A Systematic Review on Compensation and Substitution in Psychosis from Psychoanalysis

Received: 09-Dec-2022, Manuscript No. CSRP- 22-84805 ; Accepted Date: Jan 02, 2023 ; Editor assigned: 12-Dec-2022, Pre QC No. CSRP- 22-84805 (PQ); Reviewed: 21-Dec-2022, QC No. CSRP- 22-84805 (Q); Revised: 30-Dec-2022, Manuscript No. CSRP- 22-84805 (R); Published: 05-Jan-2023, DOI: 10.3371/ CSRP.MMWY.100149

Introduction

Delimitation of the object of study

The object of study of this research work, of a systematic review type, has as its main axis the delimitation of the issue of substitution and compensation in psychosis based on the distinction made in the work of Sigmund Freud and the teaching of Jacques Lacan. So, we start from the Freudian reference for the present work under the question: What do the breaking glass, the dam that breaks by the force of the tide or a tearing cloth have in common? The Freudian examples are very precise, they indicate that the breaking point has its place in the structure and that it is not "capricious." But the fracture lines silently await the encounter of some contingency that reveals them, that reveals all their consequences. However, nothing prevents another equilibrium from being reached later, solutions, repairs, more or less successful attempts at healing, more or less lasting for each rupture [1]. They bear the mark of each other's unique invention, even if they sometimes present certain typical traits.

The theory of triggering present in Lacan's teaching in the 1950s is renewed in the 1970s, without losing its orientation, but it can be said, gained both clinical richness and possibilities of formalization. It is, without a doubt, the introduction of the Borromean knots where Lacan looks for the relationships between the registers that he requires. Thus, he first tried to locate the irruption of the symptom, anxiety, and inhibition as "overflows" of one register over another in a knot of three, but then, at the end of Seminar 22 "RSI", and fundamentally in the following one, "The sinthome" will be the knot of four which will allow addressing the triggers based on tying, untying and resuming. Consequently, to follow the trace of the tying and untying is also to think of the psychoanalytic clinic from a nodal ethic [2].

Consequently, it could be mentioned that in the course of Lacan's teaching two formalizations of the clinic can be distinguished: the structuralist clinic and the Borromean clinic. Concerning the study of psychosis and in light of these two formalizations, it is determined that a specific value is given. When Lacan proposes that there are psychotic structures that do not necessarily lead to clinical psychosis, he explains it through "an imaginary compensation for the absent Oedipus", that is, a compensation through imaginary identifications of the lack of the effects of the paternal metaphor. Lacan uses these notions in the 1955/56 seminar, in the brief analysis of the case of the Katan adolescent who, faced with the difficulty of assuming a masculine position, produces a typification supported by imaginary identifications with his friend. In this same seminar and in relation to this topic, he takes up Helen Deutch's concept of personalities "as if" to also account for the recourse to the imaginary as a way of compensating the structure before the unleashing [1,3].

It is through the metaphor of the stool used that he attempts to depict untriggered psychosis. He will say that it is possible that the subject, up to a certain moment, can sustain itself even without missing a leg, the signifier of the Name of the Father, but before a certain dramatic conjuncture, he will confront the subject with that defect that has always existed. We observe then, on the one hand, the fragility that the use of the imaginary acquires to remedy a symbolic defect [3].

He will say that the primitive lack of the signifier will be what the subject will have to carry with himself, what he will have to compensate for in his life, through a series of purely conformist identifications, identifications with characters that will give him the impression of what to do. to be a man concerning these patients, he will say that they sustain themselves for a while with apparently ordinary behaviors until they are not sued to account for it. What makes the imaginary crutches weak, then, is the fact that they belong to the pure register of the mirror, and in this way, the subject lacks the recourse to the phallic interpretation and the phantasy as an apparatus of jouissance, but we could assign it its function of stabilizing the structure [1-3].

As Lacan points out in 1955/1956, "psychotics live compensated" (p. 292). This last aspect, which does not acquire special relevance in Lacan's first clinic, focused on the moment of decompensation of imaginary resources, will later open the development of special interest, from the perspective of Maleval (2009) of the function of images. indelible, as well as in the program under development of the notion of "ordinary psychoses" proposed by Miller (2009) [2,4].

