ORIGINAL ARTICLE

 DOI: 10.11606/issn.1806-6976.v10i1p-29-34

 

Psychosis and drug addiction: the construction of case in the clinical nursing

 

Psicosis y drogadición: la construcción del caso en la clínica de enfermería

 

 

Francisco Paiva Filho^I; Lia Carneiro Silveira^II

^IMSc, Substitute Professor, Universidade Estadual do Ceará, Fortaleza, CE, Brazil
^IIPhD, Assistant Professor, Universidade Estadual do Ceará, Fortaleza, CE, Brazil

Correspondence

 

 

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ABSTRACT

It is the building of a case in the context of the work as a nurse on a service of psychosocial care. For this, we seek to guide both the clinic and the elaboration written from psychoanalysis. Thus, we present the case of Raul, the "Mad Beauty", where learning to work with the unconscious guided the direction of the treatment. Realized, assuming the role of "Secretary Alienated" as alcohol consumption, to Raul, relates to an attempted social bond and how the signifier "Raul Seixas", which makes the substitutive name of the Father, allows a mooring possible for this open sky unconscious, characteristic of psychosis.

Descriptors: Psychiatric Nursing; Substance-Related Disorders; Unconscious (Psychology); Psychoanalysis; Psychotic Disorders.

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RESUMEN

Se trata de la construcción de un caso clínico en el contexto del trabajo como enfermero de un servicio de la atención psicosocial. Para eso, buscamos orientar tanto la clínica como la elaboración escrita desde el referencial psicoanalítico. Así, presentamos el caso de Raul, el "Maluco Beleza", donde el aprendizaje del trabajo con lo inconsciente orientó la dirección del tratamiento. Percibimos, asumiendo el papel de "Secretario del Alienado", como el consumo de alcohol, para Raul, se relaciona con una tentativa de lazo social y como el significante "Raul Seixas", que hace suplencia al Nombre-del-Padre, permite una amarradura posible para ese inconsciente a cielo abierto característico de la psicosis.

Descriptores: Enfermería Psiquiátrica; Trastornos Relacionados con Sustancias; Inconsciente (Psicología); Psicoanálisis; Trastornos Psicóticos.

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INTRODUCTION

Currently, the drug issue evolved from being a serious health problem to encompass whole structures of social policies; thus, requiring the attention from several areas. The discussion regarding the so called drugs is far from being unidirectional, or something destined to be dealt by simply dispensing punishment or placing restrictions.

In Brazil, the drug first became a public health problem, with the "urbanization" process of the city of Rio de Janeiro, after the arrival of the Portuguese royal family, leading to an increase in the distilled beverage trade, and in the consumption among the masses especially by the new formed working class⁽¹⁾.

In recent decades, the several public policies that were created in an effort to curtail its use looked more like an attempt to block the effects of a product created by the capitalism. There is an apparent paradox between the proliferation of entities (Non-Governmental Organizations or NGOs, universities, private organizations that fund research and diverse community groups with a focus on childhood and adolescence), intent on finding solutions, and the amazing passivity from the Brazilian society in relation to the subject.

Thus, the mental health field still lacks for specialized tools when dealing with problems associated with the use of the so-called psychoactive substances. In recent decades, several outpatient clinics were established; however the institutionalization is not only present in the bricks and concrete that lift the walls of exclusion, but mostly in the static and acritical legacy, which resonates with practices incapable of answering to the contemporaneity´s sufferings. I.e., the resistance offered by the general hospitals in accepting psychiatric beds; public funding to private institutions based on the isolation and moral correction (therapeutic communities), therapeutic projects based only on psychiatric medications.

The technical-care model still prevailing in the training of healthcare professionals has left gaps when we observe the inclusion and professional development. In psychiatry, and more recently in mental health and drug addiction, these questions started to influence the education of students, who work objectively with a subjective group of patients⁽¹⁾.

