• reflexión •
Nise da Silveira and the revolutionary use of art1 as Occupational Therapy in the psychiatric context
Received: March 2, 2022 • Sent for modification: May 1, 2022 • Accepted: June 28, 2022
Lousa, T. & Mikosz, J. E. (2022). Nise da Silveira and the revolutionary use of art as Occupational Therapy in the psychiatric context.
Revista Ocupación Humana, 22(2), 228-241. https://doi.org/10.25214/25907816.1400
Nise da Silveira y el uso revolucionario del arte como Terapia Ocupacional en el contexto psiquiátrico
Nise da Silveira e o uso revolucionário da arte como Terapia Ocupacional no contexto psiquiátrico
Teresa Lousa2
José Eliézer Mikosz3
1. Art therapy seeks the same benefits as Occupational Therapy, such as the therapeutic effect of doing and the development of the body in its motor and cognitive dimensions. However, its primary focus is on the unconscious. Hence Nise’s interest in Jung’s work..
2. Bachelor of Philosophy. Masters in Theories of Art. PhD in Sciences of Art and Heritage. Integrated researcher, Universidade NOVA de Lisboa. Researcher and assistant professor, Universidade de Lisboa. Lisbon, Portugal. teresa.lousa@gmail.com
https://orcid.org/0000-0001-6574-6901
2. Transmedia artist. Masters in Technology. PhD in Human Sciences. Associate professor, Universidade Estadual do Paraná. Integrated researcher, Universidade NOVA de Lisboa. Researcher, Centro de Investigação e de Estudos em Belas-Artes, CIEBA/FBAUL, Universidade de Lisboa. Editor, International Interdisciplinary Journal of Visual Arts - Art&Sensorium. Curitiba, Brazil. antar.mikosz@unespar.edu.br
Abstract
This paper aims to review the biography and work of Nise da Silveira, a Brazilian psychiatrist who carried out revolutionary work in the treatment of the mentally ill. This paper follows a qualitative methodology with a narrative and documentary base, highlighting the importance of her innovative action that rescued Occupational Therapy with artistic tools, in which free expression and affective contact are favored as an alternative to the conventional treatments of the time, such as electroshock and lobotomy. From a comparative perspective, Jung’s analytical psychology concepts such as myths, archetypes and the collective unconscious are related to Nise’s psychiatric therapeutic experience. The presentation of some patients case studies leads to the conclusion that the symbols and archetypes revealed in the artistic images created in occupational therapy have a structuring and healing impact, which is still followed today in various therapeutic contexts.
Keywords: Occupational Therapy, Psychiatry, Art Therapy, Jungian theory
Resumen
Este artículo propone una revisión de la biografía y la obra de Nise da Silveira, psiquiatra brasileña que realizó una labor revolucionaria en el tratamiento de las personas con enfermedades mentales. Sigue una metodología cualitativa con base narrativa y documental donde se destaca la importancia de su acción innovadora, que rescata la Terapia Ocupacional con herramientas artísticas en las que se privilegia la libre expresión y el contacto afectivo como alternativa a los tratamientos convencionales de la época, como el electroshock y la lobotomía. Se relacionan, desde una perspectiva comparativa, conceptos de la psicología analítica de Jung –como los mitos, arquetipos y el inconsciente colectivo– y la experiencia terapéutica psiquiátrica de Nise. La presentación de casos prácticos de algunos pacientes permite concluir que los símbolos y arquetipos revelados en las imágenes artísticas creadas en la Terapia Ocupacional tienen un impacto estructurante y curativo que se sigue, hoy en día, en diversos contextos terapéuticos.
Palabras clave: Terapia Ocupacional, Psiquiatría, Terapia con Arte, teoría junguiana
Resumo
O objetivo deste artigo é propor uma revisão da biografia e do trabalho de Nise da Silveira, uma psiquiatra brasileira que realizou um trabalho revolucionário no tratamento dos doentes mentais. Este artigo segue uma metodologia qualitativa com uma base narrativa e documental, destacando a importância de sua ação inovadora que resgatou a Terapia Ocupacional com ferramentas artísticas, nas quais a livre expressão e o contato afetivo são privilegiados como alternativa aos tratamentos convencionais da época, tais como eletrochoque e lobotomia. A partir de uma perspectiva comparativa, conceitos da psicologia analítica de Jung, como mitos, arquétipos e o inconsciente coletivo, estão relacionados com a experiência terapêutica psiquiátrica de Nise. A apresentação de estudos de caso de alguns pacientes leva à conclusão de que os símbolos e os arquétipos revelados nas imagens artísticas criadas na Terapia Ocupacional têm um impacto estruturante e curativo, que, ainda hoje, é seguido em vários contextos terapêuticos.