With the notion of triggering, a breaking point is designated in the subject's state, from which the psychosis begins with its clinical manifestations. You will realize that every unleashing necessarily has its conjuncture. The conjunctures are precisely the changing and contingent circumstances that define a given moment and mark a discontinuity in the existence of the subject.

In the text "From a preliminary question to any possible treatment of psychosis" (1958) he will propose a hypothesis about the triggering of psychosis: For the psychosis to be triggered, it is necessary that the Name of the Father, verworfen, precluded, that is to say without ever having reached the place of the Other, be called there in symbolic opposition to the subject. But how can the Name of the Father be called by the subject to the only place where he has been able to appear to him and where he has never been? By nothing other than an actual parent, not at all necessarily by the subject's parent, by One-Parent” (p. 558) [3,4].

The foreclosure of the Name-of-the-Father is the major condition of psychosis. To the extent that it involves a subject, it is a non-segregative approach to psychoses, in opposition to Freud who recognized in psychoses an objection to the transferential libido. However, foreclosure is a gateway, taking into account Lacan's latest developments (seminars 22 and 23 especially) that allow for a new clinic [4]. which means asking the question of how records are tied; how bodies can enter into a social bond, in a discourse that ties together the community or the couple. In this new perspective, the outside of discourse appears as primary, being the social bond, especially in neurosis, a supplementary operation. This operation was initially identified by Lacan as being that of the Name of the Father. This operation is lacking in psychosis, but it can also find substitutions. In this sense, the Joyce case demonstrates that what is a deficit on the side of the Name of the Father engenders both the asocial anomaly and the socializing exception, full of new forms of social ties. These forms can be catastrophic, but also therapeutic, even bearers of historical twists [5].

Starting from the notion of structure tied by the three registers, that is, as an existing knot between the real, the symbolic, and the imaginary, he points out that in psychosis the knot is undone. In this context he analyzes the madness crisis of Lol.V. Stein by Margueritte Duras, as a way in which the social bond can be broken. Two other cases that he deals with are the Joyce and Beckett case, both worked on by Lacan in Seminar XXIII, in which he addresses the substitution function that writing fulfills in the singularity of each case [6].

In this way, the theory of triggering psychosis present in Lacan's teaching in the '50s could be thought of as a very important antecedent that, without losing its orientation, was renewed in the '70s with the introduction of the Borromean knots, but gaining both in clinical wealth and in the possibilities of formalization [6]. And this is how, "The sinthome", will be the knot of four that will allow addressing the triggers based on tying, untying, and resuming [4,6].

It could be concluded by specifying the validity of both ways of considering the relationships between the records according to the particularities that occur in the clinic, not without paying attention to the two starting points that give rise to them: the onset of psychosis, in the structural clinic and the stabilizations that allow avoiding it, in the Borromean clinic.

Goal

Through the present study, it is intended to carry out a systematic review to explore the theme of the notions of compensation and substitution in psychosis from Psychoanalysis.

Methods

This study made use of the PRISMA method, following the quality steps for the systematic review. 19 items out of a total of 27 proposed by this methodology have been used. The items that were not taken into account were excluded since they refer to meta-analytic studies, and differ from the objectives of this study [7].

An exhaustive search of published scientific articles on the subject of the notions of compensation and substitution in psychosis from Psychoanalysis was carried out.

Process

Given the objective of this study and in response to the selected method, the items that were decided to include were: 1 (title), 2 (structured abstract), 3 (justification), 4 (objective), 6 (eligibility criteria), 7 (information sources), 8 (search), 9 (study selection), 10 (data extraction process), 11 (data list), 16 (additional analyses), 17 (study selection), 18 ( study characteristics), 20 (results of individual studies), 21 (synthesis of results), 23 (additional analyses), 24 (summary of evidence), 25 (limitations) and 26 (conclusions). The items that were decided to be excluded were: 5 (protocol and registry), 12 (risk of bias in the individual studies), 13 (summary measures), 14 (synthesis of results), 15, and 22 (risk of bias between the studies), 19 (risk of bias in the studies) and 27 (funding).

