Interface entre a psicanálise e a fonoaudiologia: uma revisão da literatura Interface between psychoanalysis and speech language and hearing sciences: a literature review

O objetivo deste estudo foi verificar na literatura brasileira e internacional produções científicas corre - lacionando a Fonoaudiologia e a Psicanálise. Foi realizada revisão de literatura utilizando as bases de dados BVS


INTRODUCTION
According to the psychoanalytic theory, the psychic apparatus is structured in three instances, namely id, superego and ego.Id is the most primitive one, related to the instinct, being led by the principle of pleasure in the search for satisfaction.Superego is the most improved instance of psyche, which, being ruled by the principle of reality, follows the social and cultural rules, determining what pulses must be satisfied, postponed, or not quenched by the ego.Ego is the conscience, the "I" that mediates between id and superego, responsible for decision-making.The pulses of id which are not carried out by ego are repressed by superego and stored in the unconscious, interfering in people's lives through dreams, Freudian slips, and symptoms 1,2 .
The unconscious is above all formed by repressed contents which were not satisfied by conscience.These contents try to return to the plan of conscience, but it is only possible if they go through a process of transformation by condensation or displacement.Condensation is a set of repressed pulses which are organized in associative chains and escape mainly through dreams.In displacement, this chain is detached and passes to another one of less intensity, and can be observed especially in psychoneurotic symptoms, there being a transfer from a symptom to another 3 .
The interface between language and hearing sciences and psychology was initially observed in the bibliographic search made between 2004 and 2014 in electronic journals of language and hearing sciences.The study demonstrated a close relation between the two areas 4 .However, the research mentioned did not indicate which theoretical school subsidized the studies that were analyzed, that is to say, if they were supported by a behavioral, innatist, constructivist, socio-interactionist, or a psychoanalytic approach.
The psychoanalytic discourse about human functioning has contributed in the exercise of clinical speech therapy, as it was demonstrated in a research conducted with the courses of language and hearing sciences in the country.The inquiries made with the professors about this theory showed that the approach is used in the processes of intervention in speech, fluency, voice, orofacial motricity and hearing 5 .
Psychoanalysis has as its object of study the unconscious and it defends that contents that are repressed and stored in this "black box" can interfere in human communication and result in psychopathologic symptoms.Regarding the unconscious, the analytic theory can contribute with the comprehension of the emotional dimensions involved in the origin of these signs 6 .However, one can ask: are there in national and international literature works which relate psychoanalysis to language and hearing sciences?When was that literature produced?In what databases were they made available?What specialties of language and hearing sciences receive more interference by the analytic view?
Thus, the aim of this study was to make a review of national and international literature, correlating psychoanalysis and language and hearing sciences.

METHODS
According to the aims that were defined, this study is characterized as both exploratoryand bibliographic, considering the technical procedures that were used in the collection of data.The follow-up period of the research defined it as longitudinal and the temporal directionality qualified it as a retrospective one 7,8 .
A systematic review of the literature about language and hearing sciences was done, correlating language and hearing sciences/communication and psychoanalysis.The collecting happened in national databases "Biblioteca Virtual em Saúde (BVS)" and "Scientific Electronic Library (SCIELO)" and international databases "Scopus" and "Pubmed".The descriptors used to find the articles in Portuguese were "Fonoaudiologia", "Psicanálise" and "Comunicação", and in English, "Speech Therapy", "Psychoanalysis" and "Communication".The search was made associating the descriptors the following way: Fonoaudiologia X Psicanálise; Comunicação X Psicanálise; Speech Therapy X Psychoanalysis and Communication X Psychoanalysis.Initially, 545 articles were found in national databases and 4,167 in international ones.
Original articles of research, bibliographic review, case studies, chapters of books and others which were available in their whole were included in this study.Whenever it was impossible to access an article for free, the Virtual Private Network (VPN) was used.It is available toundergraduate students of language and hearing sciences of the public university of the state of São Paulo.
The first analysis of the article was performed through the inspection of the title and abstract.Those which were not in accordance with the theme were eliminated, resulting in a final sample of 65 works.
Then, the detailed analysis of the works was done using a "Protocol of Classification of Articles" adapted from the study of Nascimento et al. (2016) 4 and Vasconcelos, Pessoa and Farias (2008) 9 , as shown in Figure 1.
The systematic analysis of the identified works was done by four pairs of researchers who were trained in a sixty-hour Curricular Discipline, called "Constitution of the Psychic and Linguistic Subject", besides periodic meetings with the professor responsible for the discipline.The first categorization was done individually by the judges.Then, each pair of judges defined the classifications in a consensual way.If there was not a consensus, a third judge was activated.
In order to identify the area of knowledge of the works, the journals were accessed and the mission of each journal was checked.This classification was done by pairs of researchers.
In face of all the information identified in the literature, a scheme was structured to make it possible to synthesize the constitution of the psychic subject and the linguistic subject, as well as the interface with the language and hearing symptoms.

