Group-Analytic Psychotherapy with Low-Income Patients in Brazil

GROUP-ANALYTIC PSYCHOTHERAPY WITH LOW-INCOME PATIENTS IN BRAZIL 2

Group-Analytic Psychotherapy with Low-Income Patients in Brazil

Abstract

The first analytic groups formed in Brazil were a psychiatrist initiative in the late 1950s to

meet the substantial demand for psychotherapeutic care for a large population with inadequate

access to material resources. Although group-analytic psychotherapy arrived in private

practice a few years later with great success, such therapy has always been a privilege in

public institutions that provide free care for low-income populations. This article reports the

development of a group-analytic psychotherapy process performed for over four years with a

neurotic low-income patient group in the psychiatric ward of a major urban hospital in Rio de

Janeiro. The department is responsible for clinical education and training of psychiatrists and

psychologists. The treatment provided is preferably performed in the group setting. The group

report illustrates how group-analytic psychotherapy is delivered in public institutions in

Brazil, presenting both its difficulties and specificities.

Keywords: group-analytic psychotherapy; low-income patients; public health institutions.


Group-Analytic Psychotherapy with Low-Income Patients in Brazil

The present paper reports on a group-analytic psychotherapy process performed with

neurotic low-income patients in a psychiatric ward during a four year period at the Group-

Analytic Psychotherapy Department, at a major urban hospital in Rio de Janeiro... The

clinical and personal histories of six members of the group illustrate through a social

microcosm (Yalom, 2005) the difficulties faced by low-income persons – patients from

less-favored classes facing social and economical difficulties - treated at psychiatric and

mental health ambulatory clinics in Brazil. Among the beneficial therapeutic effects of

group psychotherapy in the aforementioned population, the possibility of social inclusion

is the most significant. Group psychotherapy of usually neurotically ill patients who are

excluded from the social process because of their lack of material resources is fundamental

because it produces proven therapeutic effects and allows new and transformed insertion

of this population into society. In this sense, group psychotherapy is the preferred

treatment modality rather than individual treatment because it can provide new

identifications through group cohesion and genuine social inclusion to this deprived

population. Moreover, individual treatment usually takes more time to achieve the same

therapeutical results. The encounter or re-encounter with one’s own singularity is possible

through the therapist’s careful gaze, group acceptance, identification and transformation

of interrelationships established within the group setting. In addition, institutional group

treatment, especially in Brazil, with a large less-favored population with inadequate access

to material resources, or private health care, allows the therapist to meet several patients at

the same time, reducing the long waiting lists. Therefore, this article demonstrates, through

theoretical and clinical reflections on the difficulties and specificities faced when dealing

with such groups, that group psychotherapy is one of the most suitable and effective

treatments for neurotic low-income patients at mental health ambulatory centers. Group


psychotherapy in this population may be regarded as an effective treatment provided by

psychologists at mental health ambulatory centers.

As a consequence of this perspective, countries with a large contingent of low-income

citizens should prioritize group therapy for its intrinsic qualities at ambulatory centers,

seeking to meet the substantial demand for this type of treatment. This is the case in Brazil,

where treatment provided by psychiatrists, psychologists, and social workers at psychiatric

wards and institutions that provide services to low-income patients should preferably be

performed in the group setting. Nevertheless, only a few institutions efficiently utilize groups

when treating their patients.

The relationship between the treatment provided to low-income persons and the use of

group therapy originated with a policy that began with the dawn of group-analytic

psychotherapy in Brazil. In the first years group-analytic psychotherapy was based on the use

of the major concepts of psychoanalysis to group work. Few years later a theoretical frame to

Latin-American group-analytic psychotherapy was developed by Brazilian group

psychotherapists, based on the original concepts postulated in Argentina by Pichon-Rivière

(Zimerman,1993) The first analytic group constituted in Brazil was conducted by Alcyon

Baer Bahia in 1951 at the former Serviço Nacional de Doenças Mentais (National Mental

Health Diseases Service), which later became Universidade do Brasil (University of Brazil).

Since then, psychiatrists and psychoanalysts concerned about the large contingent of patients

left unassisted in the country’s mental health ambulatories decided to create centers dedicated

to analytic-group psychotherapy training of therapists and patient treatment. A few years later,

in 1958, similar initiatives in Brazil generated the Societies for Group-Analytic

Psychotherapy in Rio de Janeiro, Porto Alegre, and São Paulo( Zimerman,1993).

