versão impressa ISSN 0104-1169
Rev. Latino-Am. Enfermagem v.15 n.5 Ribeirão Preto set./out. 2007
The triggering of psychosis and its clinical treatment in substitutive mental health equipment: a theoretical contribution in the Freudian perspective
Lilian MirandaI; Débora Isane Ratner KirschbaumII
The present study goal was to build a framework based on the Freudian psychoanalysis in order to understand the psychosis mode of production. The methodology consisted of content analysis of terms related to the concept studied. Based on the assumption that the psychotic symptoms are a result of a fixation on the primary narcissism, we conclude that the fusion of life and death pulses, as well as the egoic constitution through identification processes in the oral phase, can keep the individual tied to primitive figures of identification and prevent him(er) from making new libidinal investments, which lead the individual to feel a constant threat and death in life. The attempts made by the psychotic person to escape from this state of death and to relate with external reality are expressed in forms known as symptoms, such as delusions and aggressiveness.
Descriptors: mental health; psychoanalysis; mental disorders
With the advent of the Psychiatric Reform, which started in Brazil at the end of the 70s, the interpretation and explanation of psychotic suffering and of its treatment possibilities have gone through severe changes. Nowadays, involuntary hospitalization and the use of invasive therapeutic techniques without clear criteria to justify it, are not recommended and restricted by federal laws(1). In addition, the interventionist methods, whose paradigm was based on the asylum model(2), were criticized and overcome through the efforts of mental health workers involved with the ideological, social and political proposals of the anti-asylum fight and of groups linked to the University and scientific societies, concerned with the investigation and implementation of ethically based technologies(3).
Some studies, however, indicate that those who intervene daily in psychotic patients, especially nursing professionals, who are responsible in the organizational culture of health services for constant contact with patient issues related to sexuality, medication use and administration of patient lives' routine, report common and intense unpleasant feelings of impotence and confusion when facing the possibilities of inadequate management, often preventing them from respecting the patients' alterity(4).
Other studies show that part of the current suffering of professionals linked to the Psychiatric Reform is due to a lack of theoretical support that focuses on the basic principles of psychotic patients' mental functioning and offer structural elements for understanding the human being from the point of view of psychosis or of an emotional world(5). The patients present processes that express this psychic functioning when they report their experiences of persecution, body alterations and feelings of depersonalization, as will be illustrated through examples at the end of this article.
Based on this assumption about the need for further theoretical instruments to work in current mental health equipment, and aiming to contribute to these workers' education and practice, in this article, the aim is to theorize on the process of psychic formation that can trigger psychotic experiences. The explanation will be based on the study of psychosexual development, formation of the ego and pulsional duality, concepts formulated by Sigmund Freud(6).
This is a Conceptual Study, whose theoretical reference is Freudian psychoanalysis. The method used was skimming of all texts that contained the terms narcissism, pulsional life, pulsional death, psychosis, dementia, paranoia, narcissistic neurosis, melancholy, delirium and hallucination, indicated by the name index of the Complete Work of Sigmund Freud. Next, issues are selected linked to what triggers psychosis and content analysis is performed, based on three thematic categories: psychosexual development, the concept of pulsional death and the relation between these two themes and ego formation(7).
RESULTS AND DISCUSSION
The formation of the ego
From the perspective of psychoanalysis(8), health is marked by the possibility of genuine contact with the other, that is, by moments in which the human being is capable of acknowledging and overcoming alterity and, in view of the difference, capable of fertilizing, allowing for biological procreation, which perpetuates the species, and the symbolic, which produces the cultural and material goods from one's social environment. The completion of a healthy development for man occurs when (s)he reaches the genital phase, when (s)he is able to repress his(er) narcissistic interests in favor of a genital choice of partners, a choice that implies tolerance of what is related to a not - I(8).
However, this ability to choose is acquired through a complex development course, initiated in the first moments of life, when the baby is still immersed in narcissism and is unaware of the existence of anyone else, though (s)he depends on external care to survive. The interaction process with the world and with the internal pulsional life is responsible for the formation of the psyche in the baby(9-10). Nevertheless, there are some vicissitudes on this path that can incur in mental suffering, including psychosis(11-12).
Several authors(8-9) affirm that, for psychotic patients, reality generally is invasive and scaring, much more than for those who suffer from other pathologies like hysterical and obsessive neurosis. It causes terrible sensations of paranoia and reactions that can appear in a continuum from affective blunting up to heteroaggressiveness.
