Approach from Therapeutic Accompaniment in Psychosis PDF

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Approach from Therapeutic Accompaniment in Psychosis...

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Approach from Therapeutic Accompaniment in Psychosis

The present work's general objective is to investigate and describe the performance of therapeutic accompaniment from a psychoanalytic point of view. To do this, a tour will be made, beginning by knowing the evolution in the field of mental health, and then incorporating the emergence of Therapeutic Accompaniment, how it was introduced into society, the changes it produced and its growth to the present day. Considering the legal aspects that support it and the insertion in the work field. Then we will continue with the psychoanalytic concepts that can be thought from said practice, taking Freud as pillars in terms of his theory of the psychic apparatus and the concepts of the Nebensmench Complex, primary and secondary process, condensation and displacement mechanisms, differentiation between psychosis and neurosis to be able to understand the uniqueness of each subject with whom one works; and to Lacan, who takes up Freud's concepts and develops the subjective constitution, Paternal Metaphor, structure, mechanisms of alienation and separation. It will also be considered to address psychosis.

Later on, psychoanalytic concepts will be articulated with the Therapeutic Accompaniment approach, to finally think about a clinical case and thus leave the work done. Carrying out this theme, arose from attending a course in which Therapeutic Accompaniment in Depressive Episodes was developed, as a complement to the patient's treatments, so the concern arises, if in a subject with psychosis, in which The therapeutic approaches carried out did not generate progress. Can the Therapeutic Companion be able to be a symbolic support and be able to reestablish the social bond? It is from this question that the possibility of thinking about the psychoanalytic concepts studied in the course of the career begins to be considered

of the Bachelor of Psychology. Which could be articulated to carry out the aforementioned practice. In this way we will aim to reach the conclusions, which will emerge from the objectives worked and the hypothesis.

Methodological Aspect The study that will be developed starts from a theoretical-clinical concern and will be carried out from a psychoanalytic perspective, taking Freud and Lacan as a fundamental axis, and working with authors who continued and later enriched their theories. The discipline that supports Psychoanalysis is used, from which the concept of psychosis is taken, and the discipline of alternative approaches provided by the concept of Therapeutic Accompaniment. Both offer the possibility of observing, analyzing and delving into the material, looking for meaningful relationships that clarify the question that guides the work. The theoretical development will be articulated with a case published in a Conference, of a 16-year-old adolescent patient, diagnosed with schizophrenic psychosis and mild mental deficiency, who was admitted to the Psychiatric Hospital and for two years did not show progress in her evolution, therefore incorporated a Therapeutic Companion. It was selected based on the problem raised, in order to find an articulation that allows clarifying the questions presented in the course of the investigation. In this, fundamental aspects were found of what is achieved with the intervention of a Therapeutic Companion and of the contributions that psychoanalysis provides to think about them in this practice. The objectives, hypotheses and research questions that emerge to carry out the investigation are: General objective: Investigate and describe the performance of Therapeutic Accompaniment from a psychoanalytic perspective.

Specific objectives:  Take a historical tour of mental illness, followed by the origins of Therapeutic Accompaniment.  From Sigmund Freud mention the constitution of the psychic apparatus, the Nebenmensch complex, primary process and secondary process and the differentiation between neurosis and psychosis.  Describe from Jaques Lacan the subjective constitution, the mechanisms of alienation and separation, the structure, paternal metaphor, the neighbor and the fellow man.  Analyze the figure of the Therapeutic Companion in psychosis, from a psychoanalytic perspective.  Theoretical-clinical articulation of the concepts worked. Hypothesis From a psychoanalytic training, the Therapeutic Companion in front of a subject with psychosis, can be positioned as symbolic support, allowing to reestablish the social bond. Research questions Does psychoanalysis allow to accommodate complementary ways of working with a subject? How can the concepts provided by Psychoanalysis be thought from the role of the Therapeutic Companion? Can the Therapeutic Companion be able to be a symbolic support and be able to generate changes in the stagnation of their treatment?

THEORETICAL FRAMEWORK

CHAPTER 1: Emergence of Therapeutic Accompaniment

We will start, being able to introduce an idea of how were the beginnings of Therapeutic Accompaniment and how it was gaining ground in society, promoting certain changes in the treatments carried out with patients. The main objective of these changes is to be able to intervene with those subjects who suffered from severe diseases and were excluded because they were considered "intractable". For this, it is appropriate to consider how mental illness was approached in the beginning. Historical Tour of Mental Illness Formerly it was believed that mental illness had a sacred origin. Thus Skiaderesis tells us that "with the passing of time, with Hippocrates, one begins to think that this was not so, since there were certain natural causes that alternated at certain times, beyond the gods" (p.3) In the 15th century, Christianity carried out the first crusades to conquer Jerusalem, unleashing the arrival of leprosy in Europe, producing a plague. Thus the first idea of a hospital was constituted, the leper colony. It begins to be run by doctors. Venereal diseases appear in Europe as the great plague of leprosy and the madness again associated with them. From this century on, the Church, which had no problem giving a rescue to the mentally ill, began to totally expel them and deny them the sacraments. You start to have some discrimination. They were expelled in the ship of fools, navigating the German rivers, and placed in squares for those who had their birth in the same town.

