Consultas terapéuticas de padres e hijos con mediaciones de videojuegos en servicios públicos de salud: relato de una experiencia exploratoria

Introduction

Psychoanalysis is a method of psychotherapy, research and a theoretical field that, through the knowledge of unconscious psychic processes, allows the understanding of the meanings of symptoms and processes of elaboration. Its “standard” method was formulated at the turn of the 20th century, based on the pillars of free association and floating attention, including interpretations of resistances and transference, and the construction of unconscious fantasies. The patient lies on a couch and the analyst sits behind the headboard. It is based on transference, the associative process and analytical listening in a long-term process (Freud, 1919, 1923, 1933). However, it has been extended to situations where the “standard” method cannot be installed, including child analysis, groups, couples, families and institutions (Kaës, 2005, 2015), like Freud (1919, p.292, our translation) has predicted long ago that «there will be for us the task of adapting our technique to the new conditions».

The work of the psychoanalytic psychologist in Brazil’s public health services is directed to interventions not only with the intrapsychic level, but the inter-subjective determinants of health and illness processes of a community through the extension of psychoanalysis to pluri-subjective situations (Fernandes, 2005). This can mobilize institutional emergents about its pertinence and technical management. By introducing changes in the “standard” method of individual treatment, according to Kaës (2005, 2015), specific dimensions of unconscious psychic reality emerge related to the new situation.

In this context, this article aims to report the experience of the technical management of therapeutic mediations with video games within the setting of parent-child therapeutic consultations for children with complaints of psychological suffering in a public health service.

Therapeutic consultations

Winnicott (1965, 1971) was a pioneer in transposing the models of therapeutic consultations and psychoanalysis to child psychiatry. He introduced them to public services to account for the diversity and breadth of psychological care demands, as a form of psychoanalysis applied to the first interviews (therapeutic interviews). He structured them as a therapeutic setting for exploring the primitive mechanisms of child development and maturation in brief consultations (between one and five sessions). It differs from long-term psychoanalysis as the analytic work is directed towards non-transferential interpretations and towards constructions reserved only for significant moments. The main interventional focus is the installation of a holding environment and an experience of trust and mutuality, through the analyst’s active adaptation and empathy for the patient’s psychic conditions. The interpretation technique, therefore, is adapted to a playful and creative way. Playing, mainly through the squiggle game, is one of the privileged techniques. In some situations, the children’s mothers can participate, which mobilizes the effects of “dual therapy”, as they can become aware of their own problems by becoming involved in the treatment of their children (Bléandonu, 1999; Winnicott, 1965, 1971).

Parent-child therapeutic consultations

Therapeutic consultations with parents and children were developed by Bléandonu (1999) through some modifications in the Winnicottian setting. Preserving some aspects such as the effects of holding and the little emphasis on interpretive interventions, it locates the therapeutic objectives in the parent-child relationship and parental conflict, building a family therapeutic moment. Parents and children participate in the session in a climate of flexibility and availability. The primordial principle is to correlate the psychic life of the child with the parental conflict, with the parental crisis. His proposal is to mobilize therapeutic effects on the child and on the parents, in sessions that include both, in a true “dual therapy”, without losing the focus that the main therapy is the child’s and the parents’ role is supportive. The main objective, therefore, is to unlock the child’s emotional development and the adjustment of inappropriate parenting.

In Brazil, Moreira (2019) researched the experience of therapeutic consultations with parents and children, considering the importance of psychological work with parents concomitantly with child care, as they suffer from intense feelings of impotence in the face of difficulties in parenting. Joint care is essential so that parents can rescue their parenting skills through the establishment of a deep, meaningful, empathetic, spontaneous, sincere and playful communication for the elaboration of anguish and recovery of their holding capacity.

Therapeutic mediations

Anzieu and Chaubert (1961) were pioneers in identifying the importance of mediating objects between the subject and the psychologist through expressive techniques and psychological tests. These methods enable forms of projection of the psychic material for the evaluation of psychological processes, for psychotherapy, for aesthetic appreciation and for pedagogical purposes. They mobilize perceptive and projective material related to transitional phenomena and unconscious fantasies, mainly archaic representations and anxieties of the mother-baby symbiotic link, good and bad objects and ambiguity.