The experience with the care of alcohol and drug users presented the nursing staff with numerous challenges. For example, working from a different perspective of the academic, this is highly prescriptive and disease-centered; furthermore, forcing them to face their own anxieties, insecurities, prejudices, and even their inability in dealing with the alcohol and drug users⁽²⁾.

There is a difficulty in articulating abstinence and harm reduction in care, among other factors specific to the area, such as, the stigma and the definition between a normal and a pathological consumption. There is a big difference between working in these clinics and the academic training where the approaches to these subjects are usually performed in a superficial manner or strongly supported on the biomedical model.

These challenges require a new approach to nursing. A position that requires changes in both theory and practice of clinical care; and requires new attitudes towards the dilemmas brought about by a world where the subjective requirements of the individuals are often relegated to the background.

Thus, the professional must relinquish the position of the beholder of the knowledge, which is supposedly shrouded not only by the Cartesian thought, but also by those who come seeking answers to their pain in a sovereign master⁽³⁾.

Psychoanalysis aims to establish an inter-subjective relationship; a new social bond that may allow the transitioning from the drug experience to the experiences of the subject. Therefore, unlike the practices of medicine and psychiatry, which replace the disease by the chemical dependency, another approach is suggested, with the understanding that this is a complex phenomenon, whose psychic dimension can contingently insert itself in the daily lives of the individuals; therefore, liable to be reversed⁽⁴⁾.

Since the work with psychoanalysis is driven by the ethics of desire, it is then presupposed that the desire is a starting point for their actions. Thus, the studies never cease, unless it is to give voice to the ones we intend to serve.

 

Building the clinical case

Because this research is guided by the psychoanalysis, we try to adopt a stance that allows us to consider the existence of the unconscious subject and the consequences of assuming such position. Thus, we chose to use a specific form of approach, based on a methodology construed after analyzing the published cases of Freud⁽⁵⁾.

The goal is to follow the "pathos" of the patients (what affects them), which only happens a posteriori. This "pathos" can be broken into three stages: the pathos-disease, pathos-transfer and in the writing of the theoretical constructs⁽⁶⁾.

The "pathos-disease" describes the history of the disease. It is a mere presentation of the symptoms and the relationship with the history of the subject’s life.

The writing of the "pathos-transfer" is the second step. It relates to the transference relationship of the researcher-subject, focused on promoting a subjective rectification, encouraging the individual to invest on the subject of his complaint.

The writing of the theoretical construct consists in the analysis and interpretation of the history of the disease and the transfer of the subject, to ascend to the level of theory construct in psychoanalysis. It aims to conduct a clinical discussion, analyzing and interpreting the data describing the "pathos-disease" and the "pathos-passion-transfer". The phenomena, themes or issues that guide the theoretical research are selected within this boundary.

We chose one of the many cases being treated in the clinical nursing context at the CAPSad. This specific case was chosen because the patient was cared for by the researcher when he first arrived at the clinic searching for help in dealing with drug addiction (alcohol and cigarettes). Furthermore, many issues have been raised during the treatment, especially the relationship between psychosis and drug use. Another important factor for this choice was the evidence of transferences that the patient directed to the researcher.

The sessions occurred between 2009 and 2011 in the context of clinical nursing in a CAPSad located in the metropolitan region of Fortaleza. Their regularity varied, as later demonstrated; however, their number was adequate for this theoretical construction. To assist in the preparation of this writing, we resorted to a private diary containing notations made after the consultations.

This work is part of a larger study entitled "Clinic of the subject, and psychoanalysis: the thinking of new intervention strategies in mental health," approved by the Ethics and Research Committee of the State University of Ceará. Protocol: 10340285-3.

It is important to remember that the research also preserves the history and identity of the subject (here known as Raul), adhering to certain contents, and specific views of the clinical case, those maintaining a relationship with the subject of investigation. This construction took place from a shared production between analyst and analysand, using free association techniques, prizing the unconscious revelations occurring during the disruptions in his speech⁽⁷⁾.

