POLITICAL AND CLINICAL RESONANCES OF THE IDEAL OF INCLUSION IN THE CENTERS OF PSYCHOSOCIAL CARE^{1 2}

ABSTRACT.

In this essay, we sought to analyze the political and clinical resonances of the presence of an ideal of inclusion of the insane in the treatment offered by Psychosocial Care Centers (Centros de Atenção Psicossocial - CAPS). To do so, in the first moment, we made a brief analysis of the Brazilian Psychiatric Reform movement taking into consideration its main influence, namely: the Italian Democratic Psychiatry. Thus, we started from the paradigmatic thinking of Franco Basaglia, in order to clarify how such an ideal is constituted. Subsequently, through a theoretical effort that went through psychoanalysis and politics, we have analyzed in detail the political and clinical consequences of taking social inclusion as the final horizon of a treatment predominantly for psychosis. Here, the concepts of ideology, ego ideal and discontent were of paramount importance. Finally, we tried to indicate some important issues for a possible clinic at CAPS, which is related to politics and that combines the attention given to the subject and the search for social transformation.

Keywords:
Psychoanalysis; mental health; psychosis

RESUMO

Buscamos, neste ensaio, analisar as ressonâncias políticas e clínicas da presença de um ideal de inclusão do louco no tratamento oferecido pelos Centros de Atenção Psicossocial (CAPS). Para tanto, num primeiro momento, fizemos um breve percurso pelo movimento da reforma psiquiátrica brasileira levando em consideração a sua principal influência, qual seja: a psiquiatria democrática italiana. Assim, partimos do pensamento paradigmático de Franco Basaglia, visando, com isso, esclarecer como se constitui o que denominamos de ideal de inclusão no CAPS. Posteriormente, pelo esforço teórico que perpassou a psicanálise e a política, analisamos, detidamente, as consequências político-clínicas de se tomar a inclusão social como horizonte final de um tratamento destinado, predominantemente, à psicose. Aqui, os conceitos de ideologia, ideal do eu e mal-estar foram de suma importância. Por fim, procuramos indicar algumas questões importantes para uma clínica possível no CAPS, que seja atinente à política e que alie a atenção dada ao sujeito e a busca por transformação social.

Palavras-chave:
Psicanálise; saúde mental; psicose

RESUMEN

Buscamos, en este ensayo, analizar las resonancias políticas y clínicas de la presencia de un ideal de inclusión del loco en el tratamiento ofrecido por los Centros de Atención Psicosocial (Centros de Atención Psicosocial - CAPS). Para ello, en un primer momento, se hiso un breve recorrido por el movimiento de la Reforma Psiquiátrica brasileña llevando en consideración su principal influencia: la Psiquiatría Democrática italiana. Así, partimos del pensamiento paradigmático de Franco Basaglia, buscando, con ello, aclarar cómo se constituye lo que llamamos ideal de inclusión en el CAPS. Posteriormente, por intermedio de un esfuerzo teórico que atravesó el psicoanálisis y la política, analizamos detenidamente las consecuencias políticas y clínicas de tomar la inclusión social como horizonte final de un tratamiento destinado, predominantemente, a la psicosis. Aquí, los conceptos de ideología, ideal del yo y el malestar, fueron de suma importancia. Por último, buscamos indicar algunas cuestiones importantes para una clínica posible en el CAPS, que sea atinente a la política y que alíe la atención dada al sujeto y la búsqueda por transformación social.

Palabras clave:
Psicoanálisis; salud mental; psicosis

Introduction: Brazilian psychiatric reform and construction of the ideal of inclusion

The Psychiatric Reform refers to a political movement in Brazil, beginning in the late 1970s. Largely influenced by a similar movement that took place in Italy - the so-called Italian Democratic Psychiatry, whose main representative is Franco Basaglia -, the Brazilian movement culminated in a profound transformation in the way society relates to insanity (Amarante, 1995).

We could devote pages to describing what it was and how it was historically constituted the movement that gave rise to substitution services for asylums known as Psychosocial Care Centers (CAPS). We are talking about political-institutional operators, whose assumptions are derived from two articulated social movements, called Brazilian psychiatric reform and anti-asylum struggle. However, the historical aspect of such a political process has already been sufficiently described and analyzed by other authors, such as Amarante (1995), Lobosque (2013), Figueiredo (2015), Yasui and Barzaghi (2018), among others. Thus, in this essay, we intend to focus on extracting what is most fundamental in Basaglia’s criticism - starting from the premise that Basaglia’s thinking is paradigmatic with regard to reform. Our purpose, therefore, is to explain how the critique of this movement is articulated with the asylum ideology, the clinic in general (whether psychiatric, psychological or psychoanalytic) as a ‘therapeutic-orientation’ practice of oppression⁵ and, especially, and how is constituted what we call the ideal of inclusion.

First of all, it is necessary to emphasize what we consider to be the critical point of Basaglia’s critique (1985) to the psychiatric institution: the perception that the violence and exclusion that permeate the daily lives of psychiatric hospitals is a reflection of similar relationships in society as a whole. Just remember the way Basaglia addresses the issue of asylums in the chapter ‘As instituições da violência’, in the book A instituição negada (1985), which reports the model experience at the Gorizia’s psychiatric hospital. In this text, before actually making his critique of the asylum, Basaglia describes relations of violence and oppression that occurred in various institutions, such as family, school, industry, etc. Thus, what Basaglia already subtly indicated in the style of the text, culminates in the now emphatic statement that what happens in the asylum is the result of the way relations are established in society as a whole, “[...] organized from the radical division between those who have (owners in the real, concrete sense) and those who do not” (Basaglia, 1985, p. 101), that is, it is the result of class division.