In the seventeenth century, boarding schools were created, as a consequence of the passage from leprosy to venereal diseases and mental illnesses. They were alienated people who died in general in situations of extreme poverty. In the 18th century, Skiadaresis clarifies: Dr. Philippe Pinel begins to found the clinical and institutional vision in relation to mental illness, holding the idea that an illness is a healthy reaction against that which disturbs the balance, whose natural ending is insanity. To place him in one institution was to save him from a habit to place him in another and within that one, to control his living conditions. There the patient was subjected to severe and paternal discipline regulated by medical law. (p.8)

It was mainly aimed at the importance of not applying violence or degrading methods. Thus beginning to appear respect for the subject. Avoiding chaining them and letting them circulate inside the asylum, with force vests. Occupations began to be included, giving training to poor people so that they could learn something useful to society and they included some “crazy people” in these work houses. Skiadaresis continues by saying "Together with Pinel, Jean Étienne Dominique Esquirol constitutes the Psychiatric Clinic, aiming to consider the relationship with the environment as something fundamental and the legislation of mental illness begins". (p.11) It is Morel, who begins to introduce the thought that there was a biological and a psychological inheritance, considering the early years of childhood, which are where the influence of the family environment appeared. At present, Skiadaresis tells us that “there are several closed, semi-open and open hospital centers. Inside the closed ones,

they find classic psychiatric clinics where repressive reinforcement, neuroleptics, application of electroshocks are used ”. (p.13) From this he clarifies "in the 1950s, regarding the hospitalization of the mentally ill, Therapeutic Communities were created to provide the mentally ill with a community context where they could make decisions." (p.14) Those institutions functioned by teamwork. They worked from the doorman to the director of it, each contributing from their role. Since mental illnesses had been observed to be dissociative, so the dissociated community did not contribute in any way. In addition, the Antipsiquátric Communities were created, which aimed for patients to reach a state of greater regression in the search for a curative attempt. With Franco Basaglia, the Socializing Communities were founded, seeking to recreate within the institution, the dimension of the social terrain in which the patient lived. Communities of the Psychoanalytic Court were established in France, so within these, the García Badaracco Psychoanalytic Therapeutic Community was created, introducing the family dimension in the treatment of madness. In contrast, the Psychodynamic Court Clinics are created, psychoanalysts who met to create a Psychiatric Clinic, interpreting the vicissitudes of the patient, hospitalizations where the team decides where to address the pathological phenomenon.

Another place was the Hostels and Psychiatric Residences, with open doors, without legal dependency. You could take a patient not as an intern, even if he was inside it. Currently, we can focus on the National Mental Health Law 26.657 that regulates mental illness and says in Chapter I: ARTICLE 1 - The purpose of this law is to ensure the right to the protection of mental health of all people, and the full enjoyment of human rights of those with mental illness who are in the national territory. (p.7)

In addition to the care that the subject should receive, the following is added: ARTICLE 9 - The care process should preferably be carried out outside the hospital confinement environment and within the framework of an interdisciplinary and intersectoral approach, based on the principles of primary health care. It will be aimed at strengthening, restoring or promoting social ties. (p.17)

Considering how the aforementioned considerations are carried out, it is established: ARTICLE 11. - The Enforcement Authority must promote that the health authorities of each jurisdiction, in coordination with areas of education, social development, work and others (...), implement actions of social and labor inclusion and community mental health care . The development of devices such as: outpatient consultations; social and labor inclusion services for people after institutional discharge; supervised home care and support for individuals and family and community groups; (…), As well as other benefits such as day hospitals, (…) socio-labor training centers, foster families. (pp. 18-19)

In this way, it is perceived how the more traditional idea of confinement, isolation, changes its gaze and introduces the idea of being able to address treatments in the patient's everyday places. Looking for alternatives that not only point to their evolution in the pathology but can also insert them into the society that lives with what they suffer. Said law continues to say: ARTICLE 12. - The prescription of medication should only respond to the fundamental needs of the person with mental illness and will be administered exclusively for therapeutic purposes and never as punishment (…). The indication and renewal of prescription of drugs can only be carried out based on the pertinent professional evaluations and never automatically. It should be promoted that psychopharmacological treatments are carried out within the framework of interdisciplinary approaches. (p.19)

This also reflects changes in the criteria when using medication in treatments, aiming for it to be under strict instructions from professionals, but not just one, but interdisciplinary. In addition, it is considered appropriate to mention how the mental illness of patients is carried out in case of requiring hospitalization, where the law mentions the following: ARTICLE 14.- Hospitalization is considered a restrictive resource, and can only be carried out when it provides greater therapeutic benefits than the rest of the interventions that can be carried out in the family, community or social environment. The maintenance of links, contacts and communication of the interned with their relatives, close friends and with the work and social environment should be promoted, except in those exceptions for duly founded therapeutic reasons established by the intervening health team. (p.21)

Where it is also established:

ARTICLE 15: Hospitalization should be as short as possible, based on interdisciplinary therapeutic criteria. Both the evolution of the patient and each of the interventions of the interdisciplinary team must be recorded daily in the clinical history (p.22) ARTICLE 20: The involuntary hospitalization of a person must be conceived as an exceptional therapeutic resource in the event that outpatient approaches are not possible, and may only be carried out when, at the discretion of the health team, there is a situation of risk for themselves or for third parties. (p.25)

Thus we become aware of the treatment carried out with patients, taking into account their particularities and the considerations that were being incorporated. By way of personal appreciation, these points worked on can be thought based on what would be the incorporation of Therapeutic Accompaniment, how the approach modality evolved and that from thinking about interdisciplinary work new possibilities are opened. Since there is a change in paradigm, work is reduced through hospitalizations, and institutions that work only during the day are being introduced, they are accompanied in the discharge, greater participation is given to relatives of the patient, the task of working is proposed with companions, teamwork is strengthened. History of Therapeutic Accompaniment We will bring Rossi (2010) who tells us that “in other countries there have been similar experiences or that they go in the same direction, although with other denominations,

having

their

particular

characteristics

according

to

the

developments of each place in which they were registered, as health system, social conceptions on the subject and the theoretical clinical schools from which they were carried out ”(p.19).

He also adds that in several Latin American countries, such as Brazil, Uruguay, Mexico, Peru and Chile, experiences have been developed in recent years that bear this name: Therapeutic Companion, although they have not had a persistent conceptualization. But it makes a caveat, in certain regions of Brazil, where the theme -based on pioneering developments- has a strong momentum today. This was worked on by Pullice (2011), where he tells us that there were moments of intense political and social upheaval in different countries of the Western world, which shows that they were the propitious terrain for the implementation of a whole series of experiences that From the strong impulse of Dynamic Psychiatry, Antipsychiatry and, fundamentally, Psychoanalysis, they began to give consistency to the idea that it was possible to advance in the treatment of those patients affected in various ways by severe psychic conditions. In addition, Pullice clarifies that this movement of opening and transformation, which began to mature since the beginning of the last century - and which has been accentuated since its second half, when the important development that Psychopharmacology began to have is added - was generating the conditions for implementation of novel outpatient care devices, which in turn led to the development of new and diverse disciplines, in response to the renewed clinical needs that, as a result, began to take place. To reaffirm this, Rossi (2010) tells us different experiences of how the concept and function of the Therapeutic Companion have been approached. There he tells us that in France it was called "animateur" (type of group accompaniment, linked to recreational activities, socialization), in Canada they work from the role they define as "clinical intervening" (as an institutional device), in Spain, The theme being worked on is called “Continuity of

Care ”(there they locate the place of the Therapeutic Companion, where they organize and coordinate care, moving from a model focused on exclusion to another based on integration into the community), among others. From this we refer to the first experiences in our country, where Rossi (2010) tells us: In our field, interesting experiences of rupture with traditional psychiatric institutionalization were unfolded, through the implementation of open systems, which revealed a new significance of insanity and its treatment, with the premise of safeguarding the social and productive insertion of the patient . Along with other alternative systems, the Day Hospital had an increasingly important place since the late 1950s, being one of the fundamental

devices

that

will

facilitate

the

implementation

and

development of Therapeutic Accompaniment. (p.20)

It is also necessary to mention the strong impact of the economic aspect that differs from what is currently happening. Generally, patients of a very good socio-economic level were treated in home hospitalizations and outpatient treatments. Their families, for social reasons or prejudices, did not want the hospitalization or the seriousness of the illness of a relative to be known. (Rossi, 2010) There he continues saying: With this system, they also avoided the deficiencies that the “hotel industry” of full-time psychiatric institutions generally had at the time. The essential thing is to think that at that time the fact of committing someone appeared as more stigmatizing, segregative, while a discriminatory idea towards the most severe mental disorders was stronger in some social sectors. This was to avoid the "stain" that a psychiatric hospitalization could leave for the social gaze. (p.30)

The history As we have been arguing, the appearance of this practice is generating many changes regarding how to deal with the sufferings of a subject, it is therefore necessary to be able to consider how they were impacting in our country. We can clarify that it has its beginnings in an indeterminate date that is situated between the end of the 60's and the beginning of the 70's of the last XX century. Therapeutic Accompaniment was born as a clinical tool that is part of a search - shared by a good part of the professionals in the field of Mental Health - whose purpose was none other than to try to subvert the then prevailing guidelines, still strongly ingrained, of the asylum model. (Pullice, 2011) There Pullice mentions that the creation by Mauricio Goldenberg, in 1956, of the first Mental Health Service with an Inpatient Room for Psychiatric patients takes place within the framework of a General Hospital - an unprecedented experience up to that time in the Western world - thus constitutes an indispensable reference guide in this search for resources, tools, and more effective devices for treating insanity. We will add what Rossi (2010, p.28) clarifies by stating that: “Dr. Jorge García Badaracco, since the 1960s, has worked with Therapeutic Companions, being the head of the JT Borda Hospital Service. This author, founder in 1967 of a Mental Health Day Hospital that some recognize as a pioneer, says that it is a technique used for many years in countries like the US, because it is not intrusive or invasive and is highly continent ”.

Said aut...