Thus, in Brazil, group-analytic psychotherapy has always been associated with

institutional practice, reaching its apex from the 1960s to 1980s at private practice offices.


However, during the 1970s, the military dictatorship established in Brazil prohibited the use

of this practice at public institutions and even shut down several institutions that had

previously offered group therapy, persecuting many of its professionals and monitoring their

activities. Such a backlash caused these professionals to abandon their analytic group work.

This type of treatment then suffered a general countrywide shrinkage, which deeply

influenced and damaged such therapy.

The consequences of suppressing group-analytic therapy during this period, both in

institutions and private clinics, were enormous and remain to be resolved. In fact, leaders

within the group movement, resentful or hurt by government intervention, retreated slowly

from the activity, increasingly devoting themselves to individual practice. However, these

practitioners have been emotionally engaged with the past, aspiring to a revival of the activity

and being involved in training within the society. Thus, they have sought to train new leaders

who can reintroduce group therapy in institutions. Despite their efforts surrounding group

processes, the sociocultural climate was demanding new solutions.

Group-analytic psychotherapy developed in Brazil over a period of economic growth

in the 1950s and was consolidated as sociocultural transformations (e.g., the decline of

patriarchy, the sexual revolution, etc.) experienced by the world in the 1960s that weakened

traditional institutions, naturally leading individuals to seek groupality (Bauman, 1997).

However, beginning in the 1970s, individuals were faced with a new social reality, the decline

of the collective paradigm, and exacerbation of private life. They found themselves permeated

by an ever-present narcissistic outlook, described by Lasch (1979) as the culture of

narcissism.

Thus, the profound cultural changes combined with the published predominance of

other psychotherapy techniques, especially lacanian theory (Zimerman,1997), shifted the

focus off group psychotherapy within the country. Nevertheless, during the 1980s and 1990s,


the group-analytic practice remained restricted to training institutes inside group societies,

although in the state of São Paulo, psychodrama underwent tremendous development.

From the 2000s onward, within the new socioeconomic context, a renewed interest in

group practices arose within institutions, especially in the treatment of low-income

populations. Nevertheless, the history of group psychotherapy is not well known in Brazil and

is largely suppressed and denied. Many professionals perform intuition-based work or even

practice based on free application of the theories and techniques of individual treatment to the

group context (Zimerman,1997). Thus, although group practices have been adopted by several

public or private institutions, their professionals do not seek group-analytic training or

training in other group therapy techniques. They are generally not aware of the training

available at the institutions of group-analytic societies, which, consequently, have fewer

people enrolled in their courses. Because of problems faced during the practice of group

therapy related to the lack of proper training, young mental health professionals appear to be

seeking information and specialized training, suggesting a re-acceleration of this activity.

Published works, however, remain sparse.

Public policy has now begun to consider prioritizing group work. Consequently, social

and medical assistance projects are now being realized in Brazil. Psychosocial Attention

Centers (CAPS), local health care units regionally located, were created at the beginning of

the 1990s (Amarante, 2003) and offer free ambulatory assistance and even hospitalization for

neurotic and psychotic patients and individuals with substance abuse. These CAPS utilize a

multidisciplinary team, including psychiatrists, neurologists, nurses, social workers,

psychologists, speech-language pathologists, audiologists, nutritionists, and occupational

therapists, and are the gateway to public mental health treatment services (Brasil, 2007).

Recently, this service has undergone administrative changes in which the triage process and

patient reception are performed in groups. Some psychological and social treatments are also


conducted in the group setting.

The CAPS were inspired by the Italian therapeutic model created in Trieste in 1986.

This public service operates in collaboration with the local community and was conceived to

provide treatment for patients with mental disorders. They follow basic principles that include

meeting 100% of the demand for assistance of persons with severe or moderate mental

disorders, providing the necessary care within their own premises, using qualified

professionals who work in shifts, and operating 24 h per day, 7 days per week (Elias, 2007).

At these CAPS, the creation of a warm and therapeutic environment for the patient is

imperative. Among their priorities are actions directed at the patient’s family members and

social insertion projects for their users. The notion of case management (i.e., keeping track of

each patient’s path within and outside the unit) and the development of an activity program

for a patient’s daily living at the unit are parts of broader project aims that seek to

deinstitutionalize the more severely ill patients and involve the entire multidisciplinary team

and particularly social workers (Elias,2007). The therapeutic projects at the CAPS are

singular - they respect regional differences and welcome theoretical and technical

contributions from team members and the initiatives originating from patients and their family

members. They also contemplate a patient’s intra-, inter-, and trans-subjective care with

respect to the social environment by combining clinical resources (including medication) with

housing, work, leisure, and welfare to promote programs of psychosocial reinsertion and

rehabilitation.

