Raquel Souza Lobo Guzzo
The authors declare that there is no conflicts of interest.
The article aimed to study the subjective configurations of a person diagnosed with cancer based on the theoretical framework of the Theory of Subjectivity in a Historical-Cultural perspective as proposed by González Rey.
For this purpose, the constructive-interpretative method was used, guided by the principles of Qualitative Epistemology, which consider the development of knowledge as constructive-interpretative production in its singular and dialogical scope. In the development of the investigation, individual conversational dynamics were used.
The results presented describe and explore how the creation of a dialogical space as a facilitating tool for new subjective productions is essential for promoting ways to minimize psychic suffering. The favorable context allows for the expression of experiences and emotions that significantly contribute to the reduction of psychic suffering.
In this perspective, it was important to understand the human experience in a complex and singular way.
O artigo teve o objetivo de estudar as configurações subjetivas de uma pessoa diagnosticada com câncer com base no referencial teórico da Teoria da Subjetividade em uma perspectiva Histórico-Cultural, proposta por González Rey.
Para esse propósito, foi utilizado o método construtivo-interpretativo, norteado pelos princípios da Epistemologia Qualitativa, que considera o desenvolvimento de conhecimento enquanto produção construtiva-interpretativa em seu âmbito singular e dialógico. No desenvolvimento da pesquisa foram utilizadas dinâmicas conversacionais individuais.
Os resultados apresentados descrevem e exploram como a criação de um espaço dialógico como ferramenta facilitadora de novas produções subjetivas é essencial para promover formas de minimizar o sofrimento psíquico. O contexto favorável permiti a expressão de experiências e emoções que contribuem significativamente para a redução do sofrimento psíquico.
Nessa perspectiva é importante compreender a experiência do ser humano de forma complexa e singular.
Chronic diseases are topics that encompass a fertile field of study that has been explored recently by both medical and psychological science. Cancer, being a chronic disease, crosses different psychology domains. Those are fields of activity that often become just another ancillary arm of Medicine, leaving aside the unique aspects of human experience. Thus, the development of new subjective resources is important in the treatment process, so that this experience can be configured with better quality (
The understanding of health is largely based on the traditional biomedical model, which epistemological and practical perspectives contribute to the invisibility of subjective processes, legitimizing immediate diagnosis. In this understanding, the human is an object, characterized by its inexpressiveness and immutability, and the health professional is “trained” to selectively listen to the report, which is then transformed into statistical and symptomatic reading. The ontological and cultural lack of health-disease processes hinders new creative ways for the individuals to position themselves in the world (
The natural form of the disease social representation can make it difficult for individuals to produce distinct subjective productions to deal with the consequences of cancer diagnosis in a person’s life, sometimes causing crystallizations in the individual’s life, such as isolation, loss of appetite, boredom, fear, among others. For many patients, cancer can mean the end of life. According to
In our investigation, we will discuss the relevance of psychotherapy as a possible alternative for people who go through the process of cancer, from a historical-cultural perspective, in the light of the Theory of Subjectivity proposed by
Subjectivity is not only evidenced and measured. In this theoretical body, the subjective phenomenon can also be analyzed in light of the construction of information that supports hypotheses of an experienced reality that theoretically create cores of meaning that guide the understanding of the psychological phenomenon reviewed. In this sense, psychotherapy aims to be an interventional alternative, even if ideal, to open a crack in the beliefs and social pressures. A social microcosm in which people can imprint their existential characteristics to develop, create, and recreate their own reference axes (
The Theory of Subjectivity opposes the positivist perspective of understanding the phenomenon in an immediate and casual way, as is commonly inferred in hospital and clinical realities from the perspective of solving the problem based on the disease. For the Theory of Subjectivity, social subjectivity is an important phenomenon, as it helps to understand the organization of social spaces and their developments in processes of singular subjectivation in the experience of living with cancer. The human, in the Theory of Subjectivity, is not the reflection of these social subjectivities. The individual is the producer of his/her subjective processes, considering the unity of the symbolic-emotional, traversed by the social subjectivities that qualify individual subjectivity. This generates organizations of diverse social spaces, capable of configuring new individual subjectivities.
Subjective production is understood as an elementary character of the symbolic-emotional unity formed in the historical, cultural and social experience that are interrelated in the individual experience. This symbolic-emotional unity is understood as a subjective sense that integrates in a plural way network of subjective senses that qualify the systemic phenomenon of subjective configuration (
In our work, psychotherapy seeks a broader clinical perspective that encompasses the understanding of social-individual phenomena as inseparable in their authentic and singular process. Considering that, in the experience of oncological treatment, the individual can produce harmful subjective senses, by experiencing processes of subjective singular devaluation, which can generate dullness for alternative productions of what is experienced. In these cases, the individual’s subjective configurations can be a source of subjective senses that unfold into a chronic situation of suffering (
The theoretical line in this research provides evidence of the human being as the protagonist, active and creative in his/her actions in the world, leaving aside the reductionist explanations by biological determinations, of social exclusivity and intrapsychic. Therefore, this work is based on the Theory of Subjectivity with view at thinking about health from another angle, with the objective of understanding the subjective configurations in the experience of living with a cancer diagnosis.