Hence the Italian psychiatrist states, in conferences held in Brazil, that “[...] the therapeutic logic and the logic of class struggle are two very close things, and only with an advance in the class struggle can a new code be created for a new science” (Basaglia, 1979, p. 32). This is what allows to affirm that there is, in Basaglia, an expressive criticism of the asylum ideology, because its practical and thought experience denounces how naive it is to think the insane and the psychiatric hospital as evidence, ignoring all historical and social process that overdetermines them. From this stem his effort to think the insane and the asylum - represented by professionals, most often psychiatrists, “[…] the new managers of violence in powe” (Basaglia, 1985, p. 102) - in a broader context, of the capitalist society divided into classes.

As we can see, Basaglia lives up to Marx’s influence on his thinking. After all, as Eagleton (1996, p. 182) explains, Marxist politics, in a certain way, implies an analysis that perceives a specific historical situation as referring to a totality that determines it: “[...] some groups and classes need to inscribe their own condition in a broader context, they intend to modify that condition”. And as far as such influence is concerned, perhaps we can say that his critique of ideology is carried out in the manner of Lukács humanist Marxism⁶, which, as Eagleton observes, works with the perspective of ‘totalizing’ the social order, that is, with the ability to refer partial experience to a whole as a possible form of reflection aimed at emancipation. As the author expresses:

[...] our routine consciousness is inherently ‘ideological’ in itself, simply because of its bias. It is not that the statements we make in this situation are necessarily false; rather, they are only true in a superficial and empirical way, for they are judgments about isolated objects that have not yet been incorporated into their full context. (Eagleton, 1996, p. 184, author’s emphasis).

From this is articulated the ‘denial’ performed by the group led by Basaglia (1985): denial of the therapeutic-orientation that sought to adapt the insane to the situation of oppression to which he/she was subjected in the asylum; denial of psychiatric diagnosis, given its ideological character of labeling; denial of oppression and violence present in the psychiatric hospital; and, finally, denial of the institution itself. The aim, therefore, was that the denial and consequent psychiatrist’s awareness of his/her position as oppressor would enable the insane to become aware of his/her role as the oppressed.

Basaglia’s critique, in this sense, is directed at the alienation caused by the mechanism of ideological ignorance that, as Safatle (2008, p. 67) attests, indicates “[...] among other things, the inability to understand the totality of structures historically determined causal factors that support the reproduction of social relations in all their spheres of values […]” - here, it is worth remembering the famous Marxist formula that reflects the ideological mechanism: ‘they do not know, but they do’. Hence its practical proposal is that of a kind of ‘disalienation’ of both the insane and the physician, through what Safatle (2008, p. 67) designates as the “[...] self-reflexive appropriation of the determinant assumptions of action”.

In short, based on this model of analysis and criticism of the relations hitherto existing between insanity and society - given that the psychiatric hospital, as Basaglia (1979) points out, responds to a strategy of social control - is deduced the attachment to the ‘ideal of inclusion of the insane’ in the appropriation of Basaglia’s thought by the Brazilian psychiatric reform movement. Here we could say that the tonic from which the CAPS are instituted translates into the following psychiatrist’s warning: “[...] besides being a body, man is the product of struggles. In addition to an organic body, man is a social body. And it is on this social body that the new medicine must act” (Basaglia, 1979, p. 60), an action that considers the social inclusion/reinsertion of the insane a kind of ideal of cure.

In the present essay, based on the Basaglia’s assumptions assumed by the Brazilian psychiatric reform, we use psychoanalysis to construct an analytical discourse about the political and clinical resonances of the ideal of inclusion present in the substitution services in mental health. Here, when we talk about the construction of an analytical discourse, we are referring to what Dunker (2013) comments about how the psychoanalysis researcher should drive himself, which in his research method/course should take into account some characteristics necessary for an analysand discourse: the ‘memory’, “[...] a discourse that can be guided by history and the affiliations and contingencies it implies […]”; the ‘implication’, “[...] a discourse that can ethically question the strangeness formations it encounters […]”; and the ‘transference’, “[...] a discourse that articulates in relation to an assumption of knowledge, that is, therefore, made at least the intention of dialogue” (Dunker, 2013, p. 71).

In short, characteristics that, in an analytical process, imply the ‘support of a subjective positioning in the face of desire ($)’. After all, as we see with Rosa (2016), the contributions of psychoanalysis to the social and political field have the peculiarity of enabling the investigation of what escapes the other fields, namely: the unconscious dimension. Thus, it implies Lacan’s movement of placing the subject in question. It is from the problematization between subject and social bond that we focus the “[...] perspective of the ‘implicated psychoanalysis’, one in which theories about desire and jouissance includes the way subjects are captured and entangled in the power machine” (Rosa, 2016, p. 28-29, author’s emphasis). That is, even though we have a sociopolitical phenomenon as the object of research, we still focus on subjectivity.

This in no way implies an individualistic perspective, since the constitution of the subject for psychoanalysis cannot be dissociated from the (social) dimension of otherness. With this in mind, the present study mapped out the political and clinical resonances of the constitution of an ideal of inclusion at the Psychosocial Care Centers (CAPS).