Palavras-chave: Terapia Ocupacional, Psiquiatria, Terapia com Arte, teoria junguiana
Figure 1. Nise da Silveira
Source: Unknown author - Arquivo Nacional (do Brasil). Public Domain.
Wikimedia Commons.
Introduction
This article starts with a brief presentation of the life and work of Nise da Silveira, following a qualitative methodology based on documental and narrative sources, such as interviews and the psychiatrist’s letters. To highlight her innovative role, the recovery of an occupational therapy center is shown, where she used art and other resources with patients. From then on, this would become an important therapeutic tool in psychiatric and therapeutic settings. The contribution that Jung’s analytical psychology gave to understanding the work Nise developed in the field is addressed. Thus, in a comparative approach, a dialogue is established between Jung’s operative concepts and Nise’s discoveries in the practice of her therapeutic and occupational ateliers with her patients in Rio de Janeiro. From that point onwards, Nise will awaken to the importance of the symbolic, mythical and archetypal qualities that she already felt intuitively in the works of her patients, as it is highlighted in Adelina Gomes’s case study. Nise therefore recognizes a collective pattern that can be of the utmost relevance for understanding the individual narrative while at the same time possessing a healing power.
In the restructuring of psychiatric services, not only in Brazil but worldwide, Nise da Silveira’s contribution is present: above all, her focus on humanized and spontaneous work present in occupational and artistic Ateliers reinforce dignity and psychosocial care.
Nise da Silveira (Maceió, 1905 – Rio de Janeiro, 1999):
Life and work
As the daughter of a pianist and a journalist and mathematician, Nise grew up in an environment influenced by two complementary universes, the emotional and the rational. On her childhood, she states in an interview:
I was an only child. Completely spoilt. My mother, a musician, bordering on genius. My father, a man who read a lot of mathematics and literature. I had a good library. Thus, I read Machado de Assis very early on. (Leal, 1994, p. 25)
Nise completed her primary education at a convent school, Colégio Santíssimo Sacramento. At only sixteen years of age, she entered the Faculty of Medicine in Bahia, Brazil, being the only woman among 157 men in her course (Biernath, 2007) (figure 2), which she completed in 1926 with a dissertation on female criminality (da Silveira, 1926). The thesis can be consulted at the Universidade Federal da Bahia - UFBA Repository.
In 1927, after her father’s death, she moved to Rio de Janeiro with her husband. In 1933, she specialized in psychiatry and trained at the neurological clinic of Antônio Austregésilo. In the same year, she won a federal contest for the psychiatrist position in Psychopathy and Preventative Mental Health Care position at the Praia Vermelha Hospital (Itaú Cultural, 2017).
During the Getúlio Vargas regime, Nise was accused of being a communist and was imprisoned for 16 months, together with Olga Prestes and Elisa Berger (Nise da Silveira, 2002). Subsequently, in 1944, she returned to work in public service, at the Pedro II National Psychiatric Center in Engenho de Dentro, Rio de Janeiro, with a deeper awareness of what it was to live in institutional confinement. Nise fostered a humanized treatment because she did not conform to the popular psychiatric treatment techniques at the time. Among such techniques were electroshock, lobotomy – developed by the Portuguese physician Egas Moniz – and insulin injection, intended to pacify the states of “aggressiveness” or “delirium” that could afflict hospital patients. Nise saw a similarity between such methods and torture, considering them aggressive and ineffective. She embarks on a battle against conventional psychiatry and is relegated to the Occupational Therapy Section of the hospital. Nise seizes this opportunity, developing a friendly, supportive and humanized atmosphere. She gives a new life to the occupational center, by making various artistic materials available to the patients and starting therapy with the support of domestic animals.
