Hecho el depósito legal que marca el Decreto 460 de 1995

 

 

Accompanied Selfrehabilitation

 

Alberto Fergusson

Medicine and Health Sciences Texts Collection

 

©  Editorial Universidad del Rosario

© Universidad del Rosario, Escuela de Medicina

y Ciencias de la Salud

© Alberto Fergusson

© Courtenay M. Harding, Foreword

 

 

Editorial Universidad del Rosario

Cra. 7 N° 12B-41 Of. 501
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editorial.urosario.edu.co

 

First Edition: Bogotá D.C., June, 2015

 

ISBN: 978-958-738-611-0 (Paperback)

ISBN: 978-958-738-612-7 (Digital)

 

Editorial coordination: El Rosario University Press

Proofreader: Louise Watson

Translation and proofreader: David McPherson

Cover Design: Miguel Ramírez, Kilka DG

Cover image: Anonymous, photographic archive of the Accompanied Selfrehabilitation Institute

Graphic design: Margoth de Olivos S.A.S.

ePub Design: Lápiz Blanco S.A.S.

 

Printed and made in Colombia

Impreso y hecho en Colombia
All rigts reserved. No part of this publication may be reproduced without prior written permission from El Rosario University Press.

 

 

 

 

 

Dedicated to Olivia, Diana, Pablo Emilio, Leopoldo, Ana maría, Alicia y Emilio

Foreword

Every once in a great while, there arises a young psychiatrist with entirely new rehabilitation ideas for helping patients retrieve their lives from psychosis. Usually such ideas initially elicit significant negative reactions from peers but a handful of sturdy physicians have continued on to show the world that something different is possible including George Brooks of the United States, E. E. Antinnen of Finland, and Franco Basaglia of Italy. Now we have to add to this list of illustrious doctors, the name of Alberto Fergusson of Colombia.

Dr. Fergusson also defied the establishment in the early 1980’s. He found poor and homeless people with serious psychological problems who had been released from custodial hospitals and took them off the city streets and introduced them to a whole new way of life. Fergusson developed high quality facilities both in Bogotá and on a farm in a nearby town. He established housing facilities and a variety of possible job sites, such as a bakery, a pottery, and laundry as well as a library and a town meeting hall. This project followed the ideas of the Institute of Accompanied Self-Rehabilitation, also know as fungrata or “La Granja” (the farm), which he founded. For about 20 years, he worked to make it successful. 

But like the pioneering rehabilitation psychiatrists before him, Fergusson kept observing what was needed and kept dreaming about what else might be possible. He decided that the “La Granja” experience was not good enough –that people were still not really part of the general community and not, in fact, managing their own lives. So he took a major step and let go of the need for control.

He began to help people find their own housing through entities serving the general public and jobs were secured through community resources as well. Fergusson, his clinical staff, and volunteers relegated themselves to supporting the efforts of patients as they worked toward recovery and tried to reclaim their lives. Therein lies the idea of Accompanied Self-Rehabilitation.

Fergusson openly shares what little scientific knowledge there is about the workings of the mind and psyche with individual biographies constructed targeting levels of functioning and psychosocial activities. Psychopathology is discussed only to discover what the triggers are and how to avoid escalating symptoms and unhelpful behaviors and cope better. Timing is different for each person. Dr. Fergusson assumes that people can ultimately be responsible for their own lives. Imagine that! He and his team of clinicians and volunteers actually walk side by side with people trading information and experiences — learning from one another in a mutually interactive, empathetic, and respectful manner. This represents a difference between acquired wisdom and knowledge gained from reading books.

The idea of stepping back to a supporting role is currently being discovered by general physicians who admit that only a few surgeries and antibiotics help to cure people. The new approach helps people learn to heal themselves by using changes in knowledge and life style choices to help resolve such diagnoses as type 2 Diabetes, high blood pressure, and many other disorders including schizophrenia. This job requires curiosity, persistence, optimism, encouragement, support, patience, kindness, and resilience on the part of the supporters as well as the person trying to recover. It also requires a strong dose of humility and a trust by the clinical team that most human beings might be able to learn to judge what is best for themselves and the timing involved. These findings are now being taught in a few medical schools and are slowly changing medical practice. Dr. Fergusson has been leading the way in psychiatry.

Courtenay M. Harding, Ph.D.