Different databases were taken into account, including Psychoanalytic Electronic Publishing (PEP), PubPsych, Dialnet, Network of Scientific Journals of Latin America and the Caribbean, Spain, and Portugal (REDALYC), Directory of Open Access Journal (DOAJ), National System of Digital Repositories (SNRD) and Regional Health Portal Pan American Health Organization, in which the treatment given to the research axis was investigated in different ways. At first, the theme was addressed in a general way without prioritizing specific filters of interest for this work, as well as without specifying special conceptual operators. Once the information collected in the different databases had been evaluated, the decision was made to approach the investigation exclusively through the search filters applied and using conceptual operators for each database, since the results obtained were more rigorous and specific for the subject to deepen [6, 7].

Search terms

After selecting the definitive databases, a first search was carried out on the construct selected to search for the research framework, namely: compensation and substitution in psychosis. Namely, variants were used according to the database in which the search was carried out.

The conceptual operator "compensation and substitution in psychosis" yielded a total of 56,784 analysis samples, individually adding the results of the seven databases mentioned above. As can be seen, the Flowchart accounts for the filtering process through various conceptual operators as well as the particular process that has been administered to each of the databases [8].

In REDALYC and DIALNET, the operator used for the search was "substitution and compensation in psychosis". While in DOAJ, Portal, and SNRD it was "substitution in psychosis", as well as in Portal the search was carried out with "compensation in Psychosis". While, in the English databases, PEP and PubPsych, the following were used: in the first, “compensation in psychosis”; and in the second, “compensation in psychosis + psychoanalysis” [9].

Once the topic was searched in the chosen databases, specific filters began to be used and the inclusion and exclusion criteria appeared. Of the corpus of works, the delimitation carried out included: Language: Spanish and English according to the database; Publication date: 2022-2010; Disciplinary study areas: Psychology; Countries of publication: Argentina, Spain, Mexico, Colombia, and Uruguay. The texts to be used would be scientific articles and full texts and articles published in conference proceedings. The amounts were quickly modified after the application of these filters, yielding considerably lower numbers [10].

Once the articles had been analysed in depth, the definitive screening was continued, taking into account criteria of specific relevance to the investigation. Subsequently, the final results were released.

Regarding the keywords, the distribution percentages according to the databases have been: PUBPSYCH (0.002%), PEP (0.002%), DIALNET (0.004%), DOAJ (0.002%), REDALYC (0.005%), Regional Portal in Health Pan American Health Organization (0.005%) and SNRD (0.005%).

In total, from the beginning, 56,784 analysis samples were obtained, 56,770 were excluded and the total number of articles surveyed was 14 (0.025% of the initial number). Of this number, there is 1 duplicate article (0.002%) in the different databases used. Therefore, 13 scientific articles (0.023%) have been worked on as shown in Figure 1 [11].

Figure 1. Flowchart

Results

Considering the types of studies, the works consulted to have an interesting variety of approaches and methodologies, which allows access to the problem from different points of view and in considerable depth. There are thirteen descriptive studies with different characteristics: descriptive studies and critical analysis, exploratory and descriptive studies, exploratory and analytical studies, as well as a review of a state of the art and approach proposal as shown in Table 1.

A plurality of scientific articles was found, where the differences lie in the readings of the experiences of the research group. On the other hand, studies focused on the analysis of clinical cases of world-renowned personalities were found, as well as the review of the foundations of FreudoLacanine psychoanalysis.

Discussion

According to what has been revealed in the studies consigned in this work, the field of psychoanalytic practice and theory is a topic of special interest and debate. Thus, relevant aspects can be highlighted in this work.