Division of Ambulatory Psychiatry at a Major Urban Hospital in Rio de Janeiro: an

experiential report

Many institutions that previously provided group therapy lost their professionals

during the military dictatorship in Brazil in the 1970s. Since the beginning of the 1990s,

progressively standardizing and implementing mental health treatment services has been


possible for low-income patients in Brazil through the CAPS. A 25-year hiatus of group

therapy at mental health institutions occurred after that time. During this hiatus, isolated

initiatives of heads of psychiatric wards of large public hospitals and university teaching

hospitals slowly restored group therapy work in Brazil. In the context of this restoration, after

the political opening of Brazil in the mid-1980s, a unique group therapy service was created

within the Division of Ambulatory Psychiatry at a major urban hospital in Rio de Janeiro.

This initiative represented an attempt by mental health professionals of a general hospital to

resume the group activity that was previously discontinued at mental health institutions. Their

purpose was to meet the large demand for psychological treatment for less-favored classes.

Since the foundation of the model treatment service at the hospital, the usual approach has

been predominantly group therapy, supported by practitioners such as physicians,

psychologists, and social workers and group-analytic psychotherapy specialization course

students. The ward has continuously had important interactions with the Sociedade de

Psicoterapia Analítica de Grupo do Estado do Rio de Janeiro (Group-Analytic Psychotherapy

Society of The State of Rio de Janeiro) and its professionals, who often teach or coordinate

reflection groups (Dellarossa, 1979; Penna, 2002) formed by multidisciplinary teams.

The vast majority of psychiatric care provided by the Group-Analytic Psychotherapy

Department of the Division of Ambulatory Psychiatry at the hospital is dedicated to the large

contingent of neurotic patients from lower social classes. The patient triage process is

performed by a multidisciplinary team and includes preliminary selection and referral to

group psychotherapists. At that particular hospital, most of the psychological treatments are

intended for the group setting, including patients with cardiopathy, diabetes, autoimmune

diseases, and chronic pain, among a wide range of other pathologies (Mello Filho, 2000).

These groups receive ambulatory treatment at the large Medicine of the Person and

Psychosomatic Medicine Center.


To illustrate the importance of group-analytic psychotherapy for the treatment of low-

income patients and discuss the application of group therapy techniques in the institutional

context where psychologists, psychiatrists, social workers, and other therapeutic agents can

utilize their expertise, this paper reports on a group-analytic psychotherapy process with

neurotic patients during a four-year period at the group therapy department in the psychiatry

ward at the hospital..Theoretical and clinical reflections on the difficulties and specificities

faced when handling such groups will be discussed to understand the importance of the group

device for the treatment of low-income populations.

The group itself: grouping, selection, and composition

Over two months, 20 interviews were conducted. Despite the wide variety of

psychopathologies among the patients of the psychiatric ward, eight patients were selected

(two men and six women1) to participate in a group-analytic psychotherapy program for

neurotic patients. The selected male patients did not show up for the first session, and the

group was then limited to the six selected women. Since forming the group, the dropout rate

drew our attention to the fact that patients who remained in the group for treatment were

generally single or divorced mature women, aged 35 to 50 years and suffering from

dissociative or conversion disorders (ICD10-F44) as the main pathology. Consequently, the

presence of dissociative or conversion disorders, without previous intention, established an

additional factor in this analytical group’s formation. This led to the observation and analysis

of such disorder specificities in this particular analytical group.

Once formed, the group was a heterogeneously composed, psychoanalytically based,

semi-open group consisting of six female patients (despite the initial effort to form a mixed

gender group) with one 90-min session per week. To introduce the reader to the selected

patients (i.e., Ana, Rosa, Celia, Sandra, Norma, and Lucia), the following is a brief

1 The vast majority of patients treated at the hospital’s group department are female patients. Selecting male

patients for groups is usually difficult because they barely manage to attend the sessions at the ambulatory center

during work hours, with the exception of those with serious clinical conditions.


description of their personal and clinical histories. Names and personal data had been

disguised for confidentiality purposes.

Ana (age 58). She was diagnosed with dissociative disorder with disorientation in time and

space, loss of memory, pain, and paralysis of both legs that led to two hospitalizations. She

reported a history of distress and abuse during childhood. She was an orphan and worked as a

maid and dressmaker but was then retired at the time of group therapy. She married twice.