In a Freudian perspective, the relationship human beings establish with the external world is built by the ego: "a coherent organization of mental processes"(10), whose task is to control the approaches of discharge of excitation to the external world, supervise all mental processes and test reality.
A baby, at the beginning of his(er) life, relates with the external world because s(he) needs it to survive, but does not recognize the world as detached from (him)herself. The contact with the mother offers pleasurable sensations originated from the satiation of hunger, but then associated to the stimulation of the mouth mucosa and several other sensorial stimuli, such as smells and sounds. This entire sensorial experience is incorporated by the baby and leaves marks, or traces, which get organized in order to form in this baby an individual way of interacting with the world(8).
At the same time as these sensorial traces are being internalized, the baby, based on the experience of sucking, initiates a process that is analogue to the act of devouring and incorporating the mother's image, as s(he) feels her. S(he) does not concretely devours or attack her, but despises some aspects that belong to her and assimilates, in him(her)self, others, without concern (because there is no cognitive condition to do it) with her subjectiveness. The traces of this whole complex incorporation is forming the baby's ego and gives him(er) the feeling, even if still vague, of possessing a subjective world. However, this refers to a relationship that for the baby is felt as such, since (s)he is unaware of anyone else than him-/herself to relate with. In the period when the formation of the ego is initiated, everything (s)he loves, that is, everything that gives him/her pleasure, is felt as being him-/herself, which therefore configures a narcissistic state(11-12).
Regarding the concept of pleasure, it should be clarified that, in the theoretical perspective adopted here(13), the only objective of all living beings is the complete absence of stimuli, so there is no need for movements towards the world, where possible answers for one's demands are found. However, this state can never be obtained because biological birth implies the existence of internal stimuli, such as hunger, and external ones like light. In view of this first impossibility, imposed by life, the human being gets satisfied with a state of constant stimuli or no disturbance. Associated to other factors, such state, as shown below, permits the formation of the ego.
The formation of the ego and the pulsional theory
The description of this ego formation process is based on the idea that all of us possess a pulsional death, a power that works towards the non-movement. It is not necessarily an effort for physical death, but a direction towards a state of non contact with aspects of life that imply further stimuli. The pulsional death stimulates the living being to maintain his(er) affective expectations as they were originally recorded in the psyche, without the need for arduous attempts to connect them to representative that make them socially shareable(13).
Jointly with pulsional death, there is in the organism a power that pushes towards the development of interaction possibilities with the external world and contact with one's own needs: it is the pulsional life(13). This power would help us in the task of associating psychic representatives to the affection we experiment, giving them representation of the word(14). It is only through these representations that we can communicate with the world, making us understand and comprehend other people's demands.
At the same as the ego, by its identification and sublimation work, helps the pulsional death to obtain control over the libido, it also works in the accumulation of a lot of libido, with desires to live and be loved(10).
What is paradoxical and at the same time brings the key to an understanding of psychosis is that the pulsional death, sometimes, also works towards life. As explained before, any person's mental survival requires the existence of an ego, even if rudimentary; an ego that begin to form itself from incorporations of objects. However, the study of the theory of pulsions shows us that this process of incorporation can only be understood by taking into account the work of the pulsional death, because that is what pushes the baby to annihilate the object and destroy its alterity, thus permitting its incorporation, after which the identification process occurs, whose marks will form the ego and, consequently, the baby's own way of dealing with him(er)self and with internal and external stimuli(12). Thus, life initiates through death, or destruction of the other.
In a normal development process, the pulsional life, acting concomitantly with the pulsional death, works in such a way that the baby can experiment other forms of pleasurable sensations. Once this baby has a rudimentary ego, (s)he can differentiate what belongs to him-/herself, even those things that are closely linked, but are part of another reality, which in some ways are detached from his(er) ego. With this perception, (s)he faces the need to invest in an external world, so (s)he manages to find the answers to his(er) needs and desires. This investment requires the pulsional life to work in order to permit a connection between affections and mental representatives.
When everything in this movement of catechization of the external reality happens reasonably well, the baby abandons previously incorporated objects and manages to connect to other figures, especially the paternal one(11). Thus, (s)he can experience the Oedipus complex and acquire the ability, to a greater or lesser extent, according to how this experience occurred, of perceiving the other and relate with him(er). Makes loving choices, gets involved with the alterity and can produce material and symbolic goods, besides generating children, perpetuating the life of the species(13). However, when there are intercurrences in this process, some diseases are triggered, including psychosis, addressed below.