In Brazil, Nise da Silveira (1981) had introduced the use of artistic resources and mediators in the psychological treatment of psychosis in adults in her occupational therapeutic studio. Between 1946 and 1974, she realized that expressive activities facilitated the projective and organizing externalization of the internal world in psychosis and the self-healing tendencies of the psyche, in such a way to «create opportunities for the images of the unconscious and their motor concomitants to find forms of expression» (p.13, our translation). The therapists who accompanied the creative-expressive processes supported a technique that favored improvisation, abstraction and empathy, in a climate of acceptance, sympathy and freedom of production. Nise da Silveira’s studio offered painting, modeling, music and crafts as therapeutic agents through which psychic chaos could be contained. The main factor in the treatment was the trusting link with the therapist.

The occupational therapeutic studio gave rise to the therapeutic workshops in Brazil’s public mental health services for the care of psychoses and severe psychological suffering. They use artistic and cultural mediating objects to operate «on the points of disconnection between the psychotic and reality… as places of mediation, as an alternative to the imposition of jouissance that invades the psychotic…. as an offer of activity, physical space, reference and address, they allow a treatment of drive deviations… the construction of another surface to locate this jouissance» (Guerra, 2008, p.52-53, our translation).

Chouvier (1999) highlighted that the work of creation enables the transformation of raw psychic matter into figurations in an external and objective materiality, facilitating the work of symbolization. Therefore, the symbol, which is the vector of the obscure parts of the psyche in material objects, «demands to be exported in a matter that is initially heterogeneous and that will be, due to the work that characterizes it, largely introjectable» (p.8, our translation). The mediating object allows access to the symbolizing plane of psychic matter due to its plastic, moldable characteristics.

From the clinical work with children and adolescents with autism and psychosis and their impasses in the symbolization and transference processes, Brun (2014) pointed out the importance of working sensorimotor and affective dimensions with mediating objects. This modality of therapeutic mediation enables the construction of a malleable attractor medium that allows access to the sensoriality and the transference of primitive experiences, re-updating the archaic and catastrophic anxieties beyond verbal language; they mobilize primary forms of symbolization that, in turn, facilitate the re-inscription of sensorimotor and affective experiences in therapeutic workshops with painting, music, modeling, collage, etc.

The «therapeutic mediation settings allow psychotic and autistic children to engage in specific modalities of symbolization, which do not go through verbal language, an aspect in which these children often find themselves in difficulties» (Brun, 2014, p.13, our translation). Mediating processes are related to the work of the intermediary and to transitional objects and phenomena, in which the Preconscious works for associating, figuring, interpreting and transforming intrapsychic objects, anxieties and drives and for delegation, representation, transmission, containment and symbolization, through phoric functions (speech bearer, symptom bearer, ideal bearer and others) and unconscious alliances, the inter-subjective links (Kaës, 2002).

Video games as new therapeutic mediations

More recently, in psychoanalytic literature and practice, we have verified the use of video games in psychotherapeutic contexts. A video game is a game in which the player immersively interacts with visual and acoustic images through the use of peripherals (joystick, keyboard, screen, headset, etc.) connected to a platform (computer, console, cell phone, etc.). As it is a popular, digital, playful and artisticcultural artifact, it has also become one of the newest strategies for therapeutic mediation in which the subject controls a playable avatar to perform desired playful actions in the game (Tisseron and Tordo, 2021).

Stora (2012) was one of the pioneers in setting up a therapeutic video game studio for children with psychotic pathologies and psychosomatic disorganizations and the rescue of the pleasure of playing. Faced with the inability of these children to speak and elaborate their anxieties, video games made it possible to use images as an expressive and interactive medium. One of his first findings was that the video game requires perseverance from the patient to acquire a certain mastery of the control commands, and he highlighted that it allows for a playful, intimate and interactive experience with the digital objects presented on the screen. The digital images of the game screen allow the relieving of destructuring feelings and affects, while allowing controlled play, placing them at a certain playful distance. Even digital games with aggressive, violent and destructive content allow the channeling of aggression, a good use of life-guarding masochism (suffering frustrations, etc.), favoring the expressive emergence of sadistic impulses playfully contextualized and contained. Video games in studios and in a group context tend to encourage transference, the ability to observe and be a spectator of the other and to persevere.

