caet-2023-0016

This article delineates a study conducted within a psychiatric day hospital in France, adhering to the principles of institutional psychotherapy and therapeutic clubs that originated from the anti-psychiatric movement of the 1970s. The study specifically explores two activities within this framework: a music club and a video club. The primary objective of each club was to establish activities involving both the patients and the care staff to dissolve the boundaries between them. Additionally, these activities aimed to engage both patients and care staff in the conceptualization and execution processes, thereby fostering a collaborative approach within the psychiatric care setting.

Keywords: therapy, institutional psychotherapy, therapeutic clubs, psychiatric day hospital, anti-psychiatry, performance, music, video, enaction

本文描述了在法国一家精神科日间医院进行的一项研究，该研究遵循起源于 1970 年代反精神病学运动的机构心理治疗和治疗俱乐部的原则。该研究专门探讨了该框架内的两项活动：音乐俱乐部和视频俱乐部。每个俱乐部的主要目标是建立涉及患者和护理人员的活动，以消除医患间的界限。此外，这些活动旨在让患者和护理人员参与概念化和执行过程，从而在精神科护理环境中培养协作方法。

关键词： 治疗, 机构心理治疗, 治疗俱乐部, 精神科日间医院, 抗精神病学, 表现, 音乐, 视频, 行动

The research detailed in this manuscript was conducted at a psychiatric day hospital in France. This facility serves individuals with mental illness, offering a structured environment where patients can spend their days participating in therapeutic activities without residing full-time in the psychiatric hospital. These individuals maintain a level of autonomy that enables them to return to their homes in the evenings and during weekends. Predominantly stabilized through prescribed medications, they exhibit the capacity to function within the community. The psychiatric day hospital serves as a space where these individuals engage in various group activities while also benefitting from individual sessions with the overseeing psychologist.

The underpinning structure of this study aligns with the principles of institutional psychotherapy and operates within what is referred to as the therapeutic club framework. The current research follows in the vein of works by Tosquelles (2003, 2007, 2021), Oury (1980, 1989, 2003, 2005, 2008, 2016; Faugeras et al., 2020), and Delion (2005, 2011, 2018, 2022, 2023a,b). These influential figures’ philosophies and contributions provide the theoretical foundation and context for the approach adopted in this study. See also Le Roux (2005) and Ledoux (2023).

The fundamental concept of institutional psychotherapy revolves around the notion that the entire institution, encompassing both staff and patients, should be actively engaged in the patient care process. This philosophy advocates for the inclusion and participation of all individuals within the institution in activities designed to support patient well-being. This article will delve deeper into the mechanisms and implications of this approach within the context of patient care and institutional dynamics.

The entirety of the institutional psychotherapy movement emerged as a significant facet of the anti-psychiatric movement during the 1970s, as evidenced in works such as Bosseur (1974) and Cooper (1978). This broader anti-psychiatric movement vehemently criticized the practice of confining psychotic patients, primarily to isolate them from society and safeguard society from their perceived abnormalities. Central to the anti-psychiatric stance was the urgent call to reconceive psychotic patients as individuals deserving recognition of their humanity, advocating for a fundamental prioritization of their well-being above all else.

It is pertinent to highlight the significant connections between the anti-psychiatric movement and the therapeutic theories of Carl Rogers, as exemplified in works such as Rogers (1980, 2003, 2004). Despite the deep roots of institutional psychotherapy in psychoanalysis, a noticeable parallel exists, in my view, with the emphasis of both these approaches on placing the patient at the core of the therapeutic process. Furthermore, they both prioritize the relationship dynamics and shared activities among the individuals involved, rather than rigid adherence to strong theoretical methodologies. Rogers (2003) even asserts that the theoretical orientation of the therapist is of minimal importance as long as they can establish a relational space with the patient.

