Description of the field of the experience

This work takes place in a general hospital under the Ministry of Health of the province of Buenos Aires, in the outskirts of the capital. The population that comes to it belongs to the working classes; it consists mostly of people who have come from the interior of the country, so that it can be affirmed that its area of influence has been, and remains, a meeting place between cultures.

This phenomenon increases marginality on the economic, political, social and cultural planes. In the field of mental health, the reproduction of the norms and attitudes of the place of origin has obliged us to reformulate the concepts of Health/Illness used by the hegemonic medical model, giving value to the life experiences of the population that calls upon us.

As head of service, for six years, I sought to develop training in systemic-cybernetic reading among the professionals who made up the service; at the same time a plan of Mental Health Residencies of the province of Buenos Aires was being created, likewise centred on this same epistemology.

The epistemology used

On the basis of this theoretical training, the professionals were able to construct “other” maps, different from those of the biologising or dynamic psychologising model, which are the foundations of the hegemonic medical model. Following Keeney, we can affirm that to name is to classify, and that to draw a map is to name. There is a coding between the thing about which one informs and what one informs about it. Consequently, and as Maturana stresses, “everything I say, I say as an observer addressing other observers”. The experience of what is external passes through my sense organs: objects are therefore my creation, and my experience is subjective.

Nevertheless, by means of denotative language, description constructs what is called objectivity; in this way, the subjective is expressed as though it were independent of us as observers.

From a cybernetic point of view, a web of recursiveness is established that would encompass both sides of the observer/observed distinction. The diversity of an ecosystem is a way of speaking about health, and what is named pathology would be a part of that totality which is health. Within this totality a self-correcting organisation would operate, on the basis of diverse sequences that would avoid recycling.

For there to be a change in our perception, there must be a change in the context in which the problem arises. All our reality is social, and we are individuals only insofar as we are social beings in language. The genetic does not determine the human: it only establishes what can become humanised. Social problems are always cultural, because they have to do with the worlds we construct in life in common.

Insertion into the hospital

For a time, the general emergency department of the hospital medicated the supposed mental health patient without seeking the opinion of the mental health team, even though there were professionals on duty in this field. The overcoming of this conflictual stage was played out at the concrete level of the task, when the non-medical reading of human problems was accepted. This work was carried out by means of clinical meetings held in the emergency department itself, with all the members of the team. The loosening of the hospital system began to occur, at the same time, in other zones of contact: outpatient consultations, inter-consultations and community work.

Psychiatric hospitals and general hospitals

Psychiatric hospitals, as agents of social control, resolve people’s crisis situations according to a model that inhibits autonomous development. For them, the crisis situation is fundamentally disorganising, and they repress the behaviours that appear in response to external or internal stimuli. Hence the use, in psychiatry, of straitjackets, of chemical straitjackets, of prolonged isolation and of confinement.

The notion of “dangerous to himself or to others” makes it possible to shut someone up in a hospital-prison. There also appears the idea of “suffering” which, in the name of the search for relief, makes it possible to justify the whole psychiatric and pharmacological arsenal.

For the systemic model, the crisis is a moment of decision, a situation of possible change in the system’s vision of the world. This occurs insofar as the resources existing at that moment are put into play. For the social system, the appearance of the symptom means the halting of the natural course of life, an attempt to neutralise the phenomenon of change by favouring stability.

This reading of reality was the result of a supposedly linear vision of the world, founded on a scientific absolutism. For our conception, the crisis functions as an alert that makes possible the development of new behaviours of one’s own, in accordance with a certain relation to the context.

It is this same shift that is described, on the scale of an entire establishment, by the experience of institutional transformation at the psychiatric hospital of San Luis.

The La Matanza model

During the first six years, we attempted to obtain recognition of the mental as immanent to man’s relation with his environment, and to introduce the reading of the eventual, the hazardous and the unforeseeable as factors of human behaviour and of the family context (where the problematic of people’s life cycle is dramatised), laying the accent on ideology, understood as the semantic connotation that gives meaning to the elements of reality.

We sought to leave behind our tendencies to label, the fruit of a historical learning, in order to arrive little by little at “a change of gaze” upon what is called mental illness.

In the emergency department, a first interview is conducted with the whole family group living under the same roof; a clinical record is drawn up there whose aim is to gather the data relating to the reasons for the consultation. Among these data are: the genogram over three generations, the members of the family group who present themselves, the reason for consultation, how long the symptom has been present and the previous attempts to resolve the conflictual situation.