It is necessary to underline that the psychoanalytic clinic is a clinic that places its intervention in a pathological field, while the starting point is the symptom, that which, as discomfort, maladjustment, and imbalance, is always referred to the prevailing discourse, its norms, and values. From this perspective, the symptom is always presented initially in its pathological aspect as "what does not work" as Lacan puts it, or as an "interference" as Freud put it. In other words, it is what Freud called "disease in a practical sense", while the subject who suffers from it complains of his impotence to make things continue as before without being able to get rid of what hinders the normal course of his life. . In this direction, we must remember that notions such as "clinical morphology", "symptom", "etiology" and "pathology" are used by Freud in the course of his work. We are then interested in underlining the new meaning that these terms acquire in Psychoanalysis, terms that Freud uses to organize the novelties that he finds from the originality of his practice [9,11]. It is of interest in the sense that the very notion of "clinical category" acquires, in solidarity with a rupture of the normal-pathological opposition that is at the foundation of psychopathological perspectives before Freud and that persists to the present [12]. From this point of view, and many of the authors taking up the position of Zanchettin (2012) and Zanassi (2009), we adopt as the axis, the definition of clinical structure proposed by Lacan, but we problematize the approach to schizophrenic psychosis in terms of the deficit, sustaining the transgenic character of the concepts that found the Freudian-Lacanian psychoanalytic field. Supported by the hypothesis that the subject in schizophrenic psychosis inhabits a field of images whose fixity paralyzes the body in a kind of dismemberment, we investigate the framing, the relevance, and the efficacy of a modality of clinical intervention that aims at the "montage of the frame of the scene" in the psychoanalytic treatment of schizophrenic psychosis [12, 13]. So, in this sense, the concept of clinical structure allows situating different subjective positions in the relationship with the Other in the one who registers, thus differentiating neuroses and psychoses, without lines of continuity. in the distinction of the structures are three forms of negation: repression, denial, and foreclosure, corresponding to neurosis, perversion, and psychosis. In the first part of his teaching, the analytical clinic is structured from discontinuous criteria, dependent on the very status of the signifier and the chain that orders it in differential and relative terms [14]. Twenty years later, Lacan opens a different perspective, especially regarding the concept of psychotic structure. Starting from the Borromean reference, he does not emphasize the concepts of repression or foreclosure, but the types of knotting of the symbolic, imaginary, and real registers. The subject is a trinitarian compound, hence the importance attached to what allows the records to be kept together. The presentation of the Borromean knot includes three roundels of rope that are untied at the beginning and are equivalent, so a fourth roundel is necessary for the knotting to take place. This fourth roundel is the "plus one", the knotting itself, "the sinthome” [14].

According to Ramirez Escobar (2008), when speaking of the cause of psychosis, Lacan psychosis has a particular production mechanism. It is the result of a foreclosure (verwerfung) that affects a specific signifier, the Name-of-the-Father, which situates it from the outset in relation to the word as cause. The signifier Name-of-the-Father orders language, and with it the world and the crucial questions about existence, such as sex, life, and death. But it must be known that the absence of the Paternal Metaphor does not automatically lead to the triggering of psychosis, but that certain conjunctural conditions will be necessary for this triggering to arise, defined as those in which the psychotic summons the Name of the Father and that answers it is a pure hole, since it cannot answer what has never been. Continuing, at the origin of the unleashing will always be the presence of a Real father; It is the moment in which the substitution, which until then had functioned as a remedy for the failure of the Paternal Metaphor [13,15].

The structuralist Lacan of the '50s understood psychosis as deficient, therefore, susceptible to compensation. Thus, substitution and deficit were inseparable in psychosis. Said time is the time of the primacy of the Symbolic over the Imaginary and the Real, also giving priority to the Name of the Father. In this regard, Lacan in his text on The Significance of the Phallus clarifies the following: "In the dynamic structuring of symptoms in the analytical sense of the term, we mean what is analyzable in neuroses, perversions, and psychoses." (1985, p.665) From what we see, at this moment, the symptom fulfills a metaphor function on the same side as the formations of the unconscious, that is, it corresponds only to the imaginary and symbolic registers. The work scheme of the symptom starts from the model of neurosis to go toward psychosis [16].