Political resonances

What are the political implications of CAPS seeking the social inclusion of the insane as a horizon to be reached from the treatment offered? In fact, the problem itself is not that such inclusion is desired, but that treatment starts from a positively defined, determined goal. In other words, the problem lies in the fact that CAPS, starting from such an ideal of cure (or rather from any ideal of cure), is identified by the mental health workers responsible for the treatment, with the figure that metapsychologically comes to embody such an ideal position: ego ideal. After all, what we call the ideal of inclusion implies the idealization of a ‘state’ to be achieved by the insane (including himself) from the Other (embodied in the CAPS professional or, if we want to go further, in society as a whole in its civilizing process). Here we talk about identification, because as we see with Lacan (2010), such an ideal position is always supposed to the analyst (i.e., whatever instance represents the treatment). It is thus up to him/her to decide whether to take or refuse such a position.

Said that, it is important to analyze what are the political and clinical resonances of the instance responsible for treatment to identify with such a position of knowledge/power that is assumed by the subject who reaches the service - especially considering the peculiarities of psychosis. With regard, first, to the political field, it will be necessary to embark on ideological issues. In this respect, by the way, Dunker and Kyrillos Neto (2015) assert that the critique of the reform may turn out to be as ideological as the asylum ideology, although they are radically opposed projects.

Here, the premise underlying the critique of Zizekian ideology that proposes to analyze it in its dialectical character is of paramount importance (Zizek, 1992, 1996a, 1996b, 2017). When the reform movement in its critique of asylum ideology directs its political project in direct opposition to the criticized project/ideology, it accomplishes Zizek’s warning (1996a, p. 9) that: “When a process is denounced as ideological par excellence, one can be sure that its inverse is no less ideological”. After all, since it is a dialectical process, it must be borne in mind that each pole of antagonism is inherent in its opposite, so that reducing criticism to the assumption of one of the poles is as ideological as occupying the criticized pole. The pendulum metaphor, presented by Safatle (2008, p. 202), may be interesting to understand this process: now, the pendulum, having its movement reduced from one pole to the other, produces a movement that maintains and conserves the same center. And at this point, Safatle is striking: “Going from pole to pole is just a more complicated way of not walking”.

So, what is this center that is conserved in projects so radically opposed: in one pole the ‘exclusion’ project via asylum and in the other the inclusion reform project via CAPS? In both cases, it is an attempt to buffer what Freud (2011c) called discontent inherent in civilization and therefore inherent in the social field - in Zizekian terms, an attempt to buffer the ‘real of social antagonism’⁷. That is, in both projects/ideologies, there is a kind of repression of the antagonistic real.

The asylum ideology ‘sweeps the insane from the street’ through internment, so that the insane as an element causing social unrest is excluded and the social Order is protected. The ideology of reform idealizes a society that receives the insane to the point that it is no longer seen as a disturbance of the Order (in the scope of this article we will not address public policies on alcohol and other drugs). As we can see, both projects fantasize about a state of complete social ‘well-being’, that is, in both cases there is an ideal of harmonious society, free from antagonism, free from discontent. Here the fantasy structure of ideology is evident (Zizek, 1992, 1996a, 1996b, 2017), for this ideal of social harmony is nothing more than an attempt to veil the inconsistency of the great Other⁸.

The fact that ideology has the structure of a fantasy is of paramount importance to our analysis because it demonstrates that it implies not only a ‘symbolic’ process of significant overdetermination but also a ‘real’ core of jouissance - let us remember that the Lacanian formula of fantasy combines the subject and object plus-de-jouir: $ <> a. This is why, by the way, Zizek (1992, p. 122, author’s emphasis) proposes two complementary methods of critique of ideology:

[...] one is discursive, it is the ‘symptomatic reading’ of the ideological text that brings the ‘deconstruction’ of the spontaneous experience of its meaning, that is, demonstrating how a given ideological field is the result of a montage of heterogeneous ‘floating signifiers’ of their totalization through the intervention of some ‘nodal points’; the other aims to extract the core of jouissance, to articulate how, beyond the field of meaning, but at the same time within that field an ideology implies, manipulates, and produces a pre-ideological jouissance structured in fantasy.

Thus, by combining the Marxist concept of ideology with the psychoanalytic of fantasy, Zizek manages to explain this ideological function par excellence of suturing antagonism, that is, of masking jouissance as an insignia of a real inherent in the symbolic world. Ideological fantasy, in this sense, would hide what generates inconsistency, so that its criticism denounces the instability of the social and unmasks its supposed homogeneity. In other words, a self-respecting critique of ideology must pay attention not only to the social determinants of a phenomenon, but also to its function of overcoming discontent.

That said, we believe that the social phenomenon of insanity is, to some extent, a symptom of the civilizing process, “[…] in the sense of a coded message, a sign, a misrepresentation of social antagonism” (Zizek, 1992, p. 123). Faced with such a symptom, the historically perceived social response tended to be totalitarian, shaped by the exclusion of the insane as if he were the source of social antagonism, when in fact antagonism is immanent to civilization. Here, the asylum ideology approaches the anti-Semitic ideology in which, as Zizek (1992) points out, the Jew (in our case, the insane) comes to embody the figure of antagonism and is therefore a kind of ‘scapegoat’. No wonder that Basaglia (1979) saw at the Asylum of Barbacena a version of Nazi concentration camps.