Her first husband was an alcoholic who underwent psychiatric treatment at the hospital. She

had two children from those relationships: one boy who was then an engineer and “cared for

her” and a daughter with whom she had a difficult relationship.

Rosa (age 44). She was diagnosed with depression caused by the death of her newborn child

and consequent sterilization after delivery. She was referred to the group by her physician.

This patient had no family bonds. She was an adopted child of a family from a very poor

village in northeast Brazil. At age 15, when she abruptly learned about her origins, she

showed dissociative symptoms that caused her to abandon her foster family and try to commit

suicide by throwing herself under a truck, after which she spent 1 year hospitalized for

treatment. After recovery, she moved to Rio de Janeiro and never met her relatives again. At

the time of therapy, she lived on her own in a house rented by her lover, cooking food for

parties for a living. Her history also showed that she had two other suicide attempts through

the ingestion of pills.

Celia (age 48). She was referred to the psychiatric ward by a neurologist after trigeminal

nerve neurosurgery and implantation of an intracranial valve. This patient was very anxious

because of her fear of implant rejection and the trauma related to surgery. She reported strong

depressive symptoms caused by the surgery and the fact that she received no support from her

daughter. She had divorced five years before group therapy began and had two children and a

granddaughter she never met. At the beginning of the group sessions, she was unemployed


and threatened with eviction from her house.

Sandra (age 28). She had multiple complaints that indicated panic disorder (ICD10-F41.0).

She came from a large family, and both her mother and father had multiple marriages. She

had been living with her companion for eight years, and they had two children. They did not

have a good relationship and faced serious financial difficulties, worsened by her husband’s

adulterous behavior and alcoholism.

Norma (age 35). Her referral to psychological treatment occurred after receiving emergency

psychiatric care and being diagnosed with dissociative disorder, including amnesia and

mutism. The patient was a lawyer before group therapy, but by the time of her enrollment in

the group, she was not engaged in her professional activities. She was in her second marriage

and reported relationship problems caused by her husband’s excessive jealousy. Her first

husband was an alcoholic who mistreated her. Their two children lived with the father. She

reported episodes of severe depression and suicide attempts by ingesting pills.

Lucia (age 30). Her referral to psychological treatment was made by the psychiatric ward after

10 years of medication and no improvement in her condition. She was diagnosed with

dissociative disorder (ICD10-F44) and additional symptoms such as convulsions, shortness of

breath, bronchitis, heartburn, gastrointestinal disorders, throat infection, and depressive

episodes. She took psychiatric medication. By the time she joined the group, she was

recovering from a strong conversion seizure with paralysis of both legs and baby talk speech.

She lived with her parents and had a rather difficult relationship with her father, whom she

accused of sexual harassment. She neither studied nor worked. She reported seduction

attempts by her father and had difficulties in her emotional life and an immense fear of

relationships with men, although sometimes she intentionally put herself in risky situations

with strangers.

The beginnings of the group


The group began with the six patients described above, four of whom were initially

diagnosed with dissociative disorder (ICD10-F44). The first sessions were characterized by

the patients’ strong need to present their dramatic life histories. The group was functioning

very tensely. Communication did not flow effectively, and the patients appeared to talk only

to themselves and to the therapist, as if they were in an individual treatment setting. At this

initial stage, the group was presumed to have primary paranoid anxieties usually present in

new groups (Zimmerman, 1993).

- Ana: “I have suffered a lot. I once believed but today I lost my hope in people and I

live depressed. I do not believe anyone. I don’t know what to do with my daughter. She

does not listen to me anymore, and she only does as she pleases…”

- Rosa: “Oh! I wish I had three daughters like yours! I have nobody. I was happy until

I was fifteen years old and used to live in a big house, with the family I thought was

mine. Then, during a family party my mother, while dunk, told me that I was adopted. I

got crazy and humiliated. I ran away and got run over. I tried to kill myself. I ended up

hospitalized for one year. When I left the hospital, I didn’t want to see my family

again. I came to Rio de Janeiro to live on my own. I wanted to have my own family so

badly. I had my daughter but I have just lost her…[She begins to cry]”

- Ana: “I am adopted myself and have been so mistreated. I was poor. I didn’t have

any shoes. They used to beat me so hard that I usually fainted and then woke up again.

