'La Comunitá La Vela': a psychoanalytically oriented approach to eating disorders

'La Comunità La Vela': besprechung von essstörungen anhand der psychoanalyse

'La Comunità La Vela': un abordaje de los trastornos alimentares orientado por el psicoanálisis

'La Comunità La Vela': une pratique d'orientation psychanalytique pour les troubles alimentaires

'La Comunità La Vela': uma abordagem dos transtornos alimentares orientada pela psicanálise

ARTIGOS

'La Comunitá La Vela': a psychoanalytically oriented approach to eating disorders

'La Comunità La Vela': uma abordagem dos transtornos alimentares orientada pela psicanálise

'La Comunità La Vela': une pratique d'orientation psychanalytique pour les troubles alimentaires

'La Comunità La Vela': un abordaje de los trastornos alimentares orientado por el psicoanálisis

'La Comunità La Vela': besprechung von essstörungen anhand der psychoanalyse

Andrea Vilanova^I; Ana Cristina Figueiredo^II

^IPsychoanalyst, Psychologist at the Institute of Psychiatry of Federal University of Rio de Janeiro – IPUB/UFRJ (Rio de Janeiro, RJ, Br); Master degree in Health Sciences – Mental Health at IPUB/UFRJ; Internship at La Vela Community in Moncrivello city, Piemonte, Italy (2011-2012) for doctoral advanced studies, participant of the Clinical Research Group in Psychoanalysis at IPUB/UFRJ, registered at CNPq. IPUB/UFRJ

^IIAssociate Professor at the Institute of Psychiatry of Federal University of Rio de Janeiro – IPUB/UFRJ (Rio de Janeiro, RJ, Br); D.Sc in Public Health at the Institute of Social Medicine of the University of the State of Rio de Janeiro – UERJ; Coordinator of the Clinical Research Group in Psychoanalysis at IPUB/UFRJ, registered at CNPq. Member of the Associação Universitária de Pesquisa em Psicopatologia Fundamental – AUPPF (São Paulo, SP, Br). IPUB/UFRJ

^{Mailing Address}

ABSTRACT

The authors discuss the experience of treating eating disorders at a psychoanalytically oriented therapeutic community in Italy. Teamwork and group activities are the bases of the treatment, at least to the point that the experience of the collectivity does not hinder the individual subjective expression of each patient. The treatment includes several different steps in the process of the admittance and release of patients and the subjectivation involved in the process is considered very important. A clinical vignette is presented at the end of the article.

Key words: Eating disorders, psychoanalysis, group work, singular experience

RESUMO

Este artigo discute a experiência de tratamento de transtornos alimentares em uma comunidade terapêutica na Itália orientada pela psicanálise. O trabalho em equipe e em grupos é o cerne to tratamento desde que a experiência coletiva não impeça a manifestação subjetiva singular do paciente. O tratamento se dá em diferentes etapas com relação ao acolhimento e à alta do paciente, enfatizando a subjetivação de todo o processo. No final, é apresentada uma vinheta clínica.

Palavras-chave: Transtornos alimentares, psicanálise, trabalho em grupo, experiência singular

RESUMÉ

Cet article discute l'expérience d'un traitement de troubles alimentaires dans une communauté thérapeutique italienne orientée para la psychanalyse. Le travail en équipe et en groupes est la base du traitement tant que l'expérience collective n'empêche pas la manifestation subjective singulière du patient. Le traitement est composé de différentes étapes, de l'accueil à la sortie du patient, et met l'accent sur la subjectivation pendant tout le processus. Une vignette clinique est présentée à la fin de l'article.

Mot clés: Troubles alimentaires, psychanalyse, travail en groupe, expérience singulière

RESUMEN

Este artículo discute la experiencia de tratamiento de los trastornos alimentares en una comunidad terapéutica en Italia orientada por el psicoanálisis. El trabajo en equipo y en grupos es el núcleo del tratamiento, que enfatiza la subjetivación de todo el proceso, siempre y cuando la experiencia colectiva no impida la manifestación subjetiva singular del paciente. El tratamiento se realiza en diferentes etapas tanto en relación a la acogida como al alta del paciente. Se presenta una viñeta clínica al final.