The development of psychosis
In the case of those people who present psychotic suffering, it is observed that there was no normal development until the Oedipus Complex. The psychosis is created from a fixation in the narcissistic phase and a consequent difficulty to abandon the first objects of identification(9). However, this difficulty implies a fixation in figures incorporated and introjected from death processes, that is, people who cannot abandon their first objects and invest in the external reality in a less destructive way are always focused on figures whose alterity was annihilated by the identification process. Thus, they manage to catechize only themselves and begin to live in a constant state of narcissism(12).
It is important to stress that, for the individual under development, the fixation in narcissism implies severe difficulties to acknowledge the existence of the other - the paternal figure - who possesses ascendancy over him and can impose limits. His/her libido goes through the other phases of development marked by fixation, which produces even more fixations and vicissitudes.
In this context, when the Oedipus complex is experienced, the ability to deal with frustration is very reduced and, consequently, intense processes of regression to previous phases of psychosexual development occur, especially to the oral phase. Facing problems to deal with the impediments and limits implicit in contact with the other, the individual tends to stay fixed on those figures (s)he introjected, not abandoning them in favor of an acknowledgement of his own failures and not being able to make new investments in the external world(9,11,14).
An individual with a narcissistic fixation always gets involved with objects that are deeply associated to the first figures incorporated. In view of his/her involvements, he never abandons his/her object of love, because his(er) ego is the object; however, when a frustration in relation to the object occurs, whether in the real or imaginary world, the ego is also the cause of frustration, since it is completely mixed with the object. Instead of abandoning and attacking the object, the individual abandons and attacks his/her own ego, because the object as an external entity does not exist.
The object relation in the paranoia
What paranoiacs is concerned, it is concluded that their persecuting objects are objects of love, because they are chosen, narcissistically, through introjection and identification processes. In order to defend themselves from the suffering these objects cause, they make use of the projection mechanism, putting the threat on someone who possesses, even if at the unconscious level, some similarity or connection with their persecuting object(9).
Because he does not bear to lose the first object of identification, psychotic patients tend to keep themselves in an inert state, not acquiring other objects from the genital phase. Therefore, they experiment a constant death threat, whose source is their first and irreplaceable object of love. They are trapped because, from the perspective of creation through identification, they are the delirious object itself(9-10).
When the person suffers frustrations imposed by alterity, his/her libido can regress to points where fixations were marked. A regression to the narcissistic phase implies a return to the libido at that moment in life when the individual had all his demands met and counted with the certainty of self-sufficiency. It is exactly in this narcissistic phase that the traces of the first sensorial experiences are found, traces that return to regression, but return to the form they were marked, in smells, sounds, tactile sensations and fragmented and distorted images, thus creating hallucinations, the classic psychotic symptom(12).
Trying to get out of the self-absorption and, in a way, to interact with the world, that is, trying to cure themselves, psychotic patients create explanations for their hallucinating experiences, developing delirious that justify the constant sensation of death in life.
Two cases of psychosis about which Freud made interesting analyses can better clarify the processes described here. The first is about a judge who wrote a book of memories(15) in which he tells about his psychotic experience. He describes several symptoms that could be grouped in hypochondria, related to intense feelings of body transformation, in which the judge believed to be dead and decomposing, or felt his body was becoming a woman's body, besides the perception of a connection with God. Jointly with these sensations, he built a deliriun that he was being persecuted and unfairly harmed by his doctor Flechsig, whom after a period of deep admiration Schereber began to accuse of the murdering of souls. In addition, over time, he got vehemently involved with mystical-religious deliria, believing he had the mission to redeem the world and restitute it to a state of beatitude.
Based on his book of memories, Freud analyzes Schereber(9), proposing that the persecution, religiosity, emasculation and self-reference deliria were understood as mental manifestations, like any other impulses of the human mind. After careful and detailed description and analysis of the relation Schereber mentions he had with his doctor and posterior persecuting figure, Freud proposes that the origin of the deliria and paranoia were linked to sexuality. He explains that, when Schereber felt himself authorized to assume a position of higher power, or when, at an advanced age, he realized he could no longer have a son to continue his lineage, he revived narcissistic conflicts of primitive origin. He then affirms that the root of all paranoia lies in the first phase of libido development, according to previous assertions.