The primary objective of institutional psychotherapy is to facilitate the transition of patients out of the psychiatric hospital environment. Essentially, the goal is to empower them to achieve a certain level of autonomy. This recognition acknowledges that while they may not function entirely within societal norms, they possess certain abilities and competencies enabling engagement in activities and attaining a measure of self-sufficiency. The concept involves providing them with a daytime setting, predominantly on weekdays, where they can interact with others, engage in activities, spend time in a communal space, including having their meals, yet allowing them to return to their homes during evenings and weekends. During their time in the psychiatric day hospital, the focus is on assisting these individuals in acquiring and honing competencies that will subsequently foster greater self-reliance. This process aims to equip them with skills that could potentially lead to employment opportunities in specialized work settings.

In 2019 and 2020, I was afforded the opportunity to engage in the operations of a psychiatric day hospital in France, where I took an active role in initiating and participating in therapeutic clubs within the framework of institutional psychotherapy.

One of the primary hallmarks of these approaches is the equal footing of both patients and professionals when involved in shared activities. Collaboration in designing activities is a central tenet, emphasizing a lack of hierarchy among participants. The fundamental belief is that everyone holds the potential to learn from each other, fostering a relationship built on symmetry.

These activities typically revolve around various forms of artistic expression. At the particular day hospital where I was involved, several such activities were organized. Among these, I will specifically delineate two related to performing arts: the music club and the video club. The subsequent sections will offer a comprehensive description of their implementation, structure, and the dynamics of a typical session within these clubs.

Upon my arrival, the music club was already in operation, and I primarily participated as a member, occasionally taking on the role of a facilitator. The club had been collectively established by the overseeing psychologist, some nurses, and a group of patients. Meetings were held once a week, specifically on Friday mornings. The club adhered to a structured format, commencing with a segment devoted to music exercises (further elaborated upon later). This was followed by a brief intermission, leading into the second segment, during which we collectively performed well-known songs. Although the session had distinct parts, they were unified in pursuit of a common goal.

The initiation of the video club occurred during my tenure at the hospital. Although a version of this club existed before my arrival, we opted to completely redefine its purpose. The decision-making process was once again collective, involving patients, the overseeing psychologist, nurses, and myself. However, I assumed the role of facilitator for this particular club.

First, let us provide an overview of several exercises conducted within the music club. The primary objective of these exercises is to create an environment where each participant has the opportunity to engage in some form of musical expression. When referring to “music,” it encompasses a wide and general spectrum of musical expression. It could involve playing a drum, creating sounds using hands and feet, or singing in harmony. The emphasis lies in the act of self-expression through a medium associated with music and performance, encouraging individuals to express themselves through performance-oriented activities.

One particularly significant exercise within the club was titled “the conductor.” This exercise was open for anyone who wished to participate. The designated person would stand in the center and lead the rest of the group. Their role involved orchestrating the session by using hand and arm movements. When their hands were raised, the volume produced by the other participants—whether playing instruments or singing—was expected to be high. Conversely, lowering their arms signaled a reduction in volume. Essentially, the individual in the center regulated the overall volume of the performance.

This exercise holds significant interest due to the sense of authority it bestows upon the conductor, granting them the power to control the volume and even determine when the music halts. Simultaneously, the experience is highly enjoyable and fulfilling for the conductor, offering a palpable sense of accomplishment.

Numerous exercises similar to the one described were part of the club’s activities. While I would not delve into each one individually, the general structure of the first part of the session aimed to provide exercises that allowed participants to both have a pleasant time and engage in activities that contributed to their personal growth in various ways.

The latter part of the session involved collaborating on the performance of a chosen song or a few, contingent upon the session. The selection of songs was a collective decision, often made in the preceding session. The lyrics were printed, and we typically listened to one or two versions of the chosen song. Subsequently, the group endeavored to perform the song collectively, leveraging the best of our combined abilities. This was done by following a recording of the song or, occasionally, with the accompaniment of someone skilled in playing the keyboard.