 

Clinical case: the "mad beauty"

The writing of the "pathos-disease"

The first contact with Raul happened during a Carnaval dance, sponsored by the CAPSad Clinic, for the patients and their families. When I am delivering the final remarks of the evening, a staggering figure with dirty clothing, clearly intoxicated, approached and asked permission to use the microphone to read some of his poems. I asked his name, and he replied: "Raul Seixas: The Mad Beauty."

He followed by reading, from a crumpled piece of paper that he withdrew from his pocket, phrases such as, CAPSad and you, it is all about. Put out the cigarette and light up your mind and live happily among us. I invited him for an initial evaluation at the clinic, and he accepted.

When I asked him why he was there, he answered: I am looking for treatment to stop drinking and smoking. He mentioned that he drank when he was feeling sad, usually in the company of friends or strangers. He drank anywhere but at home. While imbibing, he would remember his father, the dead, in addition to having stomach pain. When drinking, he had chest pains, lack of appetite, sleeplessness, sadness, heard voices telling him to destroy his family. When I asked him to elaborate on what had brought him to CAPSad clinic, Raul interspersed his speech with the lyrics from the "Cowboy fora da lei" song (without pauses).

Singsonging, he would recite the whole lyrics, and although his initial complaint was related to the alcohol and cigarette consumption, generally he followed these songs with complaints concerning psychiatric hospitalizations that he suffered: I went through several asylums... they mistreated me. They beat me; I could not say anything. It was cowardice. Cowards!

Regarding what led to these hospitalizations: Had a good job at the textile union, it was with my father’s death that I sank without reason. As for the father, Raul said this he was very aggressive and drank a lot: One day he fell ill. We took him to the hospital. He died as a result of medical malpractice. That was twenty years ago, and Raul still misses him a lot. Also mentioned that he was humiliated by his father; when they were still living in the countryside, he was forced to work since childhood, and the father would hit him and his brothers if not obeyed. He was aggressive and alcoholic.

The mother was bedridden, and Luiz, the eldest son, cared for her. Raul complained of difficulties in the relationship with this brother because he loves to put me down. Sometimes he would go hungry because he would not go into the house to get food. He ate what was offered on the streets, in bars. Moreover, he said that his brother Luiz prevented him from coming near his mother, referring to a situation that made him very uncomfortable. Luiz had to give the mother baths, and Raul would ask: How could this happen? He carries her naked from the bathroom to the bedroom.

Thus, Raul´s initial call for help regarding the alcohol and tobacco use, morphed into complaints related to the hospitalizations, his father and brother, and later on it was directed to the health professionals from the clinic. At that time, Raul has greatly reduced the alcohol consumption, which used to be a daily occurrence. It was no longer a constant in his complaints, up to the week of his birthday.

The writing of the "pathos-transfer"

He started drinking heavily again in the week after his birthday. He often showed up highly intoxicated, complaining that the staff at the clinic did not treat him well. This behavior started after the CAPSad showed the movie "Brainstorm" to the patients, on the week of his birthday. Regarding the main character in the movie, he stated: That was me. Saying that he "relived" all the humiliations suffered during the hospitalizations in psychiatric hospitals. Furthermore, during this period there was a switch in his medications, the Nozinan (Methotrimeprazine – an antipsychotic drug belonging to the aliphatic phenothiazine class) that he was taking was replaced by the Thorazine (Chlorpromazine hydrochloride), because there was a shortage of that drug in the pharmacy of the institution. I can only sleep with the Nozinan; I don´t want anything else. He began drinking heavily again, demonstrating aggressive behavior at the clinic and complaining about the lack of care.

On those occasions, the complaints regarding the service, his brother Luiz, and his dad was all combined. He spoke of his fear of being declared mentally incompetent and becoming a ward of his brother. As for the father, his speech returns to the form of song lyrics, this time the "Shoe size 36". My size is 37 my dad gives me a 36 it hurts, but in the next day I squeeze my foot again I squeeze my foot again.

