Walking and Singing...Weaving Words, Experiences and Places Through Therapeutic Accompaniment

René Schubert *

*Correspondence to: René Schubert, Psychologist. Clinical Psychology and Neuropsychology,
São Paulo, SP, Brazil.

Copyright

© 2024 René Schubert., This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 30 August 2024

Published: 20 September 2024

Introduction

“'If we are therapists, we need to realise that there is no specific place where the therapeutic encounter “has to” take place. In fact, any place can be the place of the encounter’ CLARISSA METZGER

‘Being able to listen to the person accompanied in the most diverse places: the ‘listening apparatus’ is the whole body, it is the speech heard, beyond words, it is everyday life in the geography of the world’ MAURICIO PORTO

Therapeutic Accompaniment (TA) is a resource and therapeutic option for clients who find themselves in a moment of crisis, imbalance and/or psychological distress. TA is a different kind of work in which the therapist (often a psychologist) accompanies the patient in a wide range of daily tasks and activities, enabling them to deal with the conflicting issues that arise from these activities.

As the name implies, the therapist accompanies the client. This accompaniment takes place in their family, work and academic environments, as well as in outdoor activities, social, cultural and sporting environments, among others.

The TA participates in the symbolic reconstruction of the subject after the onset of crises or a moment of intense need, because it involves a certain amount of suffering, discomfort, psychic conflict that paralyses, disturbs or impairs the person in their daily activities.

Often as part of a multi-professional team (psychiatry, neurology, psychology, occupational therapy, pedagogy, among others), they take part in building unique therapeutic projects for each client.

Generally, therapeutic accompaniment is indicated by the doctor or health professional who is monitoring the case and who, in the initial interview with the client, assesses the best therapeutic approach and strategy for the case. Once the need for therapeutic accompaniment has been verified, the professional draws up a therapeutic project together with the client. This project outlines and plans the issues to be addressed, the goals to be achieved and the average time it will take to complete. This project will be constantly reviewed and discussed with the client.

TA is proving to be a resource for social re-inclusion that is increasingly used in the field of mental health and is now being extended to the areas of mediation, education and social work. As an articulation clinic, it aims to relieve suffering through therapeutic outlining, welcoming and listening in social, cultural and educational activities, as well as interrelationship and reintegration into the client's socio-cultural reality. Its field of work is the public space itself, outside conventional treatment institutions or consulting rooms.

In an article published by FRANÇA (2017) we have: ‘The professional goes to the patient's home and often accompanies them to public places - such as parks, restaurants and nightclubs - with the aim of providing psychological support and improving social skills. Unlike traditional therapy on the couch, which analyses problems based on reports, TA immerses itself in the patient's individual universe, participating in daily life (...) TA does not replace conventional therapy, it is a clinical indication for those who need an intervention in daily life.’

Complementarily, in CEMBRANELLI (2014): ‘In TA, the focus is not so much on what is said, but on what is done, seeking through concrete actions to transform fears, insecurities, anxieties and thus rescue the power of the subject and their bet on life. This occurs through the shared construction of actions between the companion and the person being accompanied (the recovery of social life, the mediation of a conflictual family relationship, the tidying up of a cupboard, going out to the cinema, planning studies, for example) with the aim of offering psychic support to the subject and the transformation, through concrete actions, of their painful experiences into psychic and emotional development’.

This modality emerged in around 1970 when it was implemented in Argentina - as an alternative treatment for chronic patients who did not respond to conventional treatment (based on indefinite hospitalisation and internal therapeutic groups).

Together with the Psychiatric Reform and the so-called Anti-Asylum Struggle, the TA presented itself as a possibility of realising some of the latter's proposals.

‘Within the modern mental health scene, TA appears as a key element in helping to deinstitutionalise chronically ill patients.’ GHERTMAN (1997)

Deinstitutionalisation, rehabilitation and psychosocial reintegration are fundamental in contemporary treatment, as it seeks to stimulate the autonomy and development of the patient, who is active in their therapeutic process, rather than their accommodation and dependence on treatment.

In view of LAW No. 10.216, of 6 April 2001, on reformulations in mental health policy, signed by then-president Fernando Henrique Cardoso in Art. 4 we have:

‘The treatment will be aimed, as a permanent goal, at the social reintegration of the patient into their environment.’

And in Article 5: ‘Patients who have been hospitalised for a long time or for whom a situation of serious institutional dependency is characterised, due to their clinical condition or lack of social support, will be the object of a specific policy of planned discharge and assisted psychosocial rehabilitation.’

This law touches on the work of TA when it stresses the importance of working on the psychosocial rehabilitation of patients institutionalised in psychiatric clinics and hospitals. Social reintegration is the aim of the work of this unique mental health promoter.

Not that this professional's work is exclusively linked to psychiatric cases - but this is where it originated. Today, the OT carries out projects with a wide range of clinical conditions, including: depression, anxiety, phobia, drug addiction, eating disorders, learning difficulties and social adaptation, social withdrawal, hospitalised patients, elderly people in nursing homes, young people in social institutions, among many others.

As Maurício Castejan Hermann points out in the introduction to the book ‘Clínica do Acompanhamento terapêutico e Psicanálise’ (2017), TA today can be found in practical theoretical work in the most diverse approaches to psychology, psychoanalysis, philosophical currents, occupational therapy, nursing, psychiatry, law, social work, pedagogy - among many others that conceptually influence clinical practice and knowledge.