Virole (2013) found, in a clinical experience of more than 20 years of using video games in psychoanalytic psychotherapy with children and adolescents, that digital games allow the expression of fantasies and the elaboration of traumas. The video game psychotherapy technique retains many of the characteristics of children’s play therapy, with a fundamental variation in the setting: in addition to the availability of traditional play materials, video games are also offered. The patient chooses which game he wants to play among some pre-selected digital games. «Patient and therapist jointly immerse themselves in the virtual world inherent to the chosen game. The patient controls the avatar and moves it forward in the virtual world by making verbal comments or remaining silent. The therapist accompanies the patient, attentive to the adventures of the game, the choices made by the patient, his emotional reactions, and proposes, when the situation requires it, comments and even interpretations» (p.33, our translation). The therapeutic effects are mentalization, symbolization, drive restraint, narcissistic restoration in a «psychoanalysis integrated with the delegation of instances and representations to systems outside the subject» (p.47, our translation). This delegation is based on multiple processes ruled by the mechanisms of projection and identification supported by digital objects that, consequently, update for the subject its process of externalization of affects, sensations, and representations. Tordo (2017) pointed out that, in individual consultations, the narcissistic-identity and psychotic sufferings of children and adolescents can be contained, figured and transformed by the effects of the double of the digital avatar in video game mediations. The avatar allows the transitional externalization of the player’s psychic aspects, summoning his subjectivity. To this end, in the sessions the analyst can provide various technological supports such as portable video games, desktop consoles, computers, tablets, etc. The video game mediated psychotherapy technique should enable the creation of the digital double through the patient’s immersive choices and interactions with the game. The psychoanalyst’s work will include attention to the patient’s sensory-affective-motor reactions and the symbolization of transference and countertransference movements between the patient-player, the video game environment and the therapist. The analyst will observe the patient’s session also immersing himself in the game being played. «The essence of analytical listening is located at a nonverbal level, through conscious and unconscious exploration, in the game, of a co-creation, of digital actions and also of the sensations and affection engendered by them» (p.35, our translation). The analyst’s fluctuating attention in video game sessions is complemented by fluctuating participation, when the therapist not only observes, but plays concomitantly with the patient. The equivalent, in video game mediation, to the free association of predominantly verbal therapies is free action in the gameplay, without recriminations on the part of the analyst. Gameplay is the interactive immersion of the player’s skills and choices in the game with the mechanics, narrative, flow and rules of the game, which constitutes his playful agency.

The video game can be a transference attractor in the therapeutic process. This means that it is an artifact that draws the patient’s psychic economy, topic and dynamics, enabling a transferential constellation not only about the setting, about the therapist and about the mediating object. It enables a digital update of the transference over objects within the game itself through interaction, immersion and the gameplay (Tisseron and Tordo 2021; Jung, 2021). Therefore, the video game became known as a «speech facilitator object and as a support for the projective processes of patients that reduce their resistances. Its use then makes it possible to identify the transferential issues and to support the resumption of the work of thought» (Gillet and Leroux, 2021, p.23, our translation).

An exploratory report: possibilities for mediations with video games in parentchild therapeutic consultations in a public and free health care service

The place and context of this experience of parent-child therapeutic consultations was a health service linked to the Unified Health System (SUS). The SUS is a set of public policies and the provision of free health services nationwide. SUS policy follows integral actions that consider the needs of the population of a given territory in a broad understanding of health that includes its social determinants and seeks to build strategies and actions to promote health. The service to which this work refers was located on the outskirts of a Brazilian metropolitan region, in a municipality with a large population contingent in a situation of social vulnerability.

The need to change the setting of therapeutic consultations arose from a clinical emergent of some children who deliberately requested their mothers’ cell phones to play with during the sessions. Despite the parents’ attempts to inhibit this behavior during the sessions, the psychologist had the impression that the children showed that their psychic activity also found in digital games a means of ludic expression. The introduction of the video game in the session required the management of the technological material to be used and the enunciation of the contract and the framework. A portable video game device, a PSP (Playstation Portable) were selected, as well as games that were acquired for this specific purpose. The games were offered according to the emerging problem of each child or from a comment made by the child about a playful preference. The child’s chair for playing was arranged next to the psychoanalyst’s chair, while the parents’ chairs remained at the front. The child was invited to play with the PSP, or with another toy available in the room, such as the squiggle game. The instruction given to the child was very simple, something like: “I have a video game here and a game for you to play on it. You can play this or any other game you like. If you want my participation or that of your parents, you can request it. You will play alongside me so I can follow your gameplay”. The mediation with video games was introduced after some therapeutic consultations had already taken place and with parental consent.