The acquisition Schereber made of a position of higher authority would correspond to the intensification of libido which, being too powerful, sought an escape through the weakest point, in this case narcissism. Since, in this period of psychosexual development, there is no choice of object yet, the movement of the libido is homosexual (the person is his own target of love investment) and, consequently, in the case of paranoiac disease, conflicts linked to homosexuality emerge. This gives rise, for example, to the delirium of emasculation and love for the doctor which, in a process of inversion - since the ego would not bear such love - becomes the persecutor. This narcissistic regression provokes the enlargement of the ego, since all the libido is deposited in it and, thus, the megalomania, experienced by the relation with God and the task of saving the world.
A year after dedicating himself to the Schereber case, Freud published another study about the relation of paranoia with narcissism and homosexuality: A case of paranoia that contradicts the psychoanalytic theory of the disease(16). In this article, he reports on two interviews he had with a lady referred to his office by a lawyer. She had sought legal help because she felt persecuted by a man with whom she had had an affair, but her lawyer, suspicious of a disease, referred her for a psychoanalytic consultation. As she saw herself followed by a man, Freud initially suspected be a case that would contradict the homosexuality in the origin of paranoia. However, after a more detailed investigation, he realized that the lady had a homosexual relation (at an unconscious level of fantasy) with her mother, for whom she renounced from her entire social life, justified by the need to take care of her, and she reinforced this relation in the professional contact with her boss. By allowing herself to get sexually involved with a colleague from work (this was the first involvement in her life), she experienced an intensification of libido, which escaped through the weaker point of the psychosexual development; the narcissism and consequent homosexuality. The lady managed to get involved with a man through a regressive process in which, narcissistically, she did not take the mother as the object of love, but identified herself with her, becoming her (at an unconscious fantasy level) and loving her own father, unconsciously represented by the colleague. The incestuous manifestation created guilt and persecution. As it would be unacceptable for the ego to have the mother or the boss persecuting her, she projected the persecutor figure in the man. It is noted once more that homosexuality is understood as a tendency to related only with what is similar because, by not accepting something that would hurt the narcissism, the girl identifies herself with the mother, someone she considers, at mental level, to be herself.
These cases contribute to make clear that psychotic patients' attitudes, observed by health professionals, are originated in complex emotional processes that are not very evident in the observation of behaviors. Freudian psychoanalysis help us to understand the unconscious mechanisms that need to be considered in patient management, and especially in practices that involve body care, because sexual issues use tend to be deeply mobilized when the professional has some contact with the body of those (s)he delivers care to. Nursing professionals are possibly the most requested of all team members to be in contact with these practices and issues, even though, oftentimes, they do not receive the theoretical support to understand them in the dimension explored here.
After careful consideration of the Freudian theory, some reflections can be proposed on the possibilities of psychotic patients' treatments. The first one refers to deliria: as seen, they are an attempt to attribute representation of word to regressive experiences marked by hallucination, that is, an attempt to relate with the world. The delirious discourses indicate the presence of the pulsional life in the search for a potential connection between sensorial experiences and socially shared codes. Hence, it should be emphasized that deliria must be valued and carefully and respectfully heard.
Regarding the polemic issue that involves the viability of thinking in transference relationships in psychosis, the reading of Freud's texts proposes the following reflection: It is impossible not to admit that people with narcissist fixation face difficulties to relate with the other. However, it is also certain that these people have had a kind of relationship at the start of their lives which, in an ambivalent way, they devoured and incorporated the object, so that they could identify themselves with it afterwards. In view of these ideas, it can be proposed that a psychotic, from the Freudian point of view, can develop a transference relationship with the therapist. However, it is a relationship in which the therapist will be devoured and incorporated, because he will use the relationship mechanisms characteristic of narcissism, a phase in which the libido is fixed.
The work with this identification process and the path towards a construction of a possibility of contact with frustrations and then with figures that possess a more preserved alterity, will be the task of a partnership established between professionals and patients. It must be admitted, though, that this is not a simple task, because the professional will initially need to deal with a relationship in which his/her own subjectivity is completely annihilated by the patient. However, if this relationship can be created along the treatment, the narcissist individual will less and less need to regress to his/her first experiences of satisfaction and will, little by little, be able to deal with the limitations and differences of the professional who accompanies him/her, diminishing his/her identifications and making less destructive investments in the external reality.
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Recebido em: 11.9.2006
Aprovado em: 11.6.2007