A first assessment is carried out, seeking to identify the degree of flexibility and the containing capacity of the family. There follows a restitution, then the decision of an outpatient follow-up or the recommendation of a family hospitalisation, seeking to defocus the identified patient.

Hospitalisation was the object of a contract of 48 or 72 hours, renewable, avoiding going beyond seven days. In this way we attempted not to provoke, with the therapeutic team, a stereotyped and iatrogenic relation that could have led to a situation of dependence and, by that very fact, brought about a return to the psychiatric and pharmacological model.

At the end of a long process of internal discussion, of clinical meetings and of workshops, a coherence gradually took shape allowing the cybernetic reading of human behaviour.

During the first four years of the experience, there were no interferences between the hospital management and the service; we were always able to count on the support of the management team. Difficulties occasionally arose with certain heads of department, owing to the fact that the hospitalised patients, the hospital being open, walked about the establishment and that the nurses read these behaviours as full of danger. This perception of threat, present in the culture, diminished as the experience developed and as the members of the mental health team increased their presence in the different departments of the hospital, thanks to the requests for inter-consultation, the clinical meetings and the groups that brought together the professionals of the different sectors.

In the course of the two following years, the pressure of the central provincial authority increased, which produced various conflictual situations within the service; as these grew worse and our possibilities of correction came to be lacking, their final outcome was my departure from the experience.

Summary of the first part of the experience

In the course of it, we attempted to use no model other than the systemic model, which is why the biologising and pharmacological model was very little employed. For us, the use of a medication (sometimes in homeopathic doses) was justified only for the sole purpose of integrating it into a therapeutic strategy seeking to establish a feedback that favours change. This change occurs within the landscape of possibilities that the family organisation possesses, which may be inhibited by the pharmacological use of medication.

Our successes or our failures rested on our capacity (or our incapacity) to create with families alternative models for reading “reality”, models allowing us (or not) to come out of crises. I believe that, in order to be able to conduct such an experience, one must have the authorisation of the medical, psychiatric and psychological powers in order to reach these objectives. There must furthermore be an epistemological coherence internal to the therapeutic team, a coherence that must also increase as the work goes on. I consider that this last point was not fully achieved, for an operational phenomenon began to develop.

Second part of the experience

Following the request formulated by the inpatient team (with the endorsement of the head of service) as to the possibility of resuming the previously interrupted experience, the second part of the experience begins with my return as supervisor of the team. The aim of the supervision was to provoke, by perturbing the team, in order to reach a modification or a change of level.

I think that the team that summons me, as a living system, can reach a modification — and I with it — by widening cooperation and integration among all. To question the reality in which one moves on the basis of answers that do not satisfy is a principle of change.

It is quite possible that the time elapsed between my departure from the experience and the call as supervisor was the time necessary for both parties to have been able to develop a greater conceptual closeness to the epistemology that had to be put into practice. From this return onwards, this commitment was better accepted by both members of the supervisor-therapist pair.

Widening of the theoretical framework

This framework belongs to the search for the development of what is called mental health within interpersonal games, whether these take place between human beings, between families or between institutions. The dissatisfaction of some of the members in the relations that are established shows itself through symptoms that offer the whole system the possibility of reaching, starting from the crisis, another mode of organisation.

Assuredly, new forms of interaction and new options of behaviour can give rise to a healthier functioning of the system.

Within the framework of the therapeutic approach, what is called subjectivity and the inclusion of the therapist as co-constructor alongside the members of the family system fundamentally mark the search for solutions to the problems that motivate the consultation. This play of interactions puts us under the necessity of leaving behind the nosographic definitions of diagnoses that authorise the sorting and labelling of “patients”, in order to move on to descriptions of relations in which our construction, joined to the family’s responses, would find a new path towards change, understood as the breaking of an interactional game that is no longer functional.

For Bateson, all information is the perception of a difference, and he situates this knowledge in time. In order to give meaning to their lives, people organise their experiences of events into temporal sequences, seeking to obtain a coherent account of themselves and of the world around them. An acceptable outcome in therapy could be the production of alternative accounts allowing them to figure new meanings, bringing more desirable possibilities, which people would accept as more useful, more satisfying and open-ended.

On the basis of questions, a new context of reflexivity can be brought into being, one that brings people new possibilities as to the use they make of it and as to their relations. Individuation would come about, according to Whitaker, through the development of one’s own ideas, which the dominant and disqualifying accounts of the culture — relayed by other people — maintain and prevent.

José A. Marina writes: “what we see reveals to us what we are, because we grasp what we know how to grasp, and consequently the world we experience is the portrait of our negative”.

Clinical cases

María C.