RESULTS
Sixty five articles were found, correlating speech therapy/communication and psychoanalysis between 1980 and 2015.Figure 2 presents a progression in the number of articles published between 1980 and 2003, followed by a decrease in 2001, 2004 and 2005, returning to a progressive increase until 2008.A peak of the production is noticed in 2012 and, from then on, the number of publication of articles started to decrease again.
Original Articles prevailed as the type of article published.SCOPUS and BVS were the most evident databases.Most of the articles were published in Portuguese.
Table 2 shows the specialties of language and hearing sciences which present an interface with psychoanalysis, language and neuropsychology, predominating, respectively.Analysis of the study (to consider the participant subjects, age, place of the study, language and hearing alterations, psychoanalytic interference)   The national and international literature showed that the constitution of the psychic subject can interfere in the constitution of the linguistic subject through condensation and displacement, as shown in Figure 4.

PROTOCOL OF CLASSIFICATION OF STUDIES
Regarding the journals where the works were published, it is possible to notice that the area of psychology is predominantly the one that most publishes articles relating language and hearing sciences to psychoanalysis, followed by language and hearing sciences.This study demonstrated that there are national and international scientific productions that correlate speech therapy and psychoanalysis.The results were similar to those in the study by Nascimento et al. (2016) 4 regarding the year of publication, database and speech therapy specialties.
The analysis of the scientific productions allowed us to observe that language continues to be the speech therapy specialty that is the most affected by psychopathologies.Language is the first form of manifestation of children's 10 psyche and it reveals the culture, tradition and customs through the history constituted by human experience 11 .
By analyzing language under the view of psychoanalysis it is probable to identify intrapsychic and interpersonal abilities 12 .Psychoanalysis establishes a clinical field which recognizes the subject of unconscious constituted in and by language 13 .In the therapeutic space it is possible to interpret the communication established between therapist and patient 14 and investigate the importance of the communication done by the other 15 .
The speech therapy clinic is a privileged space that makes it possible to analyze and interpret language as a symbolic instance of subjective aspects, that is to say, it is a field that allows identifying the interference of latent contents of unconscious in human communication 16 .
The language and hearing sciences and psychoanalysis are crossed by common questions that evidence an interface 17 , showing that the unconscious interferes in human communication and can help to understand emotional dimensions 6 .Thus, we must have a refined comprehension of the emotional aspect involved in the communicative interchange 18 .
The unconscious contents may appear in communication in different aspects, whether in the tone of the voice, in rhythm, in prosody, or even in the structure of speech 19 .The knowledge of psychoanalysis allows changing the relationship of the subject with his own unconscious psychic processes 20 and thus identifying the origin of the symptoms and the strategies of intervention.
The analysis of the repressed contents in the unconscious can frequently redefine the therapeutic process 21 , including language and hearing.Thus, the words must be evaluated, listening beyond the content, analyzing the sound and the meaning of what was said 22 .For instance, the Lacanian psychoanalytic theory allows linking the communicative behavior and offers a set of symbolic coordinate 23 which may be escaping from the unconscious.
In the interface between psychoanalysis and speech therapy it is possible to process the experiences and restore imaginative spaces which transmit contents that are not in conscience 24 .The analysis of silence is also important in the therapeutic work, because it allows the emergence of the transitional space through non verbal communication 25 .The conversation and analysis seem to be promising to the discovering of properties of the unconscious processes 26 , favoring a linguistic hearing which is more comprehensive and qualified 27 .
The national and international literature which was identified in this study showed some cases of speech therapy that presented interface with the psychoanalytic theory.The analysis of a psychotic patient showed that the records of language helped in the building of a mental space 28 .In another psychotic patient, there were some interruptions in speech, confuse discourse and incomplete sentences, associated to the delirious psychotic picture of persecution 29 .
A research with schizophrenic patients showed that they could not distinguish the mind from the world, establishing delusions.The common distinctions between words, things, state of body and actions are absent, creating words and sentences that are not symbolic 30 .