I never knew why I was being beaten up. I have already been through tough times in

life, and I do not accept being mistreated by my own daughter. I do everything for

her…”

-Norma: “I don’t know…I kept my mouth shut from the start, and I was not in the

mood to speak, but after hearing what was said here I begin to have hope. I think

something good can come out of it. We have to believe, to value ourselves. I have


hope…”

-Rosa: “I need to have another surgery, but I will not leave the group for I am always

here at the hospital after all. This is my second home…My only regret is that the

surgery is not scheduled over the Christmas period, then I could eat as much

rabanadas [a kind of Christmas treat, made from fried bread with sugar and cinnamon

on top] as I wanted…”

-Sandra [who did not say a word and cried during the session]: “Everything I hear here

is entirely different from what I have been through. I had a good mother, who has

already passed away and I will try, as a daughter, to understand what you are

saying…”

Although this is a report of one of the group’s first sessions, we can already observe

the richness of material of both group and transferential nature. This initial phase has the

following main aspects: attempts to establish therapeutic bonds with the therapist and other

group members, manifestation of the first cross-transferences, and the presence of paranoid

and annihilation anxieties. One can observe the dispute between Ana and Rosa for the group’s

attention through the live report of their traumas, as if they were trying to prove who was the

sickest, who had the saddest life history, or who would demand greater therapeutic care.

During this group’s first session, patients introduced themselves in histrionic ways,

demonstrating what Kaës (1985) referred to as “the group being source of histrionic

excitement and space for hysterical manifestation” (Kaës, 1985). In this regard, Zimerman

(1993) affirmed that the speech of the hysterical patient2 during group treatment displays

distinctive characteristics (i.e., always recounting the day’s drama in a dramatic and theatrical

way and seeking to build reciprocal idealization though the bonds established with the

therapist).

2 Considering that dissociative and conversion disorders (ICD10-F44) are generally treated as hysteria by

psychoanalysis, this paper strives to maintain the specificity and terminology adopted by psychoanalytical

authors when referring to dissociative and conversion disorders.


Groups, during the initial group stages, display cross-transference (Foulkes, 1967) that

expresses the patients’ need for love, mutual dependency, dependency feelings toward the

therapist in the form of hope for a cure, and group bonding. However, such groups present a

paranoid nature in which opposite feelings are intertwined and hopelessness, and fear of being

deceived and rejected is manifested.

Yalom (2005) affirmed that among the main therapeutic factors found in analytical

groups is the instillation of hope. In this particular group, patients promptly showed that they

desired and expected to be cared for, to be listened to, and to have their needs met by (1) the

analyst, with whom they had already begun to establish positive transference and (2) the

institution itself, which for many patients functions as an additional transferential element.

Pichon-Rivière (1977) stated that the institutional patient develops a peculiar transference

with the medical care provider, similar to an omnipresent father or protective mother, that is

sometimes stronger than the transference developed with the analyst and group itself.

Institutional transference is seen as an important aspect to be observed and addressed when

conducting institutional group sessions, especially when dealing with a population with

failures of maternal holding (Winnicott, 1958) or a history of traumatic experiences.

The experience of universality (Yalom, 2005) is very important to such groups,

considering that their hardships can be shared, although this may sometimes turn into a

complicating factor for traumatized and victimized patients, and may represent a chance to

foster empathy, mirroring, and a genuine sharing of feelings when properly handled.

Similarly, the feelings of abandonment and the consequences of a lack of primary care

experienced by such patients may be converted into interrelationships of mutual care.

These groups’ natural ambivalence is evident when their members report life histories

replete with trauma and deprivation. In such cases, a certain polarization is noticeable within

the group regarding whether to adhere to treatment. One may quickly observe a group


functioning at the level of dependency basic assumption (Bion, 1970), in which messianic

expectations (Bion, 1970) or a tendency toward group illusion (Kaës, 1994) may infect the

group and hinder the evolution of the process. In contrast, we may find the occurrence of

transference relationships of a very primitive nature, involving adhesive, mirror, or additive

identifications (Zimerman, 1993). On such occasions, resistance, fear of repeating situations

of traumatic abandonment within the group and annihilation, and engulfment anxieties (Kaës,

1994) simultaneously compete, intensifying fight-and-flight basic assumptions (Bion, 1970)

that may lead to acting out and premature dropout.