María C. is admitted through the emergency department of the service, with a diagnosis of puerperal psychosis. She receives drug treatment, which leads to the interruption of the breastfeeding of her second daughter, three days old.

The hospitalisation takes place with her husband and her younger daughter, Gabriela. Her first daughter, Mariana, had been conceived while she was a single mother. This fact had the consequence that Mariana was brought up by her maternal grandparents — as their eleventh child —: the grandparents thus became the parents, and the little girl the sister of María C. (see figure 1 of the original article).

The arrival of Gabriela could mean, in the life cycle of María C., beginning as a mother and, according to the new construction, being able to take care of her; or else, failing that, entrusting her to others, perhaps to Mario’s parents. In this movement, María C. could become an adult, or continue to function as a daughter.

The therapeutic couple decides to work with the three generations, insisting on the possibility of Mario functioning as husband and as father, accompanying María C. in her supposed incapacity.

After two days of hospitalisation, María C. asks to breastfeed her little girl: the treatment is then withdrawn and she is discharged with a follow-up.

As the therapeutic team — composed of a psychiatrist, an occupational therapist, a psychologist, a social worker and two medical interns — became integrated and managed to work in a multidisciplinary way, its relation with the supervision team and with the families grew more flexible.

Until then, the supervisions centred on the oral presentation of the clinical records. The new proposal for supervision, as the integration of the therapeutic team took place, was to hold the supervision meetings jointly with the therapists and the consulting family.

This new form of work made it possible to leave behind a dominant account conjugated in the past and to enter into the production of alternative accounts in the present, thus enriching the possibilities of construction of reality.

María V.

An example of this movement was the clinical situation presented by María V. (see figure 2 of the original article).

She is admitted with her partner and her two children, for delusional jealousy, attempts at physical aggression and threats to leave Hilario taking her two children with her. It is a second hospitalisation in the same service, when her second son is four months old. María V. and Hilario are a couple of Paraguayan nationality who live on state-owned land, in very precarious housing that she defines as a “rancho”. It is situated at the front of the plot, and Hilario’s family (parents, brothers and sisters) lives at the back.

The couple have lived together for four years and, despite María V.’s repeated requests for marriage, Hilario refuses. Following a supposed infidelity on his part, situations of violence appear between them, with police intervention. This leads to the first hospitalisation, where she is medicated on account of her behaviours held to be bizarre. Discharge takes place two months later, the treatment continuing until the announcement of her second pregnancy.

On the proposal of the therapeutic couple, an interview is arranged with all the members of the inpatient sector, the supervisors, María V., Hilario and their sons Cristian and Elías. The work centres on the myths and the customs of Paraguayan culture, in particular on the modality learnt by Hilario from the model of his parents, which he attempts to apply with María V.

We suppose that María V., in her professional activity (domestic employee), has come into contact with other models of couple relationship, which would give her the possibility of confronting them with the model she is living with Hilario. If María V. does indeed attempt to face these models, the thing is not so easy for her, for she confronts herself with her own map of the world, similar to that of Hilario.

The therapeutic couple, in dialogue with the rest of the team, supervision included, elaborates a narrative on the theme of transculturation, which opens the possibility of discussing new agreements between the partners. These agreements would not pass through a value judgement made on each of the models; they would aim at finding a life in common with more points of convergence, arriving at a model of their own that avoids the obligatory reproduction of the models of origin.

On the way in which the reception of a family in crisis is organised in the moment, one may also read the clinical questions and technical resources in the approach to a consultation in crisis.

Conclusions of the two experiences

It is possible to create, to develop and to maintain a mental health service that functions on the basis of these constructions. The difficulty is to make the distinctions operated by the therapists such that they allow the regularities and the organisation of the family system to be grasped, and allow one to leave behind the supposedly scientific necessity of creating “dormitive principles” that only make it possible to render the situation chronic. If we could accept, ethically, that the world is made of relations that take shape in language on the basis of stories, these could make it possible to co-construct with clients new histories in which problems would no longer be a defect, but a way of expressing social discourse.

If, on the contrary, we accept, on the basis of certain theories, the establishment of a diagnosis, the possibility of understanding a situation is thereby reduced and, consequently, the evolution of what is called mental illness undergoes profound changes that very often lead to chronicity.

I consider that, insofar as the different members of the therapeutic team acquire a certain epistemological homogeneity, they can deploy a greater individual heterogeneity. Likewise, in the second stage of the work, a greater personal integration and self-valuation developed as the foregoing came about, thus making possible the process of dependence/individuation that Whitaker posits.