Department of Psychiatry (retired)

College of Physicians and Surgeons

Columbia University, New York City

March 9, 2014

Introduction

The technique of Accompanied Self-Rehabilitation and the theory of psychosis as a phenomenon of psychological destruction and decomposition are, in a certain sense, heirs to that wonderful dynamic that existed in the 1960s. Under the banner of two of its masters, Freud and Marx, otherwise officially declared dead, that generation allowed itself to dream and consider the possibility of a different kind of society, one in which human potential would be more fully developed. The Frankfurt School tried unsuccessfully to keep the two masters alive, but the evidence shows they had, in fact, in been buried alive. Their ideas have grown stronger, even though that has not been true of the movements they inspired.

Having had the chance to observe the phenomenon of psychosis for more than 40 years offers an unparalleled opportunity for insight into the human phenomenon. In this regard, this book merits the title Normalcy Illuminated by Madness. The mental mechanisms at work in the healthy and pathological minds are distressingly similar. This is why the technique of Accompanied Self-Rehabilitation, initially used in cases of severe emotional disturbances, has proved so useful in accompanying all types of people along their various life paths. The theoretical inquiries that gave rise to the Accompanied Self-Rehabilitation Institute, together with the empirical evidence gathered—in other words, the experience of Fungrata—seemed to have led to the desired objective at the end of the 20th century. Repressive and asylum psychiatry appeared to be on the road to extinction. However, a new variant has emerged that we have termed the chemical asylum, in which the chemical molecules of drugs have replaced the former asylum bars. A new resolve, therefore, is needed to ensure that sufferers become the true leaders of their life processes, in the sense that Accompanied Self-Rehabilitation describes.

The Technique of Accompanied Autoanalysis and the Theory of Psychosis as Psychological Destruction and Decomposition

Presented at the Twelfth International Symposium for the Psychotherapy of Schizophrenia. London, October 1997.

Introduction, Dr. Lina Sinisterra:

Thank you Dr. Cullberg. Good morning, ladies and gentlemen. It is my pleasure to be here with you and to have the opportunity to talk about the technique of Accompanied Autoanalysis and the theory of psychosis as psychological destruction and decomposition. As you know, these ideas were developed by Professor Fergusson and his team, of which I feel proud to be a member.

Just a couple of words about Professor Fergusson for those of you who do not know him. I first met Professor Fergusson when I was a student of psychology, and my peers and I were delighted to be in his classes. That was seven years ago, and I told him at that time that I was very interested in working at Fungrata. Fungrata is an institution founded by Professor Fergusson 15 years ago. The purpose of Fungrata, a world-renowned institution because of its high scientific standards and social impact, is to rehabilitate homeless psychotics. I have been part of his team ever since. I find it almost impossible to express the extraordinary range and breadth of Professor Fergusson’s work. It is immense. Scientific rigor, ethical values, and human rights have been Professor Fergusson’s hallmarks, and they have enabled him to develop innovative theoretical and technical approaches. Thanks to these approaches, very complicated things seem much more simple. He is currently director of Fungrata and a professor at Universidad de los Andes. The following was written entirely by Professor Fergusson.

Professor Fergusson via video:

Good morning, ladies and gentlemen. It is my pleasure to be here with you and to have the opportunity to talk about the technique of Accompanied Autoanalysis and the theory of psychosis as psychological destruction and decomposition. As some of you know, I was not able to fly to London because of my commitment to the peace process in Colombia. I hope that in the next symposium I will either be with you in person or will be able to see each of you, with the help of technology, directly via the Internet. I want to thank Dr. Sinisterra, one of the nicest and most crucial members of our team, for flying to London to meet with you. She is perfectly familiar with our views, and therefore I am quite certain that she will be an excellent ambassador for our work. It is my pleasure to participate in the Twelfth International Symposium for the Psychotherapy of Schizophrenia here in London.

We must say that we have been impressed by the changes that the following theoretical and technical developments have generated in the prognosis and overall quality of life of persons diagnosed with schizophrenia, and that has encouraged us to present these ideas to the international scientific community.

Firstly, we will briefly review the general principles that have guided us in the comprehensive rehabilitation of persons diagnosed with schizophrenia. After that, we will introduce the concept of psychosis understood as the result of psychological destruction and decomposition, and finally we will describe the technique of Accompanied Autoanalysis.

For the sake of fluidity, we will not use the his/her, she approach.