The video club operated under a distinctive framework. As a collective, we agreed to engage in improvisational exercises, record them, and subsequently view them as a central aspect of the activity. This served as the initial premise for our endeavor. Fortuitously, we were able to procure a small camera and tripod, utilizing the resources at hand. Our setting was a room furnished with tables and chairs, and we also had access to a few costumes from a prior activity at the psychiatric day hospital. Commencing in this manner, we brainstormed various topics that could serve as the basis for our improvisational work.

An unexpected development swiftly emerged shortly after the club’s inception: the collective decision to create a short film. There was a shared aspiration to produce something with a structured form that could be presented. The decision-making process was collective, a dynamic where the implications might not always be fully anticipated—a characteristic that presents an intriguing facet of this approach to collective decision-making and activity execution.

In our pursuit to create a short film, the first crucial step was determining the theme or topic for the project. One notable consideration was the fact that attendees in these activities varied from one session to another, adhering to the established rule of participation: individuals attended when they felt inclined and wished to be present.

To provide continuity despite the varying group composition, we initially settled on the theme of “emotions.” This theme offered flexibility, as we could explore different scenes in various sessions, and it was not overly reliant on the specific individuals present in the room at any given moment. We employed a simple method by inscribing the names of various emotions on pieces of paper, allowing each participant to select one. I provided a context or setting, and then they improvised based on the emotion and context given. Subsequently, we recorded these improvisations, which were then watched collectively. Participants had the autonomy to choose their level of involvement for each session: whether they wanted to act, observe, or operate the camera. Roles were assigned voluntarily during each gathering.

Having elaborated on my involvement in these artistic clubs, I would like to offer some reflections on the impact of such activities on individuals dealing with mental illness. The primary observation I wish to share pertains to the overarching goal of these activities, which fundamentally centers on promoting the well-being of patients.

The foremost aim is to facilitate mental well-being and offer an opportunity for personal advancement, however that may be defined for each individual. These activities aim to provide a platform for progress. At the very least, they afford participants a few hours to experience enjoyment, allowing them a space where the atmosphere is not overly intense or anxiety-inducing. Achieving this sense of relief and enjoyment, to whatever degree possible for each individual, already constitutes a significant accomplishment in itself.

Based on my observations, I have noticed that on certain days and for some individuals (which naturally fluctuates based on various factors), there have been visible positive changes. These include instances where participants have been observed smiling, engaging in lighthearted banter, expressing satisfaction with themselves, sharing positive interactions with each other, showcasing their creativity, and simply having fun. This presents a challenge, as many patients attending a psychiatric day hospital are typically stabilized through medications, which often have sedative effects to some extent. Thus, witnessing their active engagement and willingness to participate in activities is a pleasantly surprising and notable occurrence.

However, these observations must be contextualized. Assessing whether a patient is progressing cannot rely solely on momentary observations. The individuals best equipped to evaluate such progress are the patients themselves, along with the psychologists they meet in individual sessions, typically once a week. Additionally, their overall well-being is influenced by a combination of various elements: their participation in different activities, the individual therapy sessions with the psychologist, their personal journey, their medication regimen, among other factors. Consequently, attributing the well-being of a mental health patient to a single factor or activity is not straightforward. Their overall well-being in a psychiatric day hospital is the result of various contributing factors. Nonetheless, the simple observation of patients enjoying themselves is, in itself, an essential and encouraging outcome.

An intriguing aspect worth noting is the response of the professionals—such as the psychologist, myself, and the nurses—engaged in these activities. Notably, we found ourselves also enjoying these sessions. This observation holds significance as it illuminates the essence of these activities: it is not merely about professionals providing something to the patients; instead, it is a shared engagement, where everyone contributes their unique selves to the shared experience with the mutual aim of enjoying the activity together.

A crucial aspect emphasized here is the dissolution of barriers between patients and professionals, fostering genuine relationships rather than adhering strictly to roles where one party is the “healer” and the other the “healed.” This notion aligns with the perspective of figures like Tosquelles, who suggested that the objective goes beyond solely healing individuals—it is about healing the institution and, by extension, the broader society. This approach is not only about aiding individuals in achieving well-being but also about transforming our own perceptions and attitudes towards them. It is about fostering a paradigm shift in how we view and engage with individuals dealing with mental health issues.