Clinical work vignette

Mary and her son John (fictitious names), aged 10, attended five therapeutic appointments due to John’s problems with motor agitation, attention deficit, aggressiveness, nervousness, somatization with stomach gastritis and difficulties in school learning. Mary had a very fast speech, with mood swings, irritability and impoverished and operative reasoning. She was undergoing psychiatric treatment for bipolar disorder and had financial difficulties associated with marital problems, sometimes treating her husband as worthless.

She was able to talk endlessly about her grievances with her son at home and at school, but in a descriptive rather than elaborate way, criticizing and belittling most of John’s behavior. Nor did it seem to have a cathartic or symbolic effect. She also did not allow him to express himself in the session, interrupting his speech to present his version of what he was saying. She could not symbolize the hatred and destructiveness that appeared in the link. And the child, on the other hand, didn’t have much to say about himself or his life and wasn’t interested in playing with the doodle or other toys in the psychology room. Sometimes John reacted with some psychomotor movement or tried in vain to confront his mother’s speech, but in an eloquent and meaningless way. All of his spontaneous reactions, desires and behaviors were misinterpreted by his mother as failures or as a consequence of aggressiveness, motor agitation and attention deficit.

At some point during the consultation, it was evident that the mother, the child and the father were barely able to understand and put limits on the excess of maternal destructiveness and hatred directed at the child. The first hypothesis that occurred was that John was trapped in a thanactic link with his mother, unable to think and speak or work out this destructiveness as a consequence of his alienating fusion to an unconscious narcissistic alliance with his mother’s violence (Kaës, 2005, 2009). He seemed to be identified with her destructiveness that made him a useless subject and his suffering could be related to the lack of containment, limits and elaboration of the destructiveness in the family psychic apparatus.

Due to the few symbolization resources of the family psychic apparatus and the fused and destructive functioning, the psychologist suggested the introduction of the mediation of a digital game, Dungeon Siege: throne of agony (Supervillain Studios, 2006), a game in which the plot deals with the consequences of a cataclysm that altered the world and gave rise to sudden threats, wild monsters that must be faced by the playable avatar. The game mechanics ask the player to explore the devastated world, find resources and destroy the monsters in his path. The choice of this specific game came from the understanding that it would be necessary to facilitate the work of the intermediary of the primitive anxieties of maternal destructiveness involved in this alienating narcissistic alliance.

There were two therapeutic consultations with the video game. John’s gameplay seemed to “dialogue” with the material emerging in the consultation from his mother’s speech, revealing the difficulties he felt defending himself against his mother’s excessive psychological violence and aggression. In the last but one consultation after the introduction of video game mediation, he was able to confront his mother’s destructive criticism saying “let me think the way I want”. And in the last session the father showed up according to the psychologist request together with the mother and the child. Mary said that her son was doing more or less well, showing a psychic effort to symbolize some improvement in his behavior. The father said that he had been depressed for some time due to a significant professional loss that incapacitated him occupationally and made him feel useless in life. Due to the setting and technique of the therapeutic consultations, as well as the fragile conditions of the family psychic apparatus, no in-depth interpretation was made and the technical conduct was predominantly one of holding and facilitating the ludic and the figuration of aggression, incomprehensibility and hatred that was circulating in family functioning.

Initial explorations and hypothesis

Benghozi (1999) highlighted the importance of family genealogical continents in which, given their pathologies, the symptom bearer becomes a hologram of sick elements of the family context. In addition, marital dynamics can influence and even determine the symptoms that the child will have, according to Gomes (2011).

It was possible to verify the emergence of spontaneous, immersive and interactive actions of the children with the video game during the therapeutic consultations.

Interesting aspects emerged synchronously in the children’s gameplay in the face of the parents’ speeches about the difficulties they had in parenting, such as choices of moves or comments that symbolically corroborated or contradicted the parents’ speech. This data led us to hypothesize that, when the child plays video games in the presence of the parents and the psychologist in the consultation, he updates in his gameplay the externalization of the transference processes between the psychologist, the child and the parents, as well as those anxieties related to problems of parenting.  Gillet and Leroux (2021), J. Jung (2021) and Tisseron and Tordo (2021) also found that video games mobilize a specific type of digitally mediated transference. In the clinical vignette it seemed that, through playing with digital objects of the video game, ludic figurations of the link and parenting patterns that led to the symbolization of the tanatic unconscious alliance. In such a way, using video games in therapeutic consultations of parents and children can facilitate the expression of anxieties and promote figurative symbolizations of the pathological family context of parenting. And it also seemed to facilitate the restoration of the work of the intermediary of the family psychic apparatus by offering a video ludic transitional space in which intermediary representations of parenting link and unconscious alliances can be figured (Kaës, 2002, 2009) through gameplay.