Thus, the initial moment of group psychotherapy with such a clientele demands extra

care that must be supported by the material gathered through many initial interviews to

reinforce the therapeutic alliance that is necessary to maintain therapeutic bonds during

hesitation times. Likewise, the construction of a favorable group setting is vitally important to

patients, promoting predictability, steadiness, and holding to patients. According to Winnicott

(1958), holding is the main attribute of the analytic setting. Mello Filho (1986) adapted

Winnicott’s ideas to group practice, asserting that the therapist’s task is to further the creation

of a facilitating environment through the group setting, in which the patient’s basic anxieties

can be reproduced and fostered by the group.

Rosa’s announcement at the end of the session regarding the surgery she intended to

undergo perfectly illustrates the expectations of new group patients. Through Rosa’s fantasy

of “hospitalization” (in the group) for a “Christmas surgery” (labor or birth) when she will be

able to have rabanadas (a Christmas treat) and “eat herself nearly to death” (fill herself up) or

“even death by rabanadas,” the expression of her desire for rebirth, care, nourishment, and

protection is evident. Nevertheless, annihilation anxieties are demonstrated through her fear

of being devoured, engulfed, and stuffed to death by the breast that feeds and destroys, which

are also represented by the group.


Another aspect that attracted attention was Sandra’s only interference at the end of the

session. Although she remained quiet during most of the session, she acted as a radar (Foulkes

& Anthony, 1967), capturing the depressive content of the group, which reactivated her

anxieties of loss and was verbalized through explicit communication about her mother’s

death. Sandra’s defenses and the defenses of the other group members were threatened. She

simultaneously acted as a mouthpiece for the group’s anxieties. She protected herself against

identification with the group, signaling that she was different from the others. However, such

conflict is revealed through her uncontrollable crying.

Psychoanalysis links hysteria to sexual conflict, the girl’s identification with her

mother, and weak feminine identity (Freud, 1898, 1931). The group’s hysterical patient is a

monopolist and shows a need to be the center of the group’s attention. For such a patient, the

group functions as a stage, a place where she can be seen and where her drama can be

exhibited, all of which are under the therapist’s gaze and the gaze of others.

In this sense, we can observe that the group has a double function in the hysterical

pathology dramatization, a function that could be lost were the psychotherapy individual.

These patients’ tendencies toward conversion may emerge displaced into speech (i.e.,

seductive, cathartic, and victimized), or the group space may offer the stage and the audience

that favors dramatization of this unconscious process. At this moment, anxious talk and verbal

communication are more at service of a “not to say” or of a “as if”, kept by the hysterical

patient through his symptom.

Yalom (2005) referred to the debriefings he usually had with his patients at the end of

treatment and revealed the importance they give to certain critical incidents that elicit huge

changes and treatment progression. Thus, through a confrontation between Norma and Lucia

1 year after the beginning of therapy and various successive reports, understanding the

importance of transformations occurring in this group is possible.


Conflict within the group

Norma is a patient capable of promoting greater group interaction and reflects the

desires of the other members for change. This is clear when one observes her history in the

group and the significant improvement of her personal issues. Her participation is envied and

admired by other group members, and her role in the group is a mixture of mouthpiece and

leader (Foulkes & Anthony, 1967). Unlike Norma, Lucia is the prototype of Freud’s

hysterical patient: narcissistic, infantile, dramatic, and boring. She attracts negative counter-

transferences from others because her behavior does not allow empathy. Moreover, her

comments are prolix and self-centered, complicating group communication and progress.

Somehow, Norma’s and Lucia’s behaviors combine the projected, dissociated, and

contradictory aspects of the group.

- Lucia begins to speak: “I did badly at a test I had yesterday, precisely on the subject

that everybody did well.”

- Norma answers: “I’m sorry, but I have to say this: I have already noticed that you

care for other people’s opinion, mainly your parents’ opinion. How is your

relationship with them?”

- Lucia: “It has always been very difficult. They control everything, and I have no

freedom. I can’t wear shorts or bikinis or even arrive late at home.”

- Norma: “I understand, for I’ve always been a rebel myself. I had hard times in life,

trying to get the things I wanted. I don’t see this in you and you are not so young…”

- Lucia: “This is because I have problems at home. I will end up having to speak about

that…[she looks at the therapist, alluding to her incestuous father]. One day I was in

my bed and my father...”

- Celia: “My goodness! What an awful thing!”

- Norma: “You wish you were in your mother’s place, with your father…You are


always complaining about life, and yet you are almost 30 years old…You keep obeying

orders like a little kid and participating in your parents’ sex life. Think about your

own life! Go back to school. Be independent. Get a job...”

- Celia: “You are imagining all this. I think you are rather lazy. You complain a lot.”

