A condição do desamparo e a vida comum : um horizonte na cura psicanalítica

Tese (doutorado) — Universidade de Brasília, Instituto de Psicologia, Programa de Pós-graduação em Psicologia Clínica e Cultura, 2021.Buscamos investigar o problema geral de como podemos nos orientar na clínica psicanalítica, visto que essa orientação não se trata da aplicação de um manual de condutas, da repetição de fórmulas ou de dogmas. A hipótese inicial de pesquisa é a que há algo de crítico a ser recuperado na noção de condição de desamparo para pensarmos a direção do tratamento na psicanálise freudiana. A metodologia que utilizamos foi a pesquisa-investigação em psicanálise, que consiste em uma pesquisa teórico-metodológica, implicada no crescimento e aperfeiçoamento da disciplina e da clínica psicanalítica. O principal objetivo desta tese é demonstrar que a noção de condição do desamparo constitui uma orientação, um horizonte presente no saber-fazer de Freud em relação à técnica psicanalítica, horizonte esse crucial para o analista direcionar suas análises para a sua devida resolução, sem o qual sua prática se torna o exercício de um poder. O trabalho se estrutura a partir de dois eixos: (i) acompanhar e evidenciar dentro da tarefa analítica de Freud essa orientação em direção ao confronto com a condição do desamparo: a partir dos impasses que encontramos no fundamentos pré-psicanalíticos da clínica, na direção da interpretação e na noção de manejo da transferência; (ii) evidenciar que essa direção conduz, já na obra freudiana, à necessidade de formulação de um novo laço com o outro a ser promovido pela clínica psicanalítica. Fomos capazes de observar que o horizonte da cura psicanalítica se orienta por uma ética da desilusão, na qual a análise pretende a desarticulação dos fundamentos ilusórios e infantis das relações de poder no interior da neurose; mas também, não devemos esquecer, caso contrário corremos o risco de sustentar o ideal do desprendimento total do outro, se orienta por uma ética da reconciliação, uma reformulação criativa do laço, que nomeamos “vida comum” e “um outro com quem contar”. Ao longo da pesquisa noções freudianas inesperadas como as de Handhabung (manejo) e Bãndigung (domação) se mostraram relevantes para o encaminhamento dos nossos objetivos. Por fim, conclui-se que a condição do desamparo e a vida comum constituem dois norteadores para a teoria da direção da cura: uma direção que se orienta pelo primeiro sem o segundo faz do tratamento um encontro desesperado, melancólico e solitário com a condição do desamparo; já uma direção que se orienta pelo segundo sem o primeiro faz do tratamento o mantenimento de modelos alienantes, expectativas-crédulas e ilusões infantis. Esses norteadores, entrelaçados, no entanto, são capazes de lançar luz e orientar os problemas da posição do analista na direção do tratamento e localizar suas possíveis imposturas.We seek to investigate the general problem of how we can orient ourselves in the psychoanalytic clinic, since this orientation is not the application of a manual of conducts, the repetition of formulas or dogmas. The initial hypothesis of research is that there is something critical to be recovered in the notion of a helplessness condition to think about the direction of treatment in freudian psychoanalysis. The methodology we used was research-investigation in psychoanalysis, which consists of theoretical-methodological research, implicated in the growth and improvement of the discipline and psychoanalytic clinic. The main objective of this thesis is to demonstrate that the notion of the helplessness condition constitutes an orientation, a horizon present in freud's know-how in relation to the psychoanalytic technique, a crucial horizon for the analyst to direct his analyses to his due resolution, without which his practice becomes the exercise of a power. The work is structured from two axes: (i) to monitor and evidence within Freud's analytical task this orientation towards the confrontation with the helplessness condition: from the impasses we find in the pre-psychoanalytic foundations of the clinic, in the direction of interpretation and in the notion of transference management; (ii) to show that this direction leads, already in freudian