However, precisely because we agree with Zizek (1992) that the critique of ideology takes place in ‘two times’, we believe that the ‘Basaglia’s critique of ideology’ encompasses only the first method. Thus, Basaglia rightly realizes that the insane is a ‘symptom’ of a split regarding society as a whole (the class division). Realizing this, he does what one has to do with a symptom: interpret it. His interpretation we already know: insanity is determined by a series of historical and social processes. But as we have already said, ideology has the structure of a fantasy and, as Zizek (1992, p. 123, author’s emphasis) reminds us: “[...] fantasy should not be interpreted, but only ‘traversed’”. This is the second method of critique of ideology, the traversing of social fantasy. Ignoring it, Basaglia falls into another fantasy that still does not receive the antagonistic real, the core of jouissance of ideology. Interestingly, this antagonistic real ignored by Basaglia is precisely what is presented in the manifestations of a subject who does not conform to the supposed homogeneity of the social. In other words: insanity is indeed a social construct, as Basaglia predicted. Nevertheless, it is also the insignia of a singular condition: either as a subject that is more than a mere reflection of the social, or as a psychotic with its subjective and structural peculiarities.

This is where we find the political value of the psychoanalytic clinic - as opposed to the clinic as a practice of oppression, criticized by Basaglia - and its potential for dialogue with Basaglia’s assumptions. After all, it is configured as a clinic of traversing the fantasy, in which it seeks precisely to receive antagonism from the assumption that the great Other is barred, that the sociosymbolic Order, far from being homogeneous, is inconsistent.

When we are confronted with the patient’s symptoms, we must first interpret them, penetrate through them into the fundamental fantasy, as the core of jouissance that blocks the progressive movement of interpretation, and then we have to perform the crucial step of traversing the fantasy, putting ourselves at a distance and experiencing how fantasy formation only masks a certain emptiness, a lack in the Other (Zizek, 1992, p. 168).

By embracing antagonism, psychoanalysis is cautious about the ideals of harmony, since we believe that it is precisely in this critical stance of homeostasis that lies the main contribution of psychoanalysis to the field of mental health.

Clinical resonances

Not surprisingly, CAPS’s offer of a treatment aimed at an ideal of including the insane produces not only political but also clinical consequences. Incidentally, as already indicated at the beginning of this study, inclusion presents itself as an ideal of cure and, in this sense, may eventually take the place of a possible clinic. In this perspective, there is a confusion between mental health and clinical policy at CAPS, with the effect of reducing treatment to a policy of encouraging citizenship. As Quinet (2015) would tell us, furor curandis, already criticized by Freud (2010b), is replaced in Brazilian mental health policy by a furor includenti. Ironically, such confusion implies the dissociation between clinic and politics. In other words: confusion paradoxically indicates disruption. However, it was by noticing such a disruption - especially with regard to the American school of psychoanalysis known as Ego Psychology - that Lacan (1998b) did not shy away from reflecting on the principles of power involved in the analytical process. The analyst’s position is not dissociated from a policy expressed in the clinic as a transference management ‘strategy’ and intervention ‘tactics’.

Here, it is worth noting that when we talk about clinical and political dissociation, we are not stating that there are no clinical interventions at CAPS. An example of such an interventional technique is presented in the ‘Individual Therapeutic Project’, which should consider the question of what is possible and desirable to obtain from this patient during treatment (Secretaria de Estado da Saúde de Minas Gerais, 2006). In this sense, our critique seeks to focus on the ethical assumption (and its political, clinical and metapsychological resonances) that underlies such interventions and which may undermine the sovereignty of the subject in the name of a certain social logistics.

In this, it is clear that our analysis continues to revolve around the ideal of inclusion, that is, around its metapsychological representative, the ego ideal (this will be further developed and theoretically deepened). However, there is a specificity that should not be ignored: that CAPS as a substitution service for the psychiatric hospital generally welcomes psychotic subjects - reiterating that we are not referring to CAPS AD (alcohol and other drugs), nor to CAPS I (children). Consider, then, the clinical resonances of the ideal of inclusion, given the peculiarity of the clinic and the metapsychology of psychosis.

At this point it is necessary for us to make a brief incursion into the clinic of psychosis, more specifically, with regard to the relationship with otherness and, consequently, to the constitution of the psychotic subject in front of it. Basically, with regard to the peculiar incidence of Superego in psychosis compared to neurosis.

Let us begin, however, with the concept of the ego ideal, and then think of it from psychosis. Freud (2010a, 2011b) postulates three distinct terms regarding the theorizing of the Superego, terms that are presented in a somewhat confusing way, sometimes indicating that there is a distinction between them, sometimes denoting the same category, namely: Superego; ego ideal and ideal ego. With Lacan, such terms come to differ precisely, so that

[...] ideal ego means the idealized self-image of the subject (the way I would like to be, the way I would like others to see me); ego ideal is the agency whose gaze I try to impress with my image of self, the great Other that watches over me and impels me to give my best, the ideal that I try to follow and realize; and Superego is that same agency in its vengeful, sadistic, punitive aspect. The principle underlying these three terms is clearly Lacan’s imaginary-symbolic-real triad: the ideal ego is imaginary, what Lacan calls the little other, the idealized specular image of my Self; the ego ideal is symbolic, the point of my symbolic identification, the point in the great Other from which I observe (and judge) myself; the Superego is real, the cruel and insatiable agency that bombards me with impossible demands and then mocks my awkward attempts to satisfy them (Zizek, 2010, p. 99-100).