‘The fact that TA is a practice that takes place, above all, outside of treatment institutions - in other words, in squares and shopping centres, on the streets, in waiting rooms, in schools, in homes and bedrooms - triggers in therapeutic companions an acute sensitivity to capture what is happening in public spaces. This particular perception constitutes ‘listening’ in the TA clinic. This is amplified listening, which considers the relationships of words as much as the relationships of things - which are sometimes represented by words - as elements that make up a single narrative.’ PORTO (2015)

The names that preceded the TA were diverse: ‘recreational assistant, psychiatric assistant, sticky attendant, qualified friend’. The change in nomenclature demonstrates the transformation in the attitude and performance of this professional. They are no longer just an assistant or babysitter, but a professional who will give shape and containment to their client's psychic suffering, conflicts and disturbances through interventions, words and gestures in the open space of the city - in the walking and doing of everyday life in and around the city, society and culture.

This type of treatment can be found today mainly in mental health institutions, psychological clinics and educational environments where this work stands out for its contributions both in clinical case discussions, in the rehabilitation and social inclusion project of those being treated and in socio-educational developments in academic-labour environments.

According to METZGER (2017), this plural practice emerged in São Paulo - Brazil when the “A CASA” Institute was founded in 1979. This institution put forward an innovative proposal for the treatment of insanity based on the day hospital model, from which the first records of Therapeutic Accompaniment activity in the city can be traced. The first TA team was set up in this institution in 1981. Nowadays, TA is a relatively widespread practice in São Paulo and other states, especially in psychoanalysis and mental health circles. National and international TA meetings and symposia have been held in Latin America, Mexico and Spain. In São Paulo, there are TA courses with a wide variety of orientations, such as psychoanalysis, behaviourism and phenomenology.

Here's a frequent question/doubt: is the AT a kind of babysitter? Is it a friend we pay to be by our side?

Definitely not. Depending on the case being counselled, you might even get this idea when you look at this work through lay eyes and don't know what's involved in the counselling. In the case of a patient with a psychotic structure, the OT will do the work of translating reality, outlining the discourse, which can often be reminiscent of the careful work of a nanny, assistant or secretary. Here it is worth remembering the point made by JACQUES LACAN (1958) that the psychoanalyst acts as the ‘secretary of the alienated’. Listening and care in the management are diverse and unique for each case that presents itself, for each therapeutic project drawn up. The aim is to make the client active in the face of their difficulties and suffering in order to overcome them. Weaving and stimulating autonomy with consequence and responsibility. OT work takes into account not allowing the client to become dependent on the solutions and formulations created by the therapist, but to develop their own. It is necessary to provoke the client to search.

Take them to their formulations, reflections and creative inventions in their environment. You also have to know how to recognise them and value them when they occur, which is why listening to a clinical professional is so important. The therapeutic project previously drawn up with the therapist will gradually be transformed into personal discoveries and a guideline for the subject's life. A reference point in their treatment and subsequently in their daily lives.

Now to another recurring question: Does TA occur only in psychotic patients? Is it possible with other clinical conditions?

TA is not restricted to psychotic patients. The difference lies mainly in the Therapeutic Project. With a psychotic patient, the work is long-term and is most often a construction aimed at rehabilitation and psychosocial reintegration - in this case, multi-professional teamwork is of fundamental importance. In the case of neurotic patients or other clinical conditions, the work is generally short-term and the issue addressed is more focal. Of course, it's important to emphasise that this varies from case to case.

As SILVA (2003) points out: ‘Therapeutic Accompaniment is an activity carried out (for over 40 years) in a space not restricted to the consulting room. TA is used for anyone who needs specialised companionship outside the consulting room. There is a wide range of people who have benefited from this practice, such as the elderly, children, people with phobias, schizophrenia, autism, depression, panic, anxiety attacks, accident victims and others.’

And also by CHAVES (2021): ‘TA has no specific target audience. It is suitable for children, adults or the elderly. However, the technique is not only suitable for those who are suffering from an illness. It is also beneficial for shy individuals who want to make new friends, children who are having difficulties at school or even for people included in the witness protection programme who need to adapt to a new reality, for example. The exchanges between the therapeutic companion and the patient are ‘mediated by the city’. The idea is to combine listening with walking, so that the person being cared for can get in touch with the outside world. Walking through the city can reveal important details about patients that would be difficult to learn in a conventional psychological consultation.’

I've been working as an TA since 2001, having learnt this therapeutic strategy and posture within the psychiatric clinic from supervising psychiatrists and psychoanalysts. It's a fantastic resource for office practice. Listening to the client in social environments, on the street, in the underground, in parks, exhibitions, the theatre, bars, restaurants, at home, creates other contours and possibilities for intervention. Talking happens while walking. Listening happens while doing. The city becomes a witness and a backdrop to the therapeutic process. With both child and adult clients, TA comes as a surprise, a welcome, proximity and contour. The weaving and building of safe, inclusive and continental spaces in the family and socio-cultural context for each subject, for each singularity.

This article written by psychologist and psychoanalyst René Schubert was published in June 2024 in Brazil in the book: Estratégias terapêuticas e intervenções no atendimento psicológico da criança ao idoso by Editora Conquista.

Reference

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