Palabras claves: Trastornos alimentares, psicoanálisis, trabajo en grupo, experiencia singular

ZUSAMMENFASSUNG

In diesem Beitrag wird die Erfahrung mit der Behandlung von Essstörungen in einer therapeutischen Gemeinschaft in Italien mit Unterstützung der Psychoanalyse besprochen. Die Team- und Gruppenarbeit ist der Kern der Behandlung, sofern die Gruppenerfahrung nicht die subjektive eigenartige Äuβerung des Patienten verhindert. Die Behandlung verläuft in verschiedenen Etappen, in Bezug auf die Aufnahme und Entlassung des Patienten, wobei der Fokus auf der Subjektivierung des Gesamtprozesses liegt. Zum Schluss, wird eine klinische looping-Präsentation vorgestellt.

Schlüsselwörter: Essstörungen, Psychoanalyse, Gruppenarbeit, eigenartige Erfahrung

Introduction

Psychoanalytic practice nowadays in the context of contemporary clinical experience brings forth a certain concept of the symptom which confronts the traditionally established idea of the symptom as an addressed ciphered message to be read. It imposes new ways of approaching certain pathologies that defy the old psychoanalyst centered method as a therapeutic tool for treatment. Lacanian theory has been the landmark for this discussion for at least a decade, as it introduced a new paradigm for psychopathological research and for the reading of the social dimension of the symptom.¹

In such context the handling of certain symptomatic manifestations, defined by the DSM-IV and the ICD-10 as eating disorders, by practicing psychoanalysts forces a revision of their own practice based on the same obstacles found in confronting such cases. As Cosenza (2008) puts it, they involve a non formal semantic use of the word but rather the use connected to the dimension of the act.

Based on this principle a new clinical experience for treating severe cases of eating disorders has been developed for about fifteen years in the province of Moncrivello, city of Vercelli, Piemonte, Italy. 'La Vela' is a psychoanalytically oriented institution sponsored by the public health system. The term 'severe' here refers to cases which have already been treated in specialized institutions in the mental health network in Italy, such as: outpatient clinics, public hospitals, also therapeutic communities based on the cognitive behavioral orientation. The dimension of the untreatable presents itself as a common feature of the cases attended to in this institution.

The treatment developed there is based on a multidisciplinary team work experience in a structure conceived in the shape of a therapeutic community under psychoanalytic orientation and receives women between 17 and 40 years old without any pre-definition in respect to age limit. The team is formed by psychoanalysts from different schools, doctors, nutritionists, family therapists, psychiatrists and educators, and the community gets support from all these workers as 'operators' oriented by a common guideline of action which is subject centered, that's to say, the subject conceived as radical singularity, to be produced as an effect of the treatment device.

La Vela community is apart from the traditional orientation adopted by other therapeutic communities concerning eating disorders, basically the cognitive behavioral approach.

In this way, the very aim of this paper is to show how psychoanalysis can orient a clinical experience in an institution that proposes a radical detachment from everyday life in a sort of commitment of the patient under certain rules which work collectively but at the same time allow the emergence of what is the most singular feature in each case. This is what is at stake in this experience, the axe of the clinical work.

The communitarian device: a brief history

In the course of the history of introducing the therapeutic community as a treatment device there is a gap concerning the traditional hospital centered treatment in psychiatry. The latter maintained an orientation that withdrew all the responsibility from the subject concerning one's own treatment as a committed patient who should adapt to reality according to the doctors' parameters. The hospital centered treatment proved to be inefficient in doing so as authors like Goffman (1987) and Foucault (1999) brilliantly demonstrated referring to asylums and prisons alike as 'total institutions'.

The recognized experience in the origin of the therapeutic communities was proposed by Wilfred Bion and John Rickman in Northfield, England (Cosenza 2001). It was an experience based on the psychoanalytic orientation, mainly from Bion's theories implemented in a psychiatric ward of the British Army in 1943, aiming at treating soldiers with psychological disorders in a different way from the disciplinary superego command well known to them as practiced in the army. The new principles brought about by Bion were applied to group psychotherapy, which he became famous for, and communitarian experience having the group as the main instrument for the therapeutic institutional work. The subversive strength of this therapeutic method provoked a premature interruption of such experience. A 'total institution' like the army wouldn't tolerate inside it a threat to its hierarchy by changing the subject's relation to the institutional Other. In a command based structure it would become unbearable to leave to the subject a space to express himself in words as much as he could in order to work through his suffering putting forward what it was really about for each one particularly instead of treating their suffering as common war trauma.