A. The Basic Principles of the Rehabilitation Process of Persons Diagnosed with Schizophrenia

Since 1980, our private and institutional work has been guided by a very simple idea: the history of mankind has shown what people need to become real human beings. They need to work, develop an emotional life, have access to art, eat, sleep, have sex, have time for recreational activities, and so on.

We decided that we had to give people diagnosed with schizophrenia, or “crazy” people, the opportunity to obtain these basics. The world has been designed so that only so-called “normal” people, in a best-case scenario, are able to access these things. Nevertheless, while we wait for some genius to discover how to “cure” so-called schizophrenia, we try to identify the particular ways in which people diagnosed with schizophrenia can develop themselves as human beings. We are opposed to all kinds of asylum-like treatments and against any violation of their human rights.

In tandem with the anti-psychiatry movement of the sixties and seventies, we learned to distrust the word “crazy.” Nevertheless it is the only word that ensures that we are speaking the same language and describing the same phenomenon. It is better to combat myths about craziness than to fight the word itself. The word “schizophrenia” might disappear in the future if science confirms that it does not correspond to one specific illness.

The basic findings and ideas that led us to Accompanied Autoanalysis and to a new theory of psychosis over the past 17 years are the following:

1. Patients have to become experts on their own minds. We are not speaking of the sort of knowledge someone can achieve through psychotherapy or psychoanalysis. We mean a different and perhaps more practical sort of knowledge.

2. So-called “patients” have to reorganize their lifestyles in a creative and ingenious way—oftentimes disregarding certain social conventions—based on their newly acquired knowledge. This is true even if, at times, these people have to appear somewhat crazy in order to avoid real craziness. People who have not been diagnosed with schizophrenia may become bitter or depressed if they do not do this, while a person with a psychotic predisposition may become a so-called “psychotic.”

3. We welcome crises. We do not encourage their occurrence, and we take psychological, sociological or pharmacological steps to avoid them. When crises do occur, we try to make the most of them. Simply getting rid of a crisis can be tantamount to psychological murder. The way crises are handled (besides simply using or not using drugs) has an impact on the onset of deterioration. The rehabilitation process can be carried out with or without drugs. This depends on each individual case at every stage of the process.

4. We stress the importance of certain character traits in the therapist. Rehabilitation of persons diagnosed with schizophrenia cannot be effectively achieved by therapists who are too moralistic. It is desirable that the therapist be the type of human being who does not know what others should do with their lives. The therapist’s real self is inevitably used in any type of therapy.

5. We encourage the indirect treatment of schizophrenia. Due to all the interconnections of the mind, treating schizophrenia indirectly is as necessary as treating it directly, or even more so. We have identified certain mechanisms that are essential in determining the course of schizophrenia and other psychological conditions.

6. The conceptualization of psychosis as psychological destruction and decomposition, as opposed to psychological life and real being, has been most valuable, as we shall explain later.

7. It is important to always bear in mind our enormous ignorance with regard to so-called schizophrenia, the mind, and the brain in general. That is one of the reasons for allowing the patient’s natural healing forces to do the bulk of the work.

8. Advice (telling others what they should do) is, in our opinion, unethical.  knowledge is so scarce that no one really knows what others must do. All we can do is provide scientific information.

9. The patient is the one who does all the basic work. In the long run, all therapy is auto-therapy. “What you do not do for yourself, no one will do for you.”

10. A sense of humor is one of the best therapeutic tools, though it is seldom used tools. We encourage its intelligent use.

11. The rehabilitation process must be a pleasant experience for both the so-called patient and the therapist.

We shall now explain the theory of psychosis understood as psychological destruction and decomposition. The mind, the living mind, is, in our opinion, correctly described in terms of the conscious and the unconscious (Freud, 1915), but to understand psychosis we had to introduce the concepts of psychological destruction and decomposition, and psychological life, and real being. In our view, the psychoanalytical theory of the mind is dedicated to describing what we call psychological life: repressed psychological material is completely alive, unconscious material does not decompose, what has been subject to the mechanism of splitting remains alive, and so on.

Observation has led us to affirm that, psychologically speaking, psychosis is equivalent to psychological destruction and decomposition, this means in a certain sense, this means that psychosis, as such, is nothing. What we call psychoses really are mostly signs of psychological remains and detritus. Psychosis occurs when the real being (psychological life) of the psychological human being cannot and does not prevail. We have come to believe that psychosis and psychotic symptoms have no special meaning, that they are not defensive, and that they are just what is left of what once was the real being (the psychological life). The question is: what is the psychological life that is being destroyed, or is already decomposing? We believe the process is similar to what happens to the body of a human being after biological death. There are a variety of changes and activities occurring inside the body, but nevertheless that body is dead.