It is precisely at this point that things start to get complicated, because, as we will show below, the status of the Superego in psychosis is not so clear. It is important to remember that Freud (2011b, p. 33), in systematizing the concept of Superego, claims to be “[…] heir to the Oedipus complex”. But psychosis, Lacan (1988) explains to us, is configured as a subjective position marked precisely by the non-traversing the Oedipus from the radical negation of castration, expressed in the mechanism of foracclusion (Verwerfung). What this means - given that the moral instance that would eventually emerge in the concept of Superego, as Freud tells us (2010a), conditions and demands the repression (Verdrängung), a self-defense mechanism against neurosis as opposed to foracclusion? By no means does it mean that there is no Superego in psychosis, but its incidence is peculiar.

The ego ideal, as we can see, refers to a moral and normative instance par excellence, an instance constituted through symbolic identification that, as Zizek (1992) shows us, occurs with the incidence of the nodal point in the signifier chain. Now, for Lacan (1988), what is foraccluded on psychosis is precisely the signifier that is presented as a nodal point, which, in the case of neurosis, links signifier and meaning and thus prevents metonymic slippage of the signifier chain is unceasing. This primordial signifier he coined as the Name-of-the-Father, for it arises by identification with the paternal function as symbolic law. Thus, we can say that the ego ideal, as a product of the introjection of the father figure, would be of the order of this Superego which Freud (2011b) claims to be heir to the Oedipus complex. In this sense, he would be, at first, absent in psychosis - as Calligaris (2013) tells us, in psychosis the Father is in the real, since it is not symbolized.

When we say that CAPS, proclaiming an ideal of inclusion, identifies with the ego ideal, we are demonstrating, metapsychologically, what some authors - such as Calligaris (2013) and Dunker and Kyrillos Neto (2015) - regard as an attempt of ‘neurotization’ of the psychotic in psychiatric reform. Thus, the ideal of inclusion appears to the psychotic as an impossible imperative. It remains to know, finally, what are the clinical resonances of this superego position of the institution.

We believe we can think of two important clinical resonances, and for this the distinction between the three terms proposed by Freud in theorizing psychosis will be important to us. This is because, in the impasse faced by the psychotic in relation to the ‘symbolic’ term (the ego ideal, the Other representative of the Law), the incidence of the inclusion imperative will occur through the other two terms: either through the ‘real’ instance of the terrible and sadistic Superego; either through the ‘imaginary’ instance of the ideal ego as the idealized self-image of the ego. Now it is difficult not to see in such resonances, respectively, two of the clinical types of psychotic structure: schizophrenia and paranoia. Let us look closer look at this.

In the first clinical consequence, concerning schizophrenia, the CAPS presents to the psychotic as an absolute and mocking Other who, as such, mocks the subject. This is because, as Lacan (1998a, p. 564) reminds us, in psychosis, “[…] at the point where [...] the Name-of-the-Father is called, one can answer in the Other a pure and simple hole […]”, which triggers the psychotic crisis, leading to what Lacan (1988, p. 59, author’s emphasis) calls imaginary dissolution. In this case, the famous Lacanian aphorism that “[…] ‘what was rejected in the symbolic reappears in the real’ […]” has its clinical expression, since the non-symbolization of the castration of the Other implies its return in the real of hallucination as an absolute figure, while Other is unbarred. Here, the relation of the subject to the signifier, as Quinet (2015) shows us, is marked by the schizophrenic ‘dispersion’ mechanism, which, as its name implies fragmentation, that is, a radical dismantling of the reality of the subject, from his body to the outside world. Everything loses its imaginary consistency and the subject finds himself in a complete lack of meaning.

Paranoia is characterized by ‘retention’ (Verhaltung⁹). Thus, conversely, what happens is an excessive imaginary consistency, in which everything gains a self-referring meaning. If in schizophrenia there is schiz, radical split; in paranoia there is an illusion of unity and omnipotence (Quinet, 2015). Thus, the second clinical consequence refers to the incidence of reform ideology given the specificity of psychotic subjectivity. This is because the psychotic would tend to accept unconditionally the ideological knowledge offered by the institution. In this situation, it happens that, to the subject marked by the lack of a primordial signifier (S1) - due to the foracclusion mechanism - an S1 representative of the signifiers important to the institution is offered (Dunker & Kyrillos Neto, 2015). Now, as we saw with Quinet, the paranoid retention mechanism is characterized precisely by implying the fixation of the subject to an ideal (master) signifier that determines it.

Indeed, such a mechanism turns out to be homologous to the ideological interpellation process, as proposed by Althusser (1996). Here it is worth a quick detour to understand the consonance of the Marxist philosopher’s concept with psychoanalytic metapsychology. Ideological interpellation and, consequently, the notion of Ideological State Apparatus are postulated by Althusser in an attempt to rethink the concept of ideology at its material root, in contrast to what he called the idealist scheme, predominant in the analysis of ideology. Thus, the author reverses the vulgate that ‘ideas inspire acts’, proposing that ideology should be thought of in its material character, while ideas linked to material acts, derived from material practices, organized by material rituals that, as such, would be determined by a material ideological apparatus. From this follows the axiom that “[…] ideology challenges individuals as subjects” (Althusser, 1996, p. 131), so that the subject would be subjected, constituted by an ideological apparatus. Thus, starting from the Lacanian perspective of the imaginary relationship, Althusser proposes that the subject, through the interpellation, would be constituted specularly in front of Another Absolute Subject. For example, “[…] there can be only such a multitude of possible religious subjects under the absolute condition that there is one Absolute, Only Other Subject, that is, God” (Althusser, 1996, p. 136).