This original experience introduced by Bion in the institutional field of therapeutic practices paved the way to new initiatives. As Cosenza (2001) shows us, Tom Main (1946) reedits Bion's experience naming it as 'therapeutic community'. The new institutional device is now baptized and it also inaugurates a new orientation for the treatment of mental disorders which will face a deep breakup in traditional psychiatry. Thus, under this new concept, an institution for the mentally ill can only be therapeutic regarded that it doesn't establish itself as a 'total institution' and it does leave space for the patient's subjectiveness in the relational context of the institution. In this way the therapeutic community will harbor a series of cutting edge experiences in order to deconstruct the old asylum paradigm.

If in wartime the communitarian experiment was a way of dealing with the paralyzing effects produced by an external menace (the enemy) on the soldiers' neurosis, in peace time the therapeutic community becomes a place for looking after and possible treatment of different forms of radical suffering where what counts is the impossibility for the subject to find a placement within his family or society. (Cosenza, 2001, p. 230)

The therapeutic community would have its moments of glory mainly through the experiences developed in France under the name of Institutional Psychotherapy (Psychothérapie Institutionelle). This movement had François Tosquelles as its predecessor and appears in the French institutional scenario bringing forth the innovating idea that the institutional space has ill features and for this reason should be treated (Desviat, 1999). This constitutes one of the bases from which the La Vela community extracts its principles as guidelines for the team work, as they renew their questioning about the aims of the institution and what it is capable (or not) of developing together with each patient.

The therapeutic community as a treatment device permanently questions clinical intervention regarding borderline cases and keeps open the discussion on the real value of the institutional work facing the emerging obstacles. Besides that, the experience itself allows a vivid questioning of the institutional practice through the very cases it harbors, the treatment orientation, the practitioner's position as well as the team work. In this way, La Vela as a work community is constantly testing its institutional worthiness and the effectiveness of its treating methods having the psychoanalytic orientation as the main reference.

La Vela – Three moments in the process: admittance, getting in and separation

The main purpose of the work in La Vela resides in "assuming the fact that there is always at some point of its functioning something that gets out of hand" (Cosenza, 2001, p. 229) which implies a certain position concerning knowledge that should leave space for the coming up of something new, unpredictable, for the subject. Here it is a principle born within communitarian experience itself, established in the origin of its functioning under the Freudian influence that subverted the institutional perspective for the treatment of human suffering.

The admittance in the community does not follow bureaucratic criteria. The work through the subject's demand determines a fundamental scansion in two moments: admittance and subjective entry, the 'getting in'. Considering that we are dealing with subjects whose suffering doesn't constitute a demand to begin with, the treatment of the demand includes making room for a new demand beyond the demands of the family and the health services that send the patients.

The clinical approach to such cases presents its main difficulty in pursuing the treatment as the patients' ego syntonic position concerning the symptom blocks any critical view towards one's own suffering. The admittance then becomes a difficult moment to handle in order to allow an entry which would overcome a non subject oriented admittance, and it should figure out the particular way each subject relates to the treatment offer.

Thus the preliminary work on the demand constitutes one of the axes of the work developed at La Vela. This implies taking into consideration the position the institutional Other will occupy for the subject, which appears in manifold ways according to the subject's structure, that's to say, the diagnostic orientation towards either neurosis or psychosis for each case. Besides this, considering that the initial demand is usually alien to the subject, the work on the admittance demand is not reduced to interviewing the patient but also includes some work with the family and services involved. In doing so right from the beginning, the ambivalent dimension of the demand which presents itself to every subject is dealt with, considering that demand and desire constitute different but not excluding paths towards treatment. The main task for team work here is to sustain these two paths allowing the subject to face this enigmatic ambivalence in order to give way to a change in one's position.

The preliminary work on the demand is already a constituent part of the treatment giving the team a clue to the different ways of subjectivation implied in the eating disorder response. The aim here is not to establish patterns for reading the incoming demand for treatment but, on the contrary, to allow the team to meet with the emergence of a void in knowledge and build this knowledge together with each subject keeping the specifics concerning structural differences between neurosis and psychosis. For instance we can make sure that it would be at least imprudent to force a psychotic subject to meet with the void dimension of desire. In such cases the getting into treatment requires the finding of a "non persecuting, regulated, but not superego driven place [...]. The community then becomes a place where the subject belongs, a place inhabited in a psychological atmosphere that allows the subject to breath" (Cosenza, 2001, p. 236).

Thus the effective 'getting in' the community, the subjective admittance, implies for each patient going through a process that transforms the quality of one's stay in the institution. For the neurotic subject the dilemma between 'home' and the 'community', that appears in general as an urge to go back home, is solved when the subject acknowledges in his or her complaint something less related to the environment itself as what really matters concerns the enigma of one's own subjective position facing the symptom. The experience with psychotic patients shows that for them the community can take them in when it is capable of treating his or her 'Other' and becomes able to incarnate a tolerable Other.