When Raul showed up drunk, he could be heard in the open area of the clinic, the reception area, and in various areas that he walked through. He was very agitated, ran, and got hurt. In one of these occasions, he hurt his foot and asked me to treat the wound. As a nurse, I took care of the wound. And while I was gathering the supplies and caring for the wound, I listened to what he says, asking him to elaborate it; thus, showing interest in his suffering and personal history. He came back for the appointments, and started talking about his past, the move from the countryside to the state capital during his adolescence, the encounter with the art of Raul Seixas in the 70s, when he began impersonating the singer at the Futuro beach. Sometime later, after several attempts of running interference with the management, his medication regimen was reestablished.

In a session, he went on to say: I am the reincarnation of Raul Seixas and you are Renato Russo... Did you know that Renato is a lawful son of Raul? He had inserted me in his delirium, playing a role in his history. Incidentally, he began to address multiple letters to me, sending me the papers that he wrote.

These writings reported elements of his history, his relationship with the alcohol and his family, and his hospitalizations in a peculiar language. "Damage cosed by Achool had Good joB textile worker – textiLU Ni On was with MY father’s death I sUNk Without A Reason. My situAtion gOt WoRse."

I started to collect his writings, keep them in an individual folder. He spoke of plays that he performed in the asylums. He said that he would like to write a play, someday. Based on his writing, I started to help him construct scene by scene. The scenes were interspersed with songs by Raul Seixas and Renato Russo. The play was presented at the Clinic Christmas party: Raul, in character wearing a jacket and sunglasses, played the role of Mad Beauty.  

The writing of the theoretical construct

As we initiate the theoretical construct it is important to mention that, from listening to Raul, we could have chosen a variety of paths. However, as the title of our work already reveals, we will focus on the subject of psychosis and its relationship with the drug use. This requires following a certain route. First, we need to understand the assumption of a psychotic structure for Raul. Then, to eloquently express the delusional dictum and the typical basic phenomena of psychosis, and to relate this structure to the objects called drug, in the case of Raul, it is the alcohol. And finally, we will address the issue of the possible social bond for the psychotic individual.

Raul, in his speech, presents a very peculiar form of expression. The momentum with which he spoke his words, the entire songs, spoken without pause, the delusional thoughts related to the image of Raul Seixas are evidence of the so-called elementary phenomena. These are nothing but psychotic phenomena that may exist well before a derangement, prior to the onset of a psychosis⁽⁸⁾.

This position will be an important indicator for the course of treatment because it is the language that the subject gets psychically organized, and this can occur in different ways, depending on where he is situated⁽⁹⁾. How a subject articulates its meanings and how he uses them for the construction of a delusional sense provides strong indicators for a psychotic structure.

The structural diagnosis of psychosis stems from the foreclosure of the Name of the Father. However, this occurs at a hypothesis level, which can be identified only by the phenomena that suggest the lack of this record⁽¹⁰⁾. In the absence of the Name of the Father inscription, i.e., the father´s failure of enrolling as the detainer of the signifier who would answer to the mother´s desire at the symbolic level, results in the disruption of the signifying chain, caused by the absence of the "pivot" that would join this chain. That would prevent the assignment of meaning to the signifiers⁽¹¹⁾.

In Raul´s case, the father’s death is a cataclysm that unleashes the onset of the disease. At this point, the Name of the Father, not enrolled during the first encounter with the traumatic, was invoked. There is an absence that causes a hole in the meaning and starts a cascade of reorganizations of the signifier, which originates the increasing disaster of the imaginary, until the level of stability is reached between signifier and signified in the delusional metaphor⁽⁹⁾.

Raul brings his "No Reason" with his father’s death. This is also the starting point for the alcohol abuse. He places it at the start of his problems, the worsening of his situation. Something about this real father (the father of reality) has substituted\barred the invasion of pleasure. With his death, there is an invasion.

