), in the XXI century, I desire to propose an updated debate about the Eugène and Françoaise Minkowski’s works and its application in a particular type of therapy.

TABLE OF CONTENTS

Introduction 25

Peripatetic Therapy: history, concepts and principles 35

Definition 35

Therapeutic contract 35

Psychological technique and theory 36

The ambulant clinical setting 37

History 41

Peripatetic group therapy 47

The essay (2005) 48

The first Master’s thesis (2004) 51

The second Master’s thesis (2009) 56

The Argentinian experience 61

The concept of exclusion to peripatetic therapy 66

The challenge of translation for English 66

Phenomenology 75

Phenomeno-structural psychopathology 77

First moment 79

Second moment 81

A case of schizophrenic melancholia 85

Transference (bilateral) 93

Method 101

Local and participants 101

The ISM and the definition of therapeutic residence 101

The ISM residents 104

Peripatetic therapy in practice 106

Phenomeno-structural psychopathology in peripatetic group therapy 107

Results 111

The residence 113

The second team meets the residence 114

The ecological hiking 115

Music and dance 118

Ecological hiking 121

The planning meeting 124

Centro Cultural Banco do Brasil – CCBB (Bank of Brazil Cultural Center) 129

Picnic at the pool 136

Pool 139

Oatmeal Cookies 140

Cake 142

Games 144

September 24 and 26 147

ISM pool 147

Parque da Cidade (City’s Park) 149

Onoyama Park 152

Bingo 154

Program planning 157

Republic Museum 161

Calendar 165

A theatre play at the Federal Highway Police 167

A fall 168

An unexpected result 169

Pool and picnic 171

Mineral Water Park 172

Choosing the favorite pictures 173

Story Maps 174

Cancelled 175

Mané Garrincha Stadium, ¹⁷⁶

Goodbye 176

Ganges and the Epileptoid Constitution 179

First round 179

Second round 185

Third round 188

Fourth round: the final challenge 190

Peripatetic Group Therapy: ramifications 197

Low retention of temporality 199

Gender 202

The development of the peripatetic group therapy 203

Space-temporality 206

Ending 209

Elements of a colonial psychopathology 211

The Last Metaphor 219

Conclusion 229

Bibliography 231

Remissive index 237

Annex 239

Annex A – Resident’s fictional names 239

Annex B – Team’s fictional names 240

Introduction

Peaches can be bought. But where can you buy a whole orchard in bloom?

Dreams, Akira Kurosawa, 1990

In 2004, during the supervision of my first patient, in my first clinical psychology internship, I lived an unpleasant situation. However, it was an essential part of my choice for phenomenology. Still excited, since it was the second session of a patient, and a little naive about the professors in general, I mentioned with a humorous smile, during the supervision, the awkward situation in which my patient demanded to sit in my chair, and not in the comfortable armchair that was positioned for her. Caught by surprise, and somewhat anxious to begin the therapy session, I agreed with her wish and did not question the situation.

Immediately, I was censored: my supervisor criticized me about what I considered necessary in the case of the patient, and, presenting me her opinion as an absolute truth, she analyzed the patient’s insistence at sitting in my chair. I was censored because I did not realize the test I was submitted. My patient wanted to occupy the therapist’s place, and I totally succumbed. The management proposed by my supervisor, obviously, was that I should frame the woman in her place of patient.³ Only this way the patient could start her therapeutic process, conducted by me, the therapist. I felt blamed with such censure, after all I failed in the first test I was submitted while a clinical therapist.

Naive and inexperienced, I accepted what my supervisor said, and I got into my third session ready to show who the boss actually was.⁴ At least it was the way I felt more inclined to behave. As soon as the patient came in and tried to sit in my chair, I told her that place was not hers and that she should sit in the armchair. Embarrassed, the patient insisted on not sitting in the armchair. When I questioned her insistence, she answered that the armchair was too high for her, causing an uncomfortable situation, once her feet did not touch the floor. On the one hand, I understood that my supervisor anticipated herself and oriented me improperly concerning the short patient. However, I needed to find a lower armchair to not go against my supervisor. After all, besides being censored, I felt embarrassed in front of others interns and did not want to take any chances to pass through this situation again.

When I explained the reason why the patient did not wish to sit in the armchair, the supervisor remained impassive and did not make any further comments, but only reinforced the attention I should maintain to keep the therapist’s place. Over my progression in the internship, I realized that the supervisor probably applied the rules for herself. Therefore, she could not assume any mistakes, neither reconsider her own supervision.

Besides my closed posture, reproducing the role of a plenipotentiary person, who would not consider any questions made by my patient, I believe that the transference never happened. The patient requested the end of the therapy sessions before it completed two months. On my part, I considered if I had enough talent to work as a clinical psychologist - and I did not continue the internship at the university’s school clinic.

I better comprehended (or elaborated) this situation with time – more precisely one year later, when I reported this situation to professor Gabriela Celidônio (2004). In my last semester at the psychology undergraduate course, I took one discipline named Special Topics in Psychotherapy, in which I had an introduction to daseinsanalyse⁵, a therapeutic approach based on the phenomenological bias. Professor Celidônio (2014), still a bachelor at the time, taught the discipline as part of the teaching practice program, mandatory to hold the Master’s Degree at the University of Brasília (UnB), and used her experience as a professor for her research. On the occasion, she described the episode of my first experience as a clinical psychologist, and also her thoughts about the discussion we had in class:

This way, we thought on how specific concepts related to common ideas to the psychologist’s repertories may disturb the comprehension of fundamental questions of a patient. That is because they are concepts that made sense in the context that they were conceived, inside some theories, but, when treated as obvious, they obstruct the search for other meanings (in general, this happens with concepts that are already consolidated).⁶ (Celidônio, 2004, p.23)

The idea of being open to know and dialogue with the person in his/her uniqueness, as well as the considerable critic to the forced theoretical framework, which many psychotherapeutic approaches stimulate or favor between their practitioners, echoed profoundly in me. Celidônio (2014) made another comment about the situation that demonstrated the implications to the clinical management of the opening provided by the phenomenology during therapy:

What would be this thing called manipulation of the patient, which usually is understood as something that would be our responsibility as therapists to identify and avoid? Even that the therapist interprets the patient as manipulative, the form of dealing with this situation would be considered a form of protection? Moreover, what else this way of relation tells about this person? ⁷ (Celidônio, 2004, p.23)

The questioning itself about the posture that should be assumed in the face of a manipulative attitude confirmed the existence of a spectrum of possibilities in the role of a clinical psychologist - and was a real watershed in my professional training. The process, started in 2004, was not easy. During the discipline, other colleagues and I felt difficulties in comprehending new concepts, applications of the theory, proposals and implications of using the phenomenology as a clinical psychologist. My feeling was that I just fronted a new language that demanded a higher comprehension effort – but the seed was already sowed.

I was only aware of the multiplicity of phenomenology’s theorists at my master’s program, started in 2007. The professor Norbeto Abreu Costa e Silva, my advisor, considered that Heidegger,⁸ although his work subsidizes the daseinsanalyse theoretically, never had a direct experience, day-to-day life and sustainable with people in psychological