Leaving the treatment in the community is not less troubling. The experience of separation brings up the essential difficulty of the subject's relation to the Other. The very moment of leaving can have different meanings including restituting to the subject a non subjective entry in the institution, or rather it can present itself as an interruption or even an effective closure for the treatment. What we have then is an intricate articulation between three moments: admittance, getting in and separation.

According to Cosenza, the three moments of the communitarian institution can be articulated with the three moments of Lacan's theory of the 'logical time' – as opposed to chronological time – presented in his paper "The logical time and the assertion of anticipated certainty" (Lacan, 1945) where he distinguishes: the instant of seeing, the time for understanding and the moment of concluding and articulates them with the subjective logic.

If the admittance as the 'instant of seeing' finds its grounds in the 'time for understanding', in the subjectivation as a possible symbolic working through, the 'moment of concluding' will be supported and become evident as an effect according to the lived experience.

The experience in La Vela demonstrates that in general in the cases of neurosis there is a certain refusal to work through this separation as a refusal to face the loss, a difficulty in breaking a bond to become open to new bonds. In the cases of psychosis it is impracticable to expect this kind of working through as there is no subjective framework for it which implies in promoting the patient's release keeping the perspective of a continued work to sustain the possible identifications built up by the subject in the process.

The perspective of an effectively conclusive release for the subject, thought of in terms of a true separation process, should not be taken as a standard procedure. In spite of being very infrequent, as Cosenza puts it, it may be considered a "unique experience which always leaves in the subject an inerasable trait [...] the encounter with an Other capable of restituting dignity and the right to non self destructive satisfaction" (2001, p. 249).

The group as a motor and the team work

A psychoanalytically oriented practice can unfold different devices. We attempt here to verify, in the tension present in an institutional practice operating collectively in order to give way to the emergence of subjective effects, a singular kind of orientation for such work. We acknowledge this tension in the clinical work at La Vela as the axe of the treatment of eating disorders conceiving the Other as a discourse of the institution but at the same time decompleted by another kind of knowledge produced in the everyday practice, a constant presence promoting new encounters and confronting established solutions, denaturalizing patterns for subjective functioning and social bonds.

The functioning of the community is basically structured around the work group: there is the group of patients and the group of practitioners who establish a shared responsibility between them. If on one hand the collective work promotes new identifications favoring the initial bond present since the admittance in the community, on the other hand, the locating of a singular dimension in each case will be the result of the development of each process.

The institutional structure works towards creating possibilities of intervention in a field less permeable to the dimension of speech as the cases dealt with show us, pointing out the ineffectiveness of the traditional therapeutic method. In this way the group has an operative function, as well as the workshops and the weekly meetings with the team for the handling of the most delicate situations as each patient is invited to speak freely. Let's say that the creation of new intersections and new spaces can allow and even promote symbolization through what Cosenza defines as intervening Symbolic devices within the realm of the Real.

The consultation device also integrates the dynamics of the institution as a special way of reintroducing the singular feature of the subjects and their own interpretation of what happens in their bodies, their lives and their relationships. But this device doesn't prevail as a form of treatment in the community as all the institutional dynamics is operative in the sense that it emphasizes the symbolic as an act concerning the rules and regulations of the house aiming at regulating the subjects' everyday life. But it is important to remark that in La Vela it is the exception that operates as the rules are not worth for themselves and one is not seeking to readapt the patient or to achieve general parameters. What counts is to question what each patient can really achieve and what would be the cure in each case, therefore what counts is how to attend to each one and manage through the elements of each case to handle the artificial situation of living as a committed patient.

Let's not forget that Freud points out the dimension of an artificial relation, though he speaks of real love, when he refers to the analytic experience. It is then in a certain suspension that the institutional practice is developed but it engages in what comes from the real existence. This is what is to be found in La Vela as an effect of the analytical device itself operating in a collective logic where transference as a singular movement takes place.

As Cosenza proposes, the cardinal point for the treatment is a psychoanalytically oriented institution which can find its curing subject within the team itself. The task of each professional is to refer to the team work as a strategy to obstacle the imaginary collusion. It is then the conception of the team as a curing subject and not the belief that one professional alone can handle the imaginary aspect of transference, so frequent in such cases.