In 1946, Nise began to run an abandoned therapy center in the Occupational Therapy Section of the hospital. Nise revolutionized the very concept of Occupational Therapy: the “therapeutic” activities that had been reduced to cleaning and maintenance tasks in the hospital became activities integrated into free artistic ateliers with recourse to painting and molding. This is where she initiates a clinical approach through free artistic expression and a caring and individualized approach. It, therefore, opens up new possibilities for a deeper understanding of the psychiatric patient’s inner universe. Nise tells that one of her patients named the achievements of her work “handling emotions.” The attention and care Nise devoted to her patients led her to propose the internal replacement of the “title occupational therapy by Handling Emotions” (da Silveira in Motta, 2005, p. 14). This determination shows, on the one hand, the attention and appreciation given to patients, and on the other, the awareness that the release of emotions and internal conflicts are favored through the stimulation of creative expression.
Inspired by the works of the Dutch philosopher Baruch Spinoza (1632-1677), the literature of Machado de Assis (1839-1908), the French playwright Artaud, and Dubuffet’s Raw Art movement, and with the help of Almir Mavignier -a painting student and hospital employee-, she developed an innovative approach where artistic expression was understood as a way of enabling individuals to express their emotions through occupational practice. As a result of intense work that increasingly bore fruit, and despite the continuing boycotting by the medical team, she founded the Museum of the Image of the Unconscious, in 1952, where she exhibited the works produced by her patients: artists such as Adelina Gomes, Carlos Pertuis, Emygdio de Barros and Octávio Inácio, who contributed to the collection of what was later to become the Museum of the Unconscious in Rio de Janeiro. In her texts, for example: Imagens do inconsciente (da Silveira, 1981) and Mundo das imagens (da Silveira, 1992), Nise recorded studies on the imagery created by her patients, associating them with myths and symbols which she considered to be part of a collective unconscious, common to humanity (Itaú Cultural, 2017).
In 1956, Nise da Silveira also created the Casa das Palmeiras, a pioneering institution for the admission of all types of mentally ill people and was committed more than ever to eradicating prejudice against the “insane.” She always made a point of referring to her patients as clients, the people she served and attended to. The Occupational Therapy practiced by Nise advocated the importance of affection to promote a life-reinforcing stimulus for the people admitted to the facility. One of the ways used to produce affection, besides free artistic expression and socializing in the studio, was to stimulate the clients’ relationships with animals; dogs and cats that became “co-therapists,” in Nise’s words (Itaú Cultural, 2017). The clients were recognized for their talent, and their works were incorporated into the institution’s collection. Free artistic expression came to be understood as a new language for understanding and treating psychotic clients, mirroring their deepest emotions. The painting studio was a space for experimentation. Encouraged by Nise, clients experimented with ways of managing their emotions through the production of sculptures, models, and paintings.
Nise da Silveira and Jung in dialogue
Some aspects brought Nise closer to Jung in her analytical psychology: namely, the awareness of the power of the image as a non-verbal communication of the contents from the unconscious, and the importance of studying mythology to better understand the elements of these images, such as colours, marks, shapes, the patients’ behaviour and what they could hear. Nise sent Jung photographs of paintings created by her patients. In response to this, Jung confirms that such images represent mandalas, and he becomes extremely interested in the work developed by Nise in Rio de Janeiro. This is how they were invited to participate in the Exhibition of Psychopathological Art and the Second International Congress of Psychiatry in 1957 (Zurich), which were held simultaneously (figure 3). Nise testifies, in the account of her arrival at Jung’s house on July 13, 1957, to the importance that these images held for Jung: “The mandalas painted by Brazilian patients are a confirmation of significant interest. Some people still say that he (Jung) invented these things” (Itaú Cultural, 2017).
Nise exchanged correspondence with Jung (who understood the name “Nise” to be masculine). Jung adviced her: “If you want to do another kind of psychiatry, to understand ‘clients’ delusions and the images they paint, you will have to study mythology” (da Silveira, 2009, p. 147).
Jung’s answer encapsulated his entire theoretical system, based on the theory of archetypes and the collective unconscious. This correspondence was the first time Jungian psychology was introduced in Latin America, becoming one of Nise’s work’s fundamental tools.