Now is this not exactly what is proposed in Psicologia das massas e análise do eu (Freud, 2011a) as the crucial point for the constitution of a mass from the figure of its leader as the ego ideal of the subjects that compose it? And, as Zizek (1992) shows us in his political reading of Lacan’s constitution of the subject (to be more exact, of the graph of desire), the theory of Althusserian ideology would be inscribed precisely at the point where the ego ideal arises via symbolic identification - a moment he calls ideological basement.

The homology between paranoid retention and ideological interpellation is now evident, because in both cases, with the injunction coming from an absolute and consistent Other, the subject ends up fixing himself with the master signifier he offers, which implies a complete and immediate identification with the specular image (the ideal ego). Paranoid, in this sense, is

[...] who believes in his immediate identity with himself, who is not capable of dialectically mediated detachment from himself, as a king who thinks he is king, who takes his being-king for immediate property, not for a symbolic mandate imposed on him by a network of intersubjective relations of which he is part (Zizek, 1996b, p. 323).

Going back to our central question, we can say that the identification of the CAPS with the ego ideal, in announcing an ideal of inclusion, implies the two commented clinical resonances: or is the psychotic facing a teaser Other (schizophrenia)?, or he is confronted with an interpellator Other (paranoia). A possible way out of this scenario would be the transference management - after all, we are dealing here with the relationship of the psychotic with the otherness - on the part of the mental health worker, in which he avoids placing himself in an interventionist, superego position, giving space for the subject constitutes his healing process through his own subjective production. In short, the clinical strategy suggested by Lacan in Seminar 3 (1988), that analysts are ‘secretaries of the insane’.

Here, the political importance of the psychoanalytic clinic can once again be emphasized, because managing the transference allows the perception of this dimension that, as Zizek (1996b, p. 322) reminds us, is beyond the interpellation, in which we see that the Other, far from being consistent, is barred and missing.

This is the disregarded dimension in the Althusserian explanation of the interpellation: before being captured in identification, in symbolic recognition/ignorance, the subject ($) is captured by the Other through a paradoxical object-cause of desire in the midst of it, (a), through the supposedly hidden secret in the Other: $ <> a - the Lacanian formula of fantasy.

This dimension beyond ideological interpellation, which presupposes the traversal of social fantasy (kind of final horizon of analysis) is what allows us to think that the subject is not the mere reflection of social norms, that he is not completely determined by a great institutional Other, as makes us believe the Althusser’s ‘subjected subject’.

That is, such a subjective dimension beyond ideological interpellation - whatever interpellation is that which reduces the subject to the stigma of madness, which reduces him to a diagnostic code, or even to a citizen - is verified from the clinic. Therefore, we advocate that CAPS cannot do without the clinic as an ethical listening operator, regardless of the technical modality of intervention: be it therapeutic accompaniment, group psychological work, workshops, reception, among others.

Final considerations: listening to the psychotic subject between clinic and politics

Jacques Lacan (1998a) makes it clear that the preliminary question for every possible treatment of psychosis must start from the assumption that it is marked by the mechanism of foracclusion (in the previous section we saw the risks of ignoring this principle) and that it implies in short, the profound uniqueness that characterizes such a human experience. Interestingly, despite the originality of the French psychoanalyst’s theoretical elaboration - which caused considerable transformations in the psychoanalytic field - the premise of his clinical proposal for psychosis is expressed in a simple formula: “[…] should listen to one who speaks” (Lacan, 1998a, p. 581) is his recommendation. And if we think about the history of silencing madness in our society, Lacan’s subtle suggestion appears even more powerfully. After all, listening is presented here as an act both clinical and political.

And as far as this listening is concerned, Lacan (1988), as we have already commented, makes what was before an insult directed at powerless aliens before the alienated, a clinical strategy: to secret the insane in what he has to witness of his existence, that is, its unique relation to language and jouissance. It is in this sense that we believe that the forms of stabilization of psychosis proposed by Lacan, which go through the clinic and that value and highlight the autonomous production of the subject, are configured as a counterpoint to any normative therapy that idealizes a cure (and, in this sense, a norm to follow) for the insane.

It is important to affirm, at this point, the richness that the maintenance of the subject in his/her belonging - made possible by the movement of psychiatric reform and the anti-asylum struggle in Brazil - brings to the clinic of psychosis. If before the clinic as reception of madness through a listening operator was impracticable, given the oppressive and violent context of the psychiatric hospital; today, given the changes in Brazilian mental health, we are allowed to think of a possible clinic for CAPS, since psychotic subjects are in contact with otherness, a contact made possible by their circulation in the social bond.

This explains the emergence, in Brazil, of this political-clinical practice so dear to the field of mental health called ‘extended clinic’ (Figueiredo, 2017)¹⁰. And as far as a political-clinic is concerned, the Lacanian recommendation that we be the secretaries of the insane, by reversing the place of intervention that passes over to the analysand, allows the analyst to avoid occupying a place of power over the subject. And this was not, as we have shown, the overarching goal of the reform: to break radically from the position of alienation (derived from the asylum environment) that the insane was before the power-holding doctors? Moreover, such a recommendation is of the utmost importance with regard to the handling of the transference with the psychotic who, as we have seen, tends to expect from the Other (sometimes seen as absolute) a decisive intervention (not to mention interpellation). In other words, Lacan’s recommendation prevents the treatment instance from becoming entangled in an attempt to adapt the insane to prevailing social values (inclusion at all costs can easily become that). For, as he tells us:

That this psychosis proves to be compatible with the so-called good order is undoubtedly something, but neither authorizes the psychiatrist, even if psychoanalyst, to rely on his own compatibility with this order to believe that he has an adequate idea of ‘reality’, of which his patient would be discrepant (Lacan, 1998a, p. 583, author’s emphasis).