Psychosis is thus an anti-being situation. Psychotics are humans that are not-being. Fortunately, psychosis is usually partial, so we should say that the psychotic areas of so called psychotics are not being. Being or not-being is once again, the most basic psychological human struggle, and psychosis is the most vivid example we have of what we call psychological destruction and decomposition, or of being a human who is not fully being. Destroyed and/or decomposed psychological material is what we see in so-called psychotic phenomena.

We speak of real being and psychological life when the psychological process in question maintains its vitality, no matter what vicissitudes it may have undergone. You may call it the instinctual process or the object-relation process, or you can use whatever psychological model you wish. Psychosis, by contrast, is the destruction and decomposition of such psychological life. We have dedicated too much energy to understanding what psychosis is and very little to understanding what it is not. Real being and psychological life are the opposites of psychosis. From a different perspective, we are close to some of Fairbairn’s observations (Fairbairn, 1941) about the way in which the very existence of the ego becomes compromised in schizoid states. The difference between Fairbairn’s approach and ours lies in the fact that he finds the essence of psychosis to be psychological splitting, while we find that essence in psychological destruction and decomposition. In our view, psychological repression and splitting are both part of psychological life and are less harmful than the mechanism of psychological destruction and decomposition.

We accept the possibility of a predisposition to so-called psychosis, in the sense of a group of very particular susceptibilities, both in quantity and quality, that can inflict enormous psychological wounds and lead to psychological destruction and decomposition. Are such susceptibilities inherited, and because of that do certain events become traumatic and cause psychological destruction and decomposition? Do certain traumas generate such susceptibilities? Does a combination of inherited factors and traumas explain these susceptibilities? We do not know. What we do observe is that a very particular traumatic factor is essential to understanding psychosis.

In psychosis, there are both psychologically destroyed and decomposed areas and psychologically living areas. Psychological destruction is sometimes reversible. Psychological decomposition is by definition irreversible. As therapists, we are obliged to accept the possibility of resurrection, or at least of false decomposition. We cannot lose hope, and in fact all sorts of surprises can be found. Sometimes psychological material is buried alive, so to speak. This is discussed, with different terminology, in Courtenay Harding’s paper on the seven myths about schizophrenia.

For the psychotic person, what is at stake is a struggle between psychological life and psychological death. When we say that the person has “to become an expert on his own mind” and “design his life in a creative and ingenious way,” we mean a way in which such a person can obtain psychological life and real being as opposed to the alternative total or partial psychological destruction and decomposition. That is why designing one’s own life through Accompanied Autoanalysis is so important. Certain apparently insignificant internal and external circumstances can make all the difference between the possibility of enjoying psychological life (real being) or suffering psychological destruction and decomposition (psychosis). Internal circumstances may change, and what today creates psychological life may tomorrow generate psychological destruction and decomposition. Sometimes there is a decisive moment, an instant during which a person takes the road either toward real being and psychological life or toward psychological destruction and decomposition.

What we are saying is simply that psychological material, inasmuch as it is part of the material living world, can be destroyed. Failure to accept this would mean that psychological material is made of a different substance. We would once again be close to immortality.

Besides our work with the emotionally impaired, we also have drawn our conclusions about psychosis, psychological destruction and decomposition, psychological life, real being, and Accompanied Autoanalysis from another source. We are referring to the work we have done with writers, trying to discover the secrets of creativity. There is a popular myth about psychosis that suggests it can be productive. We believe that it is totally unproductive. People who suffer from severe mental illness and have been creative have managed to create despite their psychoses and not because of them. The paths to psychosis and creativity are similar up to a certain point but completely different in the long run. In fact, they become opposites inasmuch as creativity are psychological life and real being, and psychosis is psychological destruction, decomposition and disintegration.

Let us now review the technique of Accompanied Autoanalysis. Bearing in mind the 11 basic rehabilitation principles and the theoretical considerations about psychosis, understood as psychological destruction and decomposition, and drawing on the help of our so-called patients, we have gradually arrived through trial and error at what we now call Accompanied Autoanalysis.