In 1969, Nise created the C. G. Jung Study Group, which had been meeting informally since 1954. The aim of the group was to discuss Jung’s ideas, but in fact, it went much further, expanding particularly towards studies around art. This study group is still regularly active today at the Museum of Images of the Unconscious. Nise’s initiative was hugely significant since this became the epicenter of a new therapeutic awareness in psychiatry, sought after by all those who pursued alternatives to conventional treatments in the area of mental illness.
The collective unconscious populated with archetypes can manifest itself as symbolic or imagistic matrices, and can explain the association between mythical themes and symbols common among the most diverse cultures (Jung, 2007). Thus, in the wake of Jung, Nise proposes a universalist vision that overcomes differences in culture, race, or social background. The doctor maintained that the expressive activities could materialize what she called the internal world in images enabling it to be visualized. Curiously, to Nise’s eye, it was not only the personal life story of the patients which was condensed into their figurative themes, but also mythical themes common to the history of humanity. The production of the schizophrenics’ images revealed, strikingly, these archetypal contents, which became intertwined with their personal stories in multiple transformations of their identity. Nise da Silveira believed that through the artistic process, the unconscious could enter into dialogue with the conscious because through spontaneous and undirected creativity, images and symbols could come to the surface, and these would prove highly beneficial to her patients:
The paintings would be used as a starting point for verbal associations, accepting the criterion that images constitute a means for representations to become conscious. [...] Through them the repressed material, symbolized in the images, would reach the conscious. (da Silveira, 1992, p.12)
Nise realized together with Jung, and under his guidance, that the importance of symbols in therapeutic practice invites an awakening to the value of the myth. Since myth is a collective narrative of a symbolic nature that does not address the rational mind, it may represent a better route to archetypal symbolism: “The artist is ‘a collective individual who expresses the unconscious and active soul of humanity’” (da Silveira, 2007, p. 143).
Both Nise and Jung understood how myth and art are channels through which the unconscious can connect to an archetype and express itself, by emerging through living symbols, and that can help guide the person in their process of individuation.
Over the course of human development, we follow a mythical journey, which goes from the experience of the undifferentiated - the Uroboros, passing through the experience of the dynamics of the Great Archetypal Mother and Father, arriving at the archetypal dynamics of the Hero, to reach the Otherness, connecting with the symbols of Wisdom and, finally, returning to the undifferentiated when arriving at the Cosmic Dynamics. Along this path which Jung called the individuation process, many archetypes are constellated (Baptista & Ribeiro, 2001, p. 20).
Images reveal archetypes
In studying these images, Nise found, for example, that one of the most frequent symbols that appeared in schizophrenic patients’ work were circular shapes, which seemed to present a contradiction as an apparent symbol of unity in a disorganized and fragmented state of functioning, such as that of a schizophrenic. As she herself said, “one must not be content with the surface,” understanding art as a manifestation of the individual as well as collective unconscious and the creative process as treatment. In her correspondence with Carl Jung on the subject, Jung explained that those “circular forms were mandalas” and that they expressed the self-healing potential of the psyche, in other words, the forces of the psyche that seek order and unity in people who are experiencing periods of great confusion and mental disorganization (Mello, 2009). In the work Nise da Silveira developed with her patients, the manifestations of circles and mandalas were very dominant. Nise dedicated herself to study the rich symbolism of mandalas, understanding that mandala is the symbol of the Centre, of the Self. The ordering and healing functions of these images became the focus of her studies (Souza, 2018).
Rudolf Arheim (1980) gives an example of the attempt at mental reorganization in the work The Doll’s Dance of Death – Swan (1956) of the artist Friedrich Schröder, who spent much of his life in psychiatric hospitals: “All of the characteristics of alienated art are definitively present. A rigidly symmetrical ornamental pattern is placed in a landscape of reduced depth” (p. 138).
Symmetries, such as mandala patterns and circular shapes (figure 4), are expressions of this attempt at organization on the part of patients suffering from psychosis, but they are also created in artistic and religious contexts. In Visionary Art, we can observe this same type of pursuit. In this case, not due to pathological conditions but because of the experience provoked by extraordinary states of consciousness, whether spontaneous or induced by the use of psychoactive substances, which is why they are labelled ‘psychomimetic,’ that is, that they imitate disturbed states such as “madness”.