The common ground for the psychoanalytic orientation is not referred to any school in particular but requires the professionals to be available to create something new concerning the treatment. Inasmuch each one should put aside something from one's particular orientation in order to invent a collective work which has as petitio principii the subject as conceived by Lacan according to Freud. Yet the main question is: how will the team work escape the mirror like functioning of the imaginary transference in an ideal form of a dual relationship repositioning themselves as a third element in such relationships in everyday practice? The team's purpose is to achieve this function for the patients and also for the professionals themselves. In other words, the team sustains the transference addressed to the institution. The transference happens even before one can think about it, but the time for understanding and working through it allows its handling.

The team's wish is beyond any previous knowledge of the subject and is guided and supported by what each one can bring to the clinical practice leaving aside any personal interference. It is all about a risky, random, and not programmed meeting with the subject. As Cosenza (2000) proposes, each professional is at any time called for as a subject but must produce a response beyond his or her subjectivity, as Lacan teaches us through his concept for the psychoanalyst's position.

In programming the activities a certain void is preserved, as we should not intend to fill up the everyday work with a pre-established or rigid routine. It is rather in between activities that the suffering of each patient shows and the singular experience of the symptom takes place. What each one can do of one's free time gives way to such singular responses.

As a direction for the treatment the subject should consent and be able to show something from his or her subjectiveness, find a way to address his or her symptom to the institution despite the fact that eating disorder can be a symptom without a meaning and a refusal to address the Other. This constitutes one of the main obstacles to any approach concerning treatment.

We can find a way concerning the knowledge that guides the reading of the symptom and the team work through what Cosenza (2001) remarks as the principle of the incomplete regulation for the functioning of the community which can permit the emergence of singular responses far from any pedagogic ambition.

A clinical vignette

After a few months of her stay in the therapeutic community, Chiara speaks for the first time about her experience in beginning her treatment, which definitely does not correspond to her admission date in the community. Having lived for many years since her adolescence with a severe eating disorder associated to bulimic episodes and alcohol abuse, she refers to a moment when she started to "notice something she hadn't noticed before". Her identification with the anorexic-bulimic symptom has been a way for Chiara to keep her connection to the world for many years. But this symptom does not help her live. The case though well framed in the eating disorders category presents us with a kind of suffering that doesn't show any significant meaning concerning what really goes on in her life. When she arrives at the community she weighs so little that it threatens her health. Her object choices didn't show anything particular about her.

Her admittance in the community is due, as it happens frequently, to somebody else's demand, in this case it was from the service where she was treated in her hometown in Southern Italy. She accepts the indication for treatment in the community without any hope or further expectations and no refusal. She describes her arrival as "chaos". During the group meetings she says she "couldn't think at all", she couldn't even put forward any question to herself or to others. She didn't know why she was there, but also didn't know whether she should be anywhere else. At a certain point of the group meetings when the main theme was the bodily weight she states that she had never valued "the image of thinness" as it "turned everything more visible to the others".

It is important to remark what really shows as a singular feature concerning Chiara's relation to image, a certain invisibility seemed to be related to the impossibility of thinking, something about "keeping it secret" in order not to let anybody know what was going on with her. She assumes she really got into treatment when "a new way of perceiving things" was at stake. Definitely the gaze turned towards her: "my body had changed from what it was as far as I could remember... the skin drying out so early, my hair and teeth falling, I could no longer smile...". Her body was falling to pieces.

At a certain point she says: "something has been lost and I am not going to find it". She also says that she decided to look for another "way of living with the body that was left". In fact the incidence of the gaze that emerged from her encounter with the community exposed the recklessness of her condition and promoted the beginning of a movement of recovery in order to balance herself taking the living body into consideration. Would it be a new way of dealing with the object? It seems so. A significant recovery concerning the body image seems to have occurred. Considering with Lacan (1975-76) that the talking being adores his body, that he is captured by its image, we can guess the value of the subjectivation of such effects.

Chiara affirms that she now has "faith in the image". This is how her treatment really begins in the community. We can infer that the emergence of the institutional Other embodied in the team of practitioners has its transferencial value once the stay in the community is each patient's decision and Chiara consented in proceeding with her treatment.

Here we meet with the perspective of transference love as what allows pleasure (jouissance) to condescend to desire (Lacan 1962-63). We can also consider the effects of the variations of her relation to the object and this seems to have resulted in this particular gaze that gives life back to the body; the body that gains consistency for her, an Imaginary consistency, the only consistency available for the talking being, as Lacan (1975-76) puts it, but not without entangling the Symbolic to the Real.