Moreover, it is worth noting that, by indicating the political-clinical resonances of the CAPS inclusion ideal, we also indicate, to some extent, the possibilities of what we call a clinical-policy - a policy that is attentive to the clinic and, conversely, a policy-conscious clinic. Such possibilities include, as we have already said, the acceptance of what belongs to the order of discontent, antagonism and, in this sense, besides constituting a critique of ideology - against the ideological veiling of social antagonism - , receives madness in its facet of fundamental irreducibility to the social bond (which makes it one of the par excellence representatives of the collective discontent).

This is why we claim that Lacan’s clinical suggestion in Seminar 3 (1988) is already an ethical-political operator - although he will only elaborate an ethics of psychoanalysis more systematically three years later, at Seminar 7 (2008). Thus, being a secretary of the insane is one way for the analyst not to conform to what Lacan (2008) called the ‘service of goods’¹¹, not to conform at last to being an ideal to be followed by the analysand. For if the ego ideal is defined by Lacan in this seminar as “[…] representing the power to do good” (2008, p. 279), the ideal of inclusion which we criticize in CAPS can be summed up in his ironic speech: “What I want is the good of others as long as it remains in the image of mine” (Lacan, 2008, p. 224).

In this sense, in making a critique of the treatment that starts from a positively determined ideal; by betting on the clinic as enabling subjective manifestation and political emancipation (since it implies one beyond the ideologies and ideals that constrain us); and glimpse in listening to a political-clinical operator, we sought to assert what Lacan (1998b) says by stating that the psychoanalyst should direct the treatment, but not the patient at all.

Thus, we conclude the present essay in the hope that from the discussion undertaken it will be possible to at least glimpse what would become a preliminary question of a possible clinical-policy for CAPS. After all, being a secretary of the insane implies, in the final analysis, what Lacan (1998b, 2010) proposes to be the analyst’s position par excellence: not only a position occupied with the subject’s work, but a subjective loan, radical loan from one’s own body. A position that foresees a kind of desubjectivation, a self-mourning that, by unveiling the inconsistency of the great Other - thus welcoming the discontent, the antagonism - enables the insanity as subjectivity to be finally called into question.

Referências

• Althusser, L. (1996). Ideologia e aparelhos ideológicos de Estado: notas para uma investigação). In S. Zizek (Org.), Um mapa da ideologia (p. 105-142). Rio de Janeiro, RJ: Contraponto. Original publicado em 1970.
• Amarante, P. (Coord.). (1995). Loucos pela vida: a trajetória da reforma psiquiátrica no Brasil(2a ed.). Rio de Janeiro, RJ: Fiocruz.
• Basaglia, F. (1979). Psiquiatria alternativa: contra o pessimismo da razão, o otimismo da prática São Paulo, SP: Brasil Debates.
• Basaglia, F. (Coord.). (1985). A instituição negada: relato de um hospital psiquiátrico Rio de Janeiro, RJ: Graal.
• Calligaris, C. (2013). Introdução a uma clínica diferencial das psicoses (2a ed.). São Paulo, SP: Zagodoni.
• Dunker, C. I. L. (2013). Sobre a relação entre teoria e clínica em psicanálise. In C. I. L. Dunker. A psicose na criança: tempo, linguagem e sujeito (p. 63-73). São Paulo, SP: Zagodoni.
• Dunker, C. I. L., & Kyrillos Neto, F. (2015). Psicanálise e saúde mental Porto Alegre, RS: Criação Humana.
• Eagleton, T. (1996). A ideologia e suas vicissitudes no marxismo ocidental. In S. Zizek (Org.), Um mapa da ideologia (p. 179-226). Rio de Janeiro, RJ: Contraponto.
• Figueiredo, A. C. (2015). Psicanálise e práticas institucionais na saúde mental: o estado da arte. In V. A. Darriba & R. M. M. de Barros (Orgs.), Psicanálise e saúde: entre o Estado e o sujeito (p. 125-134). Rio de Janeiro, RJ: Companhia de Freud.
• Figueiredo, A. C. (2017). A clínica ampliada. In C. E. Lang, J. S. Bernardes, M. A. T. Ribeiro & S. V. Zanotti (Orgs.), Clínicas: pesquisas em saúde, psicanálise e práticas psicológicas (p. 33-56). Maceió, CE: Edufal/Ufal.
• Freud, S. (2010a). Introdução ao narcisismo. In S. Freud. Obras completas(Vol. 12, p. 13-50). São Paulo, SP: Companhia das Letras. Original publicado em 1914.
• Freud, S. (2010b). Observações sobre o amor de transferência. In: S. Freud. Obras completas (Vol. 10, p. 159-172). São Paul, SP: Companhia das Letras. Original publicado em 1915.
• Freud, S. (2011a). Psicologia das massas e análise do eu. In: S. Freud. Obras completas (Vol. 15, p. 9-100). São Paulo, SP: Companhia das Letras. Original publicado em 1921.
• Freud, S.. (2011b). O eu e o id. In: S. Freud. Obras completas (Vol. 16, p. 9-64). São Paulo, SP: Companhia das Letras. Original publicado em 1923.
• Freud, S.. (2011c). O mal-estar na civilização São Paulo, SP: Penguin Classics Companhia das Letras. Original publicado em 1930.
• Lacan, J. (1988). O seminário, livro 3: as psicoses (2a ed.). Rio de Janeiro, RJ: Zahar. Original proferido em1955-1956.
• Lacan, J. (1998a). De uma questão preliminar a todo tratamento possível da psicose. In: JLacan. Escritos (p. 537-590). Rio de Janeiro, RJ: Zahar. Original publicado em 1957-1958.
• Lacan, J. (1998b). A direção do tratamento e os princípios de seu poder. In J. Lacan. Escritos (p. 591-652). Rio de Janeiro, RJ: Zahar . Obra original publicada em 1958.
• Lacan, J. (2008). O seminário, livro 7: a ética da psicanálise Rio de Janeiro, RJ: Zahar. Original proferido em1959-1960.
• Lacan, J. (2010). O seminário, livro 8: a transferência (2a ed.). Rio de Janeir, R: Zahar. Original proferido em1960-1961.
• Lobosque, A. M. (2013). Saúde mental no âmbito do SUS. In: W. Melo, F. M. Lopes, M. F. Ramos, F. A. Bueno & D. R. Matos (Orgs.), Universidade e sistema de saúde: a democratização do conhecimento (p. 33-43). Rio de Janeir, RJ: Espaço Artaud.
• Quinet, A. (2015). Saúde mental e psicanálise: os foracluídos na cidade dos discursos. A peste, 7(2), 103-128.
• Rosa, M. D. (2016). A clínica psicanalítica em face da dimensão sociopolítica do sofrimento São Paulo, SP: Escuta/Fapesp.
• Roudinesco, E., & Plon, M. (1998). Dicionário de psicanálise Rio de janeiro, RJ: Zahar.
• Safatle, V. (2008). Cinismo e falência da crítica São Paulo, SP: Boitempo.
• Secretaria de Estado de Saúde de Minas Gerais. (2006). Linha guia de atenção em saúde mental. Belo Horizonte, MG.
• Yasui, S., & Barzaghi, N. (2018). História, memória e luta: a construção da Reforma Psiquiátrica no Brasil Convención Internacional de Salud, Cuba Salud.
• Zizek, S. (1992). Eles não sabem o que fazem: o sublime objeto da ideologia Rio de Janeiro, RJ: Jorge Zahar.
• Zizek, S. (1996a). O espectro da ideologia. In: S. Zizek(Org.), Um mapa da ideologia (p. 7-38). Rio de Janeiro, RJ: Contraponto.
• Zizek, S. (1996b). Como Marx inventou o sintoma? In S. Zizek(Org.), Um mapa da ideologia (p. 297-331). Rio de Janeiro, RJ: Contraponto.
• Zizek, S. (2010). Como ler Lacan Rio de Janeiro, RJ: Zahar.
• Zizek, S. (2017). Além da análise do discurso. In R. Butler & S. Stephens (Orgs.), Interrogando o real (p. 263-275). Belo Horizonte, MG : Autêntica.