Obstacles in technical management

From the point of view of the artifact platform, the problem with including video games in therapeutic consultations was the fact that the PSP screen is small and visible only to those who are playing, which makes it difficult for other people to follow the gameplay. In addition, the scope of the objectives of therapeutic consultations becomes restricted, as for someone to play with the child, it is necessary to stop playing and pass the PSP to someone else. Because of this, there are no co-op games.

Other peripherals such as a television, a platform with several joysticks where other players can enter the game (the family and the psychologist) and so on, could facilitate better interaction, immersion and cooperative gameplay. It is important to have some digital games available in the room for the patient’s own choice as well, not only the pre-selected game by the psychologist (Tisseron and Tordo, 2021).

Another important difficulty in the context of public health concerns the resources available and accessible to professionals, both from a material and technical point of view. In the technical aspect, the psychoanalyst subsidized this work proposal with his own budget. But it is important that the public system makes funds available to the psychology sector for the acquisition of materials for carrying out workshops on therapeutic mediations with videogames, which would benefit the patients. Parents’ resistance to the video game artifact can be another problem that must be clarified and interpreted according to their cultural context to process misguided moral panic diffused by some tendentious media and to advise on the most suitable ages for each type of digital game (Gillet and Leroux, 2021).

Considerations and recommendations

Psychoanalysis in groups, couples and families has contributed to expanding the analytical treatment to other situations that go beyond the standard method. Such settings not only cover a greater number of people, but mainly treat them through the psychic configurations of their social links and the effects of the inter-subjective unconscious processes, giving consequences to the Freudian hypotheses that the psychology of the individual is also social, since the subject is heir and transmitter of psychic representations forged generationality. Public (mental) health services are crossed daily, in their primary task, by destructive severe psychic and social sufferings that influence or are a consequence of the weakening of links, family and institutional breakdown (“démaillage”) processes and the pathologies of psychic transmission (Benghozi, 1999; Gaillard, 2014; Kaës, 2015). These are the reasons why plurisubjective clinical settings should be the first choice of treatment in such services.  Therapeutic mediations have emerged in psychoanalytically oriented setting to mobilize and create Preconscious and intermediate processes (Kaës, 2005). More recently, video games have also become a mediating object for working with archaic sensory-affective-motor anxieties (Jung, 2021; Stora, 2012; Virole, 2013; Tisseron and Tordo, 2021; Tordo, 2017).

Our exploratory research on the introduction of video games in the practice of therapeutic consultations in the public health service revealed that digital games can facilitate the work of the intermediary of the family psychic apparatus by digitally updating the transferential link between psychoanalyst, child and parents and figuring symbolically the difficulties of parenting processes. It seemed that the child gameplay in this specific setting “talks” to the parents’ speech and can be correlated to the work of figuration of the parenting problems. Because of the potential benefits of the video game mediations, the cost of this material must also be financed by the public system, offering adequate material for this kind of psychological service.

It is also worth mentioning the importance of reflection on autonomy in the choice of intervention processes and procedures in the work of the psychologist in the public health context, which is theoretically and technically grounded on psychosocial diagnosis processes of the community served. Important questions and reflections are called for in the current “wave” of individualization of pathologies, loss consideration for the social and inter-subjective determinants of health, pathologization of social suffering, attacks on some theories and strategies of psychoanalytical care and on the role and place of the Brazil’s Unified Health System (SUS) and its investment prospects and financing. The SUS care services and policies have been under political attack in the last four years by president Bolsonaro’s supporters, involving cuts in funding and maintenance that lead to the scrapping of services, the lack of material resources and the disqualification and demotivation of its professionals. The SUS needs to be strengthened so that it can sustain and guarantee decentralized, regionalized, technically based care strategies and in a comprehensive and equitable way.

This article hopes to contribute with an initial reflection for the careful appropriation of the therapeutic mediation with videogames in public health services that facilitate the work of the intermediary in parental links, which is fundamental in the care of psychic suffering in contemporary society. Further research can reveal other adjustments to the setting of video game mediations with couples, family and groups, and therapeutic workshops in public (mental) health services, specifically for Brazil, where there is still little research in the area of psychoanalytic mediations with digital games.

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