According to information given by the team, a few months after being admitted Chiara didn't show signs of eating disorder symptoms any more, but remained very strict in her way of connecting with others demonstrating a certain carelessness that intrigued everybody together with an apparent suppression of the symptoms. She went on in the community keeping herself strict and rational always with well elaborate arguments to confront her mates.

Through time she began to talk about her expectations for a change in her life and brought about a new interest concerning new experiences outside the institution. A demand for other life prospects began to show and there was a time, some months later, when Chiara moved to a group apartment² in order to develop other activities outside the institution. She was accepted somewhere as an intern to work with wood restoration.

To the team's amazement, Chiara though being warned from the beginning about the precocious suppression of her symptoms shows the same symptoms again after a few weeks, but this time it was somehow different as her subjective state of 'absence' present at the time of her admittance is no longer there. Now she can say: "I know I'm not located in the symptom", referring to her eating disorder and abusive drinking, "nor in the rational words" she is able to utter. It seems now that we are facing a fresh start where differently from the suppression of the symptoms Chiara doesn't hide her troubles and accepts her own puzzle. In the last individual session with her analyst she brings a fragment of a dream: she is facing her analyst, inside the consulting room in the institution, she approaches him and removes an adhesive tape off her own forehead. It seems that she can now present herself to him in a different way, unwrapping herself.

Acknowledgements:

To La Vela work team and patients for the chance of having this experience and learning so much from being together with them in their hard and outstanding work. To Domenico Cosenza who accepted my application for the internship and generously shared his experience and also his worries.

Bibliography

ANA CRISTINA FIGUEIREDO

Av. Venceslau Brás 71 – fundos – Botafogo

22290-140 Rio de Janeiro, RJ, Br

e-mail: [e-mail]

Received/Recebido: 16.6.2012 / 6.16.2012

Accepted/Aceito: 21.8.2012 / 8.21.2012

Conflict of interest/Conflito de interesses: The authors declare that has no conflict of interest. / Os autores declaram que não há conflito de interesses.

Editor/Editor do artigo: Prof. Dr. Manoel Tosta Berlinck

Copyright: © 2009 University Association for Research in Fundamental Psychopathology / Associação Universitária de Pesquisa em Psicopatologia Fundamental. This is an open-access article, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. / Este é um artigo de livre acesso, que permite uso irrestrito, distribuição e reprodução em qualquer meio, desde que o autor e a fonte sejam citados.

Funding/Financiamento: The authors have no support or funding to report. / Os autores de claram não ter sido financiados ou apoiados.

References

• COSENZA, D. Il desiderio dell'operatore nella comunità terapêutica. In: GUIDI, A. (cura) Agalma. La logica del desiderio. Il desiderio come cura della malattia mentale (Fort-da). Firenze: Casa editrice Clinamen, 2000. p. 19-30.
• COSENZA, D. La comunità terapeutica come luogo della cura. In: COLOMBO, D.; COSENZA, A.; COZZI, A. Villa La cura della malattia mentale Il trattamento Milano: Mondatori Editori, 2001. p. 227-251.
• COSENZA, D. Il muro dell'anoressia. Rome: Casa Editrice Astrolabio. Ubaldini Editore, 2008.
• DESVIAT, M. A Reforma Psiquiátrica Rio de Janeiro: Editorial FIOCRUZ, 1999.
• FOUCAULT, M. Vigiar e Punir: nascimento da prisão. 21. ed. Petrópolis, RJ.: Vozes, 1999.
• GOFFMAN, E. Manicômios, prisões e conventos 2. ed. São Paulo: Perspectiva, 1987.
• LACAN, J. (1962-1963). Le Séminaire. Livre 10. L'angoisse Paris: Seuil, 2004.
• LACAN, J. (1975-1976). Le Séminaire. Livre 23. Le Sinthome Paris: Seuil, 2003.

1

. See the works of Hugo Freda and Bernard Lecoeur on new forms of symptom especially concerning drug addiction. The directions for this new paradigm can be found in the course developed by Jacques-Alain Miller e Eric Laurent (1996-1997).

2

. The group apartment is a structure connected to the community, a kind of therapeutic residence whose functioning allows a greater autonomy concerning the patients' everyday life including preparing their own meals, yet under supervision on a daily basis.

Publication Dates

• Publication in this collection
  07 Jan 2013
• Date of issue
  Sept 2012

History

• Received
  16 June 2012
• Accepted
  21 Aug 2012