According to Jung (quoted by da Silveira, 2007):
Mandala in Sanskrit means circle. This Indian term refers to ritual circular designs. It designates what can be understood as a symbolic representation of the center of the human psyche. Nise argues that the expression of totality is the mandala, whose central core is a source of energy that [...] manifests itself as an almost irresistible compulsion to lead the individual to become what they are, in the same way that every organism is led to assume the characteristic form of its nature, whatever the circumstances. (p. 89)
Our physical body is designed to fight illness; just as it seeks to regenerate when injured, it would be no different with aspects of the psyche. Nise explains her encounter with the symbolism of the circle (mandalas) and makes clear the tension she observed between the “dissociated” and the “healthy” elements. The circle and the sphere represent the movement of the whole psyche around a central point or axis; in disequilibrium this axis can be broken. The self is, principally, the archetype of psychic synthesis. The construction of a symbol is processed as a “reparative reconstruction” or rather as a “restoration of the internal world” (Segal, 1993, p. 104). “What heals, fundamentally, is the stimulus to creativity” (da Silveira, 2009, p. 115).
During the period in which Nise da Silveira worked at the National Psychiatric Center in Engenho de Dentro, she came across the perfect example case of Adelina Gomes (1916-1984), a woman of humble origins from the interior of Rio de Janeiro State. After strangling her family’s pet cat, she was admitted to this institution at the age of 21 and was diagnosed as schizophrenic. Adelina was locked-in with her autism and not very communicative. She began to visit Nise’s studio in 1946 and never stopped producing work. She made over 17,500 creative works, paintings and sculptures, many of which are in the collections and holdings of the Museum of Images of the Unconscious. Its dominant theme was the female figure surrounded by flowers.
Nise da Silveira analyzed the images produced by this patient on the basis of analytical psychology references. Nise’s theory was that the root of her pathology could be the repression of her female instinct and it was this instinct that manifested itself very strongly through archetype representation, which was found in the imagery of her works.
It could be interpreted that her works describe how the femininity of the schizophrenic patient was suffocated in her repressive family environment, and above all, in relation to an unconscious immersion in a world of archetypal feminine images, with which the young peasant girl blends in a series of ontological transformations: cats, flowers, mothers, universal symbols of the feminine. (Magaldi, 2018, p. 134)
In Images of the Unconscious, Nise da Silveira observes in Adelina’s works her personal journey in constant relationship with the mythological archetypes that the patient was unaware of. The inability to fully develop her feminine instinct and being prevented from experiencing her own love story due to a repressive upbringing and an austere and chastising mother, made Adelina project herself onto images of plants, trees and flowers, “Like the Greek nymph who turned into a laurel tree, Adelina wanted to turn herself into a flower, metamorphozing into the plant kingdom” (Nastari, 2007, p. 36).
Adelina also creates several paintings in which cats are represented. Nise interprets the strangulation of the pet cat as Adelina’s projection onto her mother who repressed her feminine instincts (da Silveira, 1981). Adelina draws the female cat free and joyful and women wearing a crown, white dress and a veil with cat ears (figure 5).
Finally, on her journey, she reached deeper layers of the psyche where this identification with the mother figure led her to the archetype of the Great Mother: “Adelina’s figures are characterized by an archaism that immediately makes one think of the Stone Age mother goddesses [figure 6]. They are corpulent, majestic women. These women depicted early on certainly deserve the label of Terrible Mothers” (da Silveira, 1981, p. 213).
Nise da Silveira recognises that Adelina’s recovery is noticeable through these changes in the pictorial content of her works. In the end it is no longer the Great Mother who emerges, “[...] but Mary [...] venerated by the Christian world” (Magaldi, 2018, p. 132).
The maternal archetype, like all archetypes, has an incalculable variety of manifestations. It can be one’s own mother or grandmother, stepmother or mother-in-law, a woman to whom we relate “[...] the goddess, among any number of symbols that can convey the notion of a recipient and also any useful animal such as the cow and the rabbit” (Jung, 2008, p. 92).
In his work Man and his Symbols, Jung (2008) correlates the importance of certain symbols that commonly appear in fine art with states of manifestation of the unconscious: “[...] each of these symbols had a psychological significance that remained constant, from the most primitive expressions of consciousness to the most sophisticated art forms of the 20th century” (p. 232).