Placing all these insights into perspective, it becomes evident that the primary objective of institutions such as the psychiatric day hospital extends beyond mere participation in activities. The overarching aim is to facilitate the transition of patients towards greater autonomy. The ultimate goal is to enable individuals to a point where they might secure employment outside the institution and eventually depart from it. Remarkably, I have personally witnessed these achievements on several occasions during my time at the psychiatric day hospital, and each instance was celebrated collectively by all involved.

These instances of successful transition toward autonomy and integration into external employment demonstrate the tangible and meaningful outcomes resulting from the efforts and initiatives within the institution. The collective celebration that follows such milestones underscores the significance and success of the institution’s endeavors in fostering personal growth and independence for the individuals it serves.

To conclude this paper, I emphasize the significance of the shared space we provide for patients within the framework of activities where everyone is equally engaged. This collective participation brings forth a certain quality to the interactions among individuals and within the group dynamic.

A crucial element I find noteworthy is the quality of attention we offer them and, reciprocally, that they extend to us and to each other. This focus on attention evolves throughout a session, yet the overarching objective remains to collectively invest our attention in the ongoing activity and in each other, fostering a shared and meaningful moment.

This aspect resonates with the principles of Carl Rogers and person-centered therapy (Rogers, 2003). I believe there are strong parallels between these two theoretical approaches, as previously highlighted in the initial sections of this paper, despite the more psychoanalytic nature of the institutional psychotherapy approach.

In further research, I would aim to conduct more experiments and possibly observe other cases. It is important to note that not every psychiatric day hospital adopts the framework of institutional psychotherapy and therapeutic clubs. In fact, it is not particularly widespread in France. I consider myself fortunate to have encountered a setting where these practices were being implemented.

Continuing this research would indeed necessitate a deeper immersion into the theoretical underpinnings. Exploring works by key figures such as Tosquelles, Oury, Delion, and Rogers would be fundamental in understanding the context and roots of these theories and how they can be more effectively applied in the contemporary context.

Moreover, investigating the connections between a theory deeply rooted in psychoanalysis and the person-centered approach of Carl Rogers would be particularly intriguing. Unraveling the similarities, distinctions, and potential intersections between these diverse theories would shed light on innovative ways to merge their principles for enhanced patient care.

In line with the work of Rogers, delving into the application of the enactive paradigm to the relationship between a patient and their caregiver would be a compelling avenue of exploration. The enactive paradigm, developed by Varela (1989), Varela et al. (1991), postulates an interaction between cognition and perception/action. It suggests that these components are intertwined and mutually influencing one another. If this relationship is pivotal for well-being, it could be due to an inherent enactive quality. This concept could be termed as “the enactive nature of the therapeutic relationship” or “enactive therapy.” Further investigation in this direction could provide valuable insights into how this paradigm shapes and influences therapeutic interactions, potentially enriching the understanding and practice of therapeutic relationships in mental health care.

The author expresses deep gratitude to Nader Aghakhani, the overseeing psychologist at the institution, for his invaluable guidance and supervision throughout this work. The author also acknowledges and appreciates the insightful and enriching discussions provided by Nader, which greatly contributed to the depth and quality of this research. This publication was made possible through a funding from the Excellence Initiative of Aix-Marseille Université, A*Midex, which is part of the French “Programme Investissements d’Avenir” (funding no. AMX-19-IET-005).

The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Ivan Magrin-Chagnolleau is an artist philosopher who has been involved in art making as well as academic research and teaching for many years. He is affiliated with the CNRS in France, and currently works with the PRISM Laboratory in Marseille, a joint-lab between CNRS and Aix-Marseille University investigating on the relationships between art and science. He is also affiliated with Chapman University in California.

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