Lucia was silent, very angry, trying to defend herself.

- Lucia: “I am trying. I’m looking for a job, but it’s been very difficult to find.”

- Norma, emotionally affected, speaks again: “You know, Lucia, I got married twice,

got beaten[begins to cry]…I thought it is important to give you a word of advice for I

remember being happier when I was working and struggling. I gave in, and I ended up

like this…Now I want to recover this fighter within me. It irritates me seeing you

wasting time!”

Lucia also begins to cry. Both of them cry a lot.

- Therapist: “I think what is happening today in the group is very important. Norma

and Lucia spoke of delicate issues never mentioned here before. The group brought its

irritation towards Lucia which is actually an irritation with secrets, with inertness,

with each one’s complaints, with sexuality, with life put aside! Today, each of you has

been able, even with some difficulty, to see yourselves in the other, in the other’s

emotions…”

- Lucia: “I think it was nice of Celia to have spoken during the group’s last session,

about her feelings towards her doctor, when they met. It was nice knowing about her

desires…”

Celia then starts to tell some episodes of her life, related to sex, that amuse the other group

members and relieve the tension of the previous moments.

- Therapist: “It seems that now, here in the group, we are able to speak about sex and

other difficult issues to all of you. Precisely today, when hard and intimate issues were


addressed, you have been able to get closer to each other, to feel more connected to

each other, and to speak of other intimacies…”

This session reveals a substantial change in the group. Such a change has been in

process for a while, announcing the beginning of a new and productive phase. The beginning

of treatment had little integration, and the group was functioning essentially at primary

process level, with many periods of discontinuity and moments of dissociation. The

communication within the group, once restricted to stanch and individualistic small-talk and

hysterical speeches, developed into free-floating discussion, leading the group to more

cohesive and integrated performance.

During the treatment’s initial stage, Lucia’s behavior, defenses, and belle indifference

disturbed the other group members. However, they used Lucia to avoid discussing their own

issues and consequently resist group work. During the session described above, the group was

able to face its forbidden, denied, and repressed aspects (e.g., incestuous fantasies, repressed

sexuality), enabling identification and greater cohesion within the group.

Feelings of belonging, strengthening of group identity, and operating on a less

repressive level lead to an explosion of desire and enable the group’s members to better deal

with their sexuality and the opposite sex. This development was manifested through the

willingness to accept male patients in the group from that moment onward. Until this time,

each time this subject was raised, patients rejected it, referring to the male presence in a

pejorative and devaluated way. Their negative experiences in life prevented both men and

their sexuality from being part of treatment. After that session, the presence of men in the

group was reclaimed, and after a few interviews, two male patients were selected for the

group. Since then, talking about desires, sexuality, fragility, and men has been possible.

As the group process progressed, relationships began to change. The members became

less ambivalent, and feelings of genuine concern prevailed among the group members. At this


stage, new participants were happily received. Two new members, both male, joined the

group, and their arrival was replete with expectations and acceptance. After the new member

adaptation period, the group functioned more harmoniously, with broader role distribution.

Each patient, with the exception of Lucia, began to experience significant improvement in

their family and marital relationships, as well as in their precarious financial lives. Some

returned to work and restarted modest, although profitable, professional activities. Once they

were outside of the group, patients were able to reflect on their renewed relationships with the

environment and the transformations they experienced in the group. After four years of

treatment, the group found itself fit for closure. Only Lucia appeared to have benefitted little

from group treatment and was referred to individual therapy. She is still receiving

psychological and medical treatment, which revealed a chronicity of symptoms and led us to

consider other possible diagnostic hypotheses for her case.

Regarding certain aspects of transference, observing the growth of group

interrelationships and confidence and the development of greater abilities among group

members to solve problems was possible. Clear changes in the patients’ dependency on the

therapist, their acceptance as “another group member,” and the dilution of transference

resulted in greater cohesion. However, institutional transference (Pichon-Rivière, 1977)

remained strong and idealized. The hospital, introjected as good-object and protective father,

remained important to the group members.

Group Cohesion

Based on the work of Winnicott, Mello Filho (1986) asserted that group evolution

repeats the same journey of an individual’s development. The group is not integrated in its

origins, similar to the sum of different pieces not directly related to each other. Subsequently,

similar to a child who receives from a good-enough mother an adequate holding environment,

the group develops to an integration stage in which participants form a cohesive and harmonic


unit. This integration produces a series of modifications to group functioning, and

identifications can then generate integration, growth, and the acceptance of new group

members. Considered in winnicottian terms, the group develops from a stage of absolute

dependency to a stage of relative dependency on the way to independence (Mello Filho,

1986).