work, to the need to formulate a new bond with the other to be promoted by the psychoanalytic clinic. We were able to observe that the horizon of psychoanalytic healing is guided by an ethics of disillusionment, in which the analysis intends the disarticulation of the illusory and childish foundations of power relations within neurosis; but also, we should not forget, otherwise we run the risk of sustaining the ideal of the total detachment of the other, is guided by an ethics of reconciliation, a creative formulation of the bond, which we call "common life" and "another with whom to tell". Throughout the research unexpected Freudian conceptions such as those of Handhabung (handling) and Bãndigung (domation) were relevant for the referral of our objectives. Finally, it is concluded that the condition of helplessness and common life constitute two guiding points for the theory of the direction of healing: a direction that is guided by the first without the second makes the treatment a desperate, melancholic and solitary encounter with the condition of helplessness; already a direction that is guided by the second without the first makes the treatment the maintenance of alienating models, expectations-gullible and childish illusions. These guiding, intertwined, however, are able to shed light and guide the problems of the analyst's position in the direction of the treatment and locate their possible impostures.Buscamos investigar el problema general de cómo podemos orientarnos en la clínica psicoanalítica, ya que esta orientación no es la aplicación de un manual de conductas, la repetición de fórmulas o dogmas. La hipótesis inicial de la investigación es que hay algo crítico que recuperar en la noción de condición del desamparo para pensar la dirección del tratamiento en el psicoanálisis freudiano. La metodología que utilizamos fue la pesquisa-investigación en psicoanálisis, que consiste en una investigación teórico-metodológica, implicada en el crecimiento y mejora de la disciplina y clínica psicoanalítica. El objetivo principal de esta tesis es demostrar que la noción de la condición de desamparo constituye una orientación, un horizonte presente en el saber-hacer de Freud en relación con la técnica psicoanalítica, un horizonte crucial para que el analista dirija sus análisis a su debida resolución, sin la cual su práctica se convierte en el ejercicio de un poder. El trabajo se estructura a partir de dos ejes: (i) monitorear y evidenciar dentro de la tarea analítica de Freud esta orientación hacia la confrontación con la condición del desamparo: desde los impasses encontrados en los fundamentos pre-psicoanalíticos de la clínica, en la dirección de la interpretación y en la noción de manejo de la transferencia; (ii) mostrar que esta dirección conduce, ya en el trabajo freudiano, a la necesidad de formular un nuevo lazo con el otro promovido por la clínica psicoanalítica. Pudimos observar que el horizonte de la cura psicoanalítica está guiado por una ética de la desilusión, en la que el análisis pretende la desarticulación de los fundamentos ilusorios e infantiles de las relaciones de poder dentro de la neurosis; pero además, no debemos olvidar, de lo contrario corremos el riesgo de sostener el ideal del desapego total del otro, se guía por una ética de la reconciliación, una reformulación creativa del lazo, que llamamos "vida común" y "otro con quién se pueda contar". A lo largo de la investigación, concepciones freudianas inesperadas como las de Handhabung (manejo) y Bãndigung (domación) fueron relevantes para la referencia de nuestros objetivos. Finalmente, se concluye que la condición de desamparo y la vida común constituyen dos puntos rectores para la teoría de la dirección de la cura: una dirección que es guiada por la primera sin la segunda hace del tratamiento un encuentro desesperado, melancólico y solitario con la condición desamparo; ya una dirección que es guiada por la segundo sin el primero hace del tratamiento el mantenimiento de modelos alienantes, expectativas-crédulas e ilusiones infantiles. Estos guías, entrelazados, sin embargo, son capaces de arrojar luz y responder los problemas de la posición del analista en la dirección del tratamiento y localizar sus posibles imposturas