• 1
  This essay is an offshoot of the master’s research entitled Psychosis and CAPS: between metapsychology, clinics and politics,.
• 2
  Support and funding: Fundação de Amparo à Pesquisa do Estado de Minas Gerais (FAPEMIG).
• 5
  For this, see Basaglia (1985) and Dunker and Kyrillos Neto (2015).
• 6
  What we are pointing to is a similarity and not necessarily a direct reference from Basaglia to Georg Lukács. In fact, in the Basaglia’s texts used in this essay, the only direct, subtle, reference to a Marxist theorist (in addition to Marx himself) is to his countryman Antonio Gramsci. We believe that such a shortage of direct theoretical references in Basaglia’s text is indicative that its main purpose was practical rather than ‘academic’.
• 7
  It is worth noting that Zizek ‘imports’ Ernesto Laclau and Chantal Mouffe’s concept of social antagonism. As he tells us: [...] the socio-symbolic field is conceived as a field structured around a certain traumatic impossibility, a certain fissure that ‘cannot’ be symbolized. In short, Laclau and Mouffe reinvented, as it were, the Lacanian notion of the Real as impossible, they made it useful as a tool for social and ideological analysis” (Zizek, 2017, p. 263-264, author’s emphasis).
• 8
  When considering Lacanian psychoanalysis, the concept of the great Other is central and full of theoretical resonances. Regarding this article, an interesting way of understanding it is from the following definition in the Dicionário de psicanálise: “[...] the subject is determined, according to Lacan, by a symbolic order designated as ‘place of the Other’ and perfectly distinct from what is ‘within the scope of a relationship with the other’” (Roudinesco & Plon, 1998, p. 559, author’s emphasis). However, there is a point at which the subject does not completely conform to this symbolic order, at which point he cannot fully determine it, and this point is expressed in the fact that such order, that is, of the Other being inconsistent.
• 9
  Verhaltung is not a psychoanalytic term, but a concept used by Lacan in his doctoral thesis and taken from the German psychiatrist Ernst Kretschmer (Quinet, 2015).
• 10
  Given the importance of the extended clinic as a practice in the field of mental health, we have chosen to make a reference to it, although it is impossible to deepen the guidelines of this proposal within the scope of this article, which is only intended to proceed with a theoretical discussion taking into account political, clinical, metapsychological and ethical issues in the field of mental health.
• 11
  Lacan (2008, p. 368) brings the service of goods closer to a morality based “[...] entirely on a certainly tidy, ideal order […]”, that is, a “[...] moral of the master, made for the virtues of the master, and bound to an order of powers”.

Publication Dates

• Publication in this collection
  16 Mar 2020
• Date of issue
  2020

History

• Received
  08 Oct 2018
• Accepted
  14 May 2019