Mello Filho (1986) stated that if the initial holding environment is created by the

therapist, then when the group is more integrated and cohesive, this role will be played by the

group matrix. Remembering Foulkes, this group will develop from a stage of non-integration

to integration through the therapist’s active function experienced by the group from its origins

to its evolution. In this regard, as the group becomes more cohesive, it can gradually work

without the therapist, relying only on the group matrix. Thus, the role of holding environment

provider will progressively be part of this therapeutic group interaction, such that the group

becomes more autonomous during its journey and relies less on the therapist for such tasks.

When well-integrated and developed, the group itself gradually plays the role of the good-

enough mother.

The winnicottian approach to group issues also considers transitional phenomena.

Winnicott (1971) conceptualized the intermediary area, a potential space, fundamental to the

development of the self, creative play, and cultural experience. Group psychotherapy

promotes the creation of a space, an experimenting area among group members, where the

exchange of experiences and mirroring phenomena (Foulkes & Anthony, 1967) may offer

new identities and allow the development of creativity and a group culture. Mello Filho

(1986) suggested that the group therapist may represent the transitional object to the patient,

personifying not only the external and objective reality but also the subjective object at the

service of the patient’s inner reality. In this sense, the therapist must agree to be used by the

patient (i.e., as an object), being predominantly authentic and empathetic.


The potential space created by group therapy is essential not only for patients suffering

from dissociative disorders, but also for patients generally treated in group settings. This

particular group setting provided a space where patients could receive a distinguished gaze

and where the strangling effect of hysteria had a voice and meaning. The cohesive group

maintains the demand for a distinguished gaze and a space to be filled with new

identifications and exchanges support and working-through that re-signify experiences.

Therefore, through new identifications and signified and re-signified words, the group is able

to verbalize what has once only able to be expressed through the body.

Therefore, the potential space created in the therapeutic group setting contributes to

the psychosocial development of low-income patients. With this particular group, composed

of patients who had lives impacted by illness and social exclusion, analytical psychotherapy

was a decisive element that promoted cohesion, re-signification, and new identification bonds.

Group therapy with a low-income population demonstrated that its effectiveness goes beyond

results obtained by general psychotherapy. The reception, triage process, analytical listening,

and group treatment provided by psychiatrists, psychologists, and social workers at mental

health ambulatory centers create a singular space of acceptance and identity promotion that

are indispensable for these patients.

Among the numerous theoretical concepts of group processes that can be discussed

here, the notion of internal group (Pichon-Rivière, 1977) has major utility and relevance for

the actual comprehension of what occurs in group therapy or community group treatment.

The internal group is formed from the first internalized bonds, beginning with family bonds

and expanding to subsequent groups throughout life. An individual’s internal group will

always work as an approach/withdrawal model for each new experience. The analytical group

furthers the creation of a different internal group, favoring new identifications that are

introjected by patients as a good object and promoting the foundation and construction of


truer relationships (matrices) in accordance with social contexts. The group experience, not

necessarily analytical treatment but other methods through which a good transferential or

working relationship with the therapist and other group members can be established, can

promote working-through and positive changes in the inner world and can be extremely

helpful for patients whose realities have been affected by poverty, trauma, or failures in the

development of subjectivity. Based on the relationships renewed and legitimized by both the

social environment and personal and institutional bonds, a new and unique place in the social

insertion process may emerge for such patients.

The delivery of mental health-psychotherapeutic services for low-income persons,

especially in countries like Brazil, with large populations and inadequate material resources

should utilize both the group device and a variety of professionals to promote group therapy

treatment programs. Such initiatives, if given higher priority, will contribute greatly to

improve quality of life and the promotion of social insertion. Individual treatment in

institutional settings could also be recommended, but only for special cases .

The Brazilian experience with group work has 60 years. Although it has been through

periods of rise and fall, now it seems to start a new phase with further encouragement of

public policies. It is hoped that the experience of the pioneers will inspire the work of new

generations, building a bridge that will enable the continuity of knowledge and clinical

work with groups in Brazil. Despite the predominance of the oral tradition and the lack of

publications on the subject, Brazilian group psychotherapists with their knowledge and

creativity can enrich the theoretical framework of group psychotherapy at an international

level.


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Group-Analytic Psychotherapy with Low-Income Patients in Brazil

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