Mental health, gender and elderly in the nursing home

Este trabalho teve como escopo investigar como a velhice é vivenciada, de forma “gendrada”, por homens e mulheres em uma instituição geriátrica e sua relação com a saúde mental. Foram realizadas 18 entrevistas, baseadas em um questionário semi-estruturado (9 com homens, 9 com mulheres). A análise das falas mostrou como as relações de gênero alicerçam as vivências das idosas e dos idosos institucionalizados, implicando em importantes diferenças e especificidades de sofrimento psíquico. Os resultados sugerem a importância de se levar em consideração os valores de gênero na formulação de políticas públicas de saúde mental para essa população. ______________________________________________________________________________________________ ABSTRACTThe scope of the present study is to investigate how aging is experienced in a gendered way, by men and women in a nursing home and its relation to mental health. 18 interviews, using a semi-structured questionnaire (9 with men, 9 with women) were performed. The analysis of the speeches showed how gender relations underpin the experiences of the institutionalized elderly (women and men), implying important differences and specificities of psychological distress. The results suggest the importance of taking into account the values of gender in the formulation of public policies on mental health for this population

La impotencia sexual en la obra de Freud

Dissertação (mestrado)—Universidade de Brasília, Departamento de Psicologia Clínica e Cultura, Programa de Pós-Graduação em Psicologia Clínica e Cultura, 2017.Esta dissertação pretende investigar a impotência sexual masculina tal como a psicanálise de Freud a concebeu. Partimos da sugestão do manual diagnóstico psiquiátrico (DSM) de que os transtornos sexuais, dentre eles a disfunção erétil, admitem uma etiologia de base psicogênica. Nosso principal objetivo é demonstrar que a obra de Freud oferece um campo fecundo de exploração no qual podemos extrair diversas teorias da origem psíquica da impotência. Nesse sentido, o trabalho se estrutura em duas partes: na primeira, analisamos os textos iniciais de Freud, em que se refere de maneira tangencial ao tema, e extraímos formulações que anunciam a sua complexidade; na segunda, expomos quatro hipóteses da etiologia da impotência sexual que podemos encontrar em sua obra: a hipótese da fixação incestuosa, a hipótese da inibição por ameaça de castração, a hipótese do horror ao feminino e, por último, a hipótese da atitude masoquista. A obra de Freud fornece não apenas uma descrição etiológica da impotência, revela as falhas inerentes à constituição sexual humana. O sintoma da impotência deixa de ser apenas sinônimo do medo e do fracasso, e passa a se revelar uma resposta singular do sujeito à castração e uma fonte de satisfação paradoxal e obscura.This master thesis intends to investigate male sexual impotence as Freud's psychoanalysis conceived it. We start from the suggestion in the psychiatric diagnostic manual (DSM) that sexual disorders, including erectile dysfunction, admit a psychogenic basis etiology. Our main objective is to demonstrate that Freud's work offers a fertile field of exploration in which we can extract various theories of the psychic origin of impotence. In this sense, the work is structured in two parts: first, we analyze the initial texts of Freud, in which he refers in a tangential way to the theme, and extract formulations that announce their complexity; second, we present four hypotheses of the etiology of sexual impotence that we can find in his work: the hypothesis of incestuous fixation, the hypothesis of inhibition by threat of castration, the hypothesis of the horror of the feminine, and, finally, the hypothesis of the masochistic attitude. Freud's work not only provides an etiological description of impotence, reveals the inherent flaws of the human sexual constitution. The symptom of impotence ceases to be only a synonym of fear and failure, but it turns out to be a singular response of the subject and a source of paradoxical and obscure satisfaction.Esta tesis de maestria investiga la impotencia sexual masculina tal como el psicoanálisis de Freud la concibió. Partimos de la sugerencia del manual diagnóstico psiquiátrico (DSM) de que los trastornos sexuales, entre ellos la disfunción eréctil, admite una etiología de base psicogénica. Nuestro principal objetivo es demostrar que la obra de Freud ofrece un campo fecundo de explotación en el que podemos extraer diversas teorías del origen psíquico de la impotencia. En ese sentido, el trabajo se estructura en dos partes: en la primera, analizamos los textos iniciales de Freud, en que se refiere de manera tangencial al tema, y extraemos formulaciones que anuncian su complejidad; En la segunda exponemos cuatro hipótesis de la etiología de la impotencia sexual que podemos encontrar en su obra: la hipótesis de la fijación incestuosa, la hipótesis de la inhibición por amenaza de castración, la hipótesis del horror al femenino y, por último, la hipótesis de la actitud masoquista. La obra de Freud proporciona no solo una descripción etiológica de la impotencia, sino que revela las fallas inherentes a la constitución sexual humana. El síntoma de la impotencia deja de ser solo sinónimo del miedo y del fracaso, pasa a revelarse una respuesta singular del sujeto a la castracción y una fuente de satisfacción paradójica y oscura

Testimonies during the pandemic: psychoanalytic reflections on trauma, State, economy and death

Este trabalho propõe-se a refletir sobre a experiência do sujeito perante a pandemia de covid-19 por meio de uma perspectiva psicanalítica. O material analisado discursivamente foi constituído por testemunhos de estudantes de graduação em psicologia publicados em um espaço virtual durante o período de distanciamento social. Os processos de subjetivação destacados em nossa análise foram discutidos em quatro núcleos temáticos: enfrentar o potencial traumático: poder testemunhar a queda do Outro; o (des)amparo dos sujeitos por parte do Estado: a potencialização do sofrimento psíquico; o imperativo superegoico da produção capitalista e os vestígios produtivos da improdutividade; (im)possibilidades do luto: transformações da nossa atitude diante da morte. Ao fim, buscamos evidenciar criticamente o aspecto destrutivo e autoritário da gestão estatal dos afetos sobre os sujeitos e a potência transformativa (analítica e política) das experiências da improdutividade, da indeterminação e do desamparo.This study aims to reflect on the subject’s experience in the face of the covid-19 pandemic by a psychoanalytic perspective. The material analyzed discursively was constituted by testimonies of undergraduate psychology students published in a virtual space during the period of social distance. The subjectivation processes emphasized in our analysis were discussed in four thematic groups: facing the traumatic potential: being able to witness the fall of the Other; the (un)protection of the subjects by the State: the potentiation of psychological suffering; the superegoic imperative of capitalist production and the productive traces of unproductivity, and (im possibilities of mourning: changes in our attitude towards death. Finally, we seek to critically evidence the destructive and authoritarian aspect of the state management of affections on subjects and the transformative power (analytical and political) of the experiences of unproductivity, indeterminacy and helplessness

Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background: Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods: In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings: Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference -1·69 [-9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5-8] vs 6 [5-8] cm H2O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52-23·52]; p<0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75-0·86]; p<0·0001). Interpretation: Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research