Through analytical psychology, we understand that an archetype corresponds to its dynamic or emotional components, symbolism, material component, and structure. These are primordial images of the human psyche, innate dispositions that can be accessed at any time, anywhere, by any individual, people, or nation. As Jung (2009) remarks: “The primordial image that I have also called archetype, is always collective, that is to say, it is at least common to all peoples and times. Probably the main mythological motifs are also common to all races and times” (p. 832).
Nise understands that through free artistic expression and in a spontaneous / occupational context, patients end up meeting a personal mythology that, in Nise’s words:
It’s the expression of the unconscious, so to speak. Myth is like a kind of trail. If you start from the myth, you get wherever you want. [...] It is important to know that when the conscious is suffocated by the unconscious, the person starts to communicate through the language of myths. (Leal, 1994, p. 23)
The extraordinary artistic talents that were revealed in these people caught the art world’s attention, namely of a well-known critic called Mário Pedrosa who termed this art as Arte Virgem (Virgin Art) due to the fact that these people had no artistic training whatsoever (Dionísio, 2012).
Conclusion
Nise da Silveira dedicated her life to mental health, her treatment revolutionizing it through the adoption of new therapeutic practices such as the promotion of Occupational Therapy as Art Therapy. Her hallmark was essentially a practice of humanized psychiatry. All of her work was driven by the pursuit of a more compassionate care, a commitment to eradicate prejudice against mental illness. Nise da Silveira’s pioneering work contributed greatly to the establishment of Occupational Therapy as an approach in psychiatry fully accepted today by the medical practice in Brazil.
The Art Therapy model of free artistic expression, inspired by Nise da Silveira, has been used today as a preferred model. With successive demonstrations of good results in situations of post-traumatic stress, Art Therapy has been used in different contexts of humanitarian crisis: in emergency and post-traumatic stress contexts, caused by the huge humanitarian crises, practiced in reception centres for migrants and refugees, it contributes to,
[...] give back a sense of freedom to the person and restore their ability to make decisions. It can help to recover self-confidence, facilitate access to the inner world and can help in observing what causes pain at a safe distance. Finally, the unconscious and the conscious can enter into dialogue without conflict. (Lousa & Hughet, 2022, p. 815)
In Art Therapy Workshops of Psychosocial Care Centres in Brazil, associations for children and young people were created in favelas. For example, the social project “Eu sou”, “I am” - identity through art - in the Jacaré neighbourhood of Rio de Janeiro, coordinated by Hélio Rodrigues and psychologist/artist Fabiana Geraldi, with the main purpose of helping children and adolescents to ‘construct’ their identities, so fragmented and distorted in the social context. This experience obtained positive results in reducing anxiety levels and improving interpersonal relationships, and helped in the construction of the identity of young people “who face death and violence in their daily lives” (Alves & Diniz, 2009, p. 295).
It can be concluded that the images recovered through free artistic expression in therapeutic context, based on Nise da Silveira’s model and Jung’s analytical psychology, reveal both archetypes of the collective unconscious and personal mythologies leading to processes of self-healing and centering.
Financing: This article was supported by CHAM (Center of Humanities) of the Faculty of Social and Human Sciences (FCSH) at NOVA University of Lisbon, through the strategic project sponsored by Faculdade de Ciências e Tecnologia (FCT) (UIDB/04666/2020).
Figure 2. Nise da Silveira with her medical colleagues, 1926. Bahia Faculty of Medicine, Salvador, BA, Brazil.
Source: Museu de Imagens do Inconsciente (Under the permission of the Museum).
Figure 3. Nise da Silveira and Carl G. Jung at the inauguration of the exhibition at the Museum of the Unconscious, on the occasion of the Second International Congress of Psychiatry, 1957. Zurich, Switzerland.
Source: Photograph by Almir Mavignier (detail), reproduced with permission of the Museu Imagens do Inconsciente.
Figure 4. Carlos Pertuis. Mandala. Circa, 1953.
Source: Museu de Imagens do Inconsciente (under permission).
Figure 5. Adelina Gomes’ paintings. No title. (n.d.).
Source: Museu de Imagens do Inconsciente (under permission).
Figure 6. Adelina Gomes. No title (plaster copy of clay modelling), 1950.
Source: Museu de Imagens do Inconsciente (under permission).
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