In the interaction with a severe 20-year-old autistic, verbal communication was tried by the therapist, but the young man was resistant and with out of context laughs of escape.In one of the sessions the young man exposed about his father's death, and from then on started to establish a connection with the therapist and to have a verbal communication 31 .In this case, the death of his father could be something latent, pressing the subject's ego, contributing to the origin of language and hearing alterations.
Psychoanalysis also offers rich opportunities for the early treatment of the autism spectrum disorder, especially those that are out of the oedipal contact 32 .In a study carried out with three autistic children, between 2 and 4 years old, loose and out of context sentences, echolalic speech, jargons, stereotypies of hands, gesture communication, unintelligible speech and words without meaning were observed.Interviews with their parents were carried out, and they were interpreted based on a psychoanalytic analysis.The intervention allowed changes of feelings in the couple and in the behavior of the parents towards the children, having positive effects concerning the language disorders 33 .
During a speech therapy attendance to three siblings, a delay in the development of language was identified in one of the children.Subsequently, the other sibling started presenting the same characteristics.The same happened to the third one, however with changes in speech and interposing of language.With the psychoanalytic approach it was possible to realize that the parents unconsciously used to make a comparison between the children, creating a competition and conflict between them, causing language and hearing alterations 34 .
A study carried out with eighteen relatives responsible for children with phonological disorders, sent to the Center of Language and Speech Study (CELF) of the Service of Speech Therapy Attendance (SAF) of the Federal University of Santa Maria (UFSM) allowed observing possible interventions in the language and hearing therapy.It was possible to identify that knowledge about the psychoanalytic theory improves the therapeutic performance 35 .
The speech therapeutic process, when it is supported by the psychoanalytic theory, offers subsidies that the professional may carry out intervention even in written production 36 , as well as in other areas of the different specialties of language and hearing sciences like, for instance, the voice.
In relation to the voice disorders, a review in the library of the Brazilian Society of Psychoanalysis (SP) allowed observing that disphonia can be a representation of unconscious contents.In this case, the speech therapist must be alert not only to the acoustic production, but also to the meanings of the voice in the patient's history 37 .Another study carried out with 40 patients with vocal alterations ratified that psychogenic disorders may interfere in the quality of the voice 38 and consequently in communication.
Besides, psychoanalysis can also contribute with the analysis of cases of hearing and stuttering.Studies carried out with deaf adolescents, in the light of psychoanalysis, indicated that family emotional conflicts may be interfering in their hearing quality 39 .Concerning disfluency, a plan of treatment of chronic stuttering carried out with 30 patients in the Institute of Psychoanalysis of Chicago demonstrated that the profile off personality can improve the development of individual plans of treatment 40 .
Literature demonstrated so far that the speech therapeutic practices have an interface with the psychoanalytic theory and are predominantly clinic.However, a psychosocial study was identified.An intervention carried out in a Center of Psychosocial Attention demonstrated contributions from psychoanalysis to the field of Mental Health.The theoretical formulations of Freud and Lacan allowed changes in the act of telling and building stories, as well as in the interaction and communication established between the members of the groups 41 .

CONCLUSION
This study identified researches which were published in national and international journals and that integrate psychoanalysis to language and hearing sciences.The predominant language was Portuguese and Original Article, the prevalent type of study.It was noticed that language and hearing manifestations do not appear isolatedly.They are influenced directly or may be caused by issues that are inherent to the psychic aspect of the individual.
Psychoanalysis contributes to the analysis and intervention of the cases of hearing, stuttering, voice, writing and, especially, language.Language is the object of study of language.hearing sciences and psychoanalysis, however, the journals of psychology are the ones that most publish researches about psychoanalysis and speech therapy/communication.
As observed in this study, the knowledge about the psychoanalytic theory offers subsidies for speech therapists to identify the origin of the symptoms and define the most adequate strategies of intervention for each case.Thus, an interface between these two areas is necessary, in order to provide a better comprehension and intervention in the communicative alterations.

Figure 1 .
Figure 1.Protocol of classification of studies

Figure 2 .
Figure 2. Distribution of the studies published each year

Figure 3 .Figure 4 .
Figure 3. Area of knowledge where the studies were published

Table 1 .
Classification of the studies according to the type, database and language

Table 2 .
Specialties of Speech Therapy in interface with Psychoanalysis.