Given the distress caused by the loss of his father, Raul uses this artifice, the drinking and the bars as places where he can live, eat, and behave as Mad Beauty. Raul did not drink alone, only in the company of friends. Thus, the drinking and the constant presence in the bars appear as his attempt to insert himself in the social environment, supported by the Raul Seixas signifier.

During the treatment, I began to act as what Lacan calls "the Secretary of the Insane" by collecting the writings or just listening to him. Lacan believes that one should not reject the words of the foolish; to the contrary, this is what is the most valuable because it is the most peculiar. If we learn to listen, the delirium of chronic hallucinatory psychosis manifests a very specific relationship of the subject in relation to the set of language systems in its various orders. Only the patient can witness this with the greatest energy⁽¹²⁾.

Raul starts to systematically address his writings to me. Initially in the form of letters which parades his enigmatic signifiers. Subsequently, tells me that he wanted to write a play and it in this format that he starts to present his writings. My role as secretary will be to collect these writings, and subsequently help him organize his play. 

In this respect, helping Raul in the production of his stage play was an important endeavor. It can be said that we presented him with a place of mediation, an alternative to the invasion of pleasure. That surpassed the inventive or creative, and opened possibilities for work across the borders between the self and the other. It created limits, demarcating the action, space, and time⁽¹³⁾.

With the play, he delineates his own trajectory in the search for a new social bond. He did not forsake the bars, continues to frequent them, but now he uses other spaces as well, including the CAPSad where he plays the Mad Beauty.

Quinet notes that the social bond is made from the stabilization of psychosis, not otherwise. By simply forcing the psychotic to live outside the asylums, it will not automatically form the social bond. It is necessary to provide for an addressability place based on the treatment that he affors to the phenomena which affect him⁽¹¹⁾.

He gradually conquered his place in the house. If before he would not go inside even to eat, now he became the cook in the family, the one responsible for the food. It is noteworthy that it was not our determination of his pattern of alcohol consumption that guided his treatment. From his speech, the alcohol was perceived as an object, and the observations of the relationships established with his language structures were rather crucial to the treatment.

There were no attempts to bring the patient back to a supposed "reality", or to rehabilitate him. There was, instead, the acceptance of his testimony; a commitment which is in accordance with the ethics of desire.

Regarding Raul, it was essential to look for alternatives to prevent the invasion of the pleasure, a consequence of the lack of the Name of the Father inscription. The alcohol, the delusions, the writings, and the art appear as attempts to imprison the pleasure, which could minimally symbolize the objects.

There was always a common signifier among all of these alternatives: Raul Seixas, in the bars, in a speech about the hospitalizations, in the lyrics, and in the play. This signifier seems to have fit him like a glove, in the search for a replacement to his failure in the phallic signifier. Or rather, this signifier seems to have a perfect fit to his purposes as he follows his destiny.

 

FINAL CONSIDERATIONS

We believe that not only the nursing, but the entire Mental Health field should be better equipped to deal with the issue of the subjectivity, in the process of overcoming the outdated models that see the subjects as mere objects. This need becomes more evident when dealing with psychosis and drug addiction cases; "forcing the patient to face reality" does not offer the subject the opportunity to reverse his relationship with the object, in this case the drug. It is necessary to listen, be patient, and make sure that the treatment is guided by the speech using free association techniques, noticing the placement of the object (the drug) based on the structure, whether psychotic or not.

In the psychosis case, the secretary´s position, the receiver of productions, indicates a possible pathway for treatment. As Mad Beauty reminds us "there is a singing voice, a voice that dance, a voice that turns ...". It seems to show us a pertinent question: What are we going to do with these incessant voices that like it or not, reach our ears in the everyday practice?

 

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CORRESPONDENCE
Francisco Paiva Filho
Avenida General Osório de Paiva, 670, Apto. 103
Bairro: Parangaba
CEP: 60720-000, Fortaleza, CE, Brasil
E-mail: chicopf@yahoo.com.br

Received: Sept. 10th 2013
Accepted: Nov. 11th 2013