The knot clinic will study, then, how each speaking being ties the three registers that make it up (RSI), which by structure would be loose, both for neurosis and for psychosis, and whose suture both perform in a different through a fourth knot, always present, that Lacan will name in Seminar XXIII: The Sinthome. It will be in this seminar that Lacan will introduce the symptom as one of the possible forms of knotting; substitution thus ceases to be something exclusive to psychosis to become a general phenomenon of the parlêtre [5,17]. This implies that the substitution is no longer what responds to the deficit of the Name of the Father of Oedipus, but what keeps the three registers together, untied from the outset. The topology of the knot will deal with the chaining and unleashing processes between registers, it will be what condenses and locates jouissance as the remainder of a lost real, which entails a redefinition of the term symptom. Said term will no longer be an attempt to decipher starting from the Other. From now on the symptom will take its reference from the real, which allows a generalization of the foreclosure including the neurotic symptom as the particularity of treatment of the real by the name of the father. The symptom will therefore be a generalized substitution to regulate the relationship of the speaker with jouissance [18].

In terms of substitution, stabilization, and compensation, Llull casado (2020) follows the path of Deutsch that Lacan himself (1955) takes when he places the importance of imaginary identification in the compensation of the schizophrenic structure. However, it would be important to establish how the imaginary identification of the subject under some of the modalities described by Deutsch can function as a knot that prevents or delays the onset of psychosis [17,19].

The opposition between the discretion of psychosis and the notable of work, or in other words, of the ordinary of one and the extraordinary of the other, constitutes a point that it is necessary to question regarding ordinary psychoses in general. As Miller (2009) stated when considering this term, these do not constitute a clinical entity per se but rather a signifier that delimits a field of very diverse clinical problems that share the trait of presenting discrete psychotic phenomena that can reach the point of difficult to be recognized or delimited [14]. He included in this field compensated psychosis, supplemented psychosis, non-triggered psychosis, medicated psychosis, psychosis in therapy, psychosis in analysis, psychosis that evolves, and psychosis without symptoms [20].

It is so, Galiussi; and Godoy (2019) points out that artists and thinkers have provided valuable written testimony by examining their own experience, giving an account of the phenomena they suffered and how they were intertwined with their creative processes. That is why Aguirre (2012) investigates Van Gogh and the resources that enabled the artist to provisionally remedy the symbolic deficiency, taking autobiography as a clinical case [1, 21].

So, it should be noted, as Baur (2012) does, that the terms stabilization, substitution, and sinthome appear frequently in clinical works and elaborations about psychoses. Ferreyra (2019) mentions the existence of different theoretical references regarding psychotic decompensation, for example, Garró (2015) expresses that in neurosis we can think of urgency from fantastic vacillation, while in psychosis moments of urgency go from the hand of unleashing and destabilization [22].

We return to the importance of the topic proposed here, as Fachinn (2016) points out, multiple clinical phenomena cannot be easily classified as neurotic or psychotic; can be considered as 'fuzzy' [5]. Contemporary Lacanian perspectives can offer theoretical and clinical tools to clarify and treat these 'fuzzy' clinical phenomena [23]. The aim is to provide an understanding of clinical situations that are no longer "rare cases", but require an approach that emphasizes the flexibility of treatment and the uniqueness of the subjective devices that allow jouissance to be administered.

Finally, different lines of research are presented based on the material collected:- To understand in a broader way everything that is implied by the non-establishment of the phallic signifier as a regulator of all jouissance, therefore, and in order to articulate this issue with the possible cause or weakening of the social bond currently evidenced and promoted due to globalization, like that contemporary symptom, which in turn generates, a type of generalized foreclosure leads us to rethink this conception from a current perspective, anchoring it to the demands evidenced today, demands that mark a trend in the postmodern subject, crossed perhaps for a unique jouissance that leads him to be visualized as a subject who enjoys his own unbridled jouissance, leaving aside that essential signifier that alludes to the paternal metaphor as regulator and bearer of the law, which proposes a rethinking of himself in the capitalist discourse, one could speak of a drop in the name of the father, since the changes in the current social bond come from capitalism, which, without a doubt, g It was a looseness of that bond. The foregoing allows us to conceive a current subject moved and traversed by technoscience, postmodernism, and globalization, by the new forms of "modernization" that fulfill a blurred function of the phallic signifier par excellence, where each subject manages it arranges with its way of jouissance, thus annulling the need for the other and the Other as guarantor of language, to then make room for a new type of “foreclosure”, that is, a “generalized foreclosure”.

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