This study is based on Qualitative Epistemology and the constructive-interpretative method of
The participant Heitor (fictitious) is 30 years old, has a law degree, is single and lives with his mother and sister. He has had two types of cancer, the second of which was a recurrence. Heitor was diagnosed with cancer in 2015, after having a coughing fit. The participant signed the informed consent form. The investigation was approved by the Ethics Committee under opinion number 3.104.791/18, at the 23rd Ordinary Meeting of CEP-UniCEUB of the year, on December 14, 2018.
The instrument chosen was: Conversational dynamics. In this instrument, the surveyor uses general topics, with the aim of involving the investigation subjects, in order to comply with the themes of interest (
Heitor was referred by a psychologist, a specialist in psycho-oncology, and monitored for the production of the investigation for four months. The research site was the University Center of Brasília (UniCEUB). The information from the dynamics was treated and analyzed through an episodic selection and organized for the interpretation of the subjective contents throughout recaps of the experiences of the dynamics. The construction and interpretation of the information were carried out through the researcher’s descriptions of the characterization of the social context, life history, the forms of affective expressions in relationships and their developments and effects of the oncological scenario in the production of his subjectivity.
In the meetings with Heitor, the topics that were expressed spontaneously referred to the importance of being welcomed by health professionals; the family as a mobilizing factor; and the naturalness of illness and death. Some excerpts from our conversations can illustrate how the participant expressed himself on the topics addressed.
During the process of establishing the diagnosis, Heitor said he was not very shaken. When we spoke about the subject, he clarified:
Surveyor: What was it like for you when you were told the diagnosis? Heitor: “I had no problems [...] For me it was a calm thing [...] I have always tried to spare my mother, my family, my sister. They are also a more desperate people”.
Heitor talks about the peace of mind he felt when he received the news of the diagnosis to spare his family from worry. We can raise an indicator related to protection and care for the family. Caring for the family expresses subjective resources so that he can deal with the adversities that are usually generated when the diagnosis is communicated. The way in which the health professional communicates the diagnosis is extremely important. It is common for people in this situation to generate intense emotional states when faced with a cancer diagnosis, whose social subjectivity sows subjective feelings related to fear, pain and uncertainty (
When Heitor arrived to start our conversational dynamic, he was already aware of the situation regarding the research context and the topic to be addressed. The way he introduced himself was so confident and calm that it caught my attention. “It’s about cancer, right?” and I replied “yes”. It was then that I raised the question of exploring the moment when the diagnosis was discovered. Although the question raised had not been planned based on my preconceptions, I found it interesting to start from what he proposed.
What Heitor said generated an involuntary response expressed by a “Wow!” that took shape in stereotypical social subjective productions of how the moment of communicating the diagnosis should be. Soon after, Heitor smiled with an ironic and mocking air, as if my involuntary response was already something expected. At that moment, I thought “what if this way of behaving is a fallacy?”, the fear seemed not to resonate, not only in what was said, but in his expressions. However, the dialogic process is not guided by truthfulness on the part of the psychotherapist/researcher. The role of the psychotherapist is, from the perspective of the Theory of Subjectivity, to understand how the subjective productions in the context are configured in the life of the individual and in his history.
In this sense, the psychotherapist’s subjective productions generated in the dialogue process are of utmost importance, when well-managed, since the psychotherapeutic setting is a singular social subjective configuration organized in the dyad. Thus, the subjective productions of one individual can provoke new subjective senses in the other. In this case, Heitor generated subjective senses distinct from the hegemonic social subjective productions in relation to what should be a cancer patient. Heitor was able to demarcate the way he wanted to be treated and seen. Therefore, an atmosphere of trust, tranquility, and an ironic and mocking smile can be articulated with the indicator related to family care and protection. This construction gains strength in the following statement by Heitor:
Heitor: [...] I think it was because I made an effort to be well. She (mother) was well. I think I always dealt with this idea that I need to be well for my home to be well. What gave me strength, I think, was preserving what I already did i.e., sparing my mother and sister.
In this excerpt, there is a repetition that occurs at a different moment in our dialogue in which Heitor seems to be more involved in the process. We can construct an indicator related to ideal care. Heitor produces subjective senses articulated with the social subjectivity of understanding that the care provider needs to present healthy dimensions. For Heitor, his mother and sister do not have the psychological conditions, like he does, to deal in a healthy way with what he is going through. This is expressed in subjective senses of causality “I need to be well for my home to be well”. In this way, we can understand how Heitor’s family context is configured, guided by the social subjectivity of the biomedical model that seems to feed back into the subjective productions of his mother, his sister and Heitor himself, in the sense that his well-being causes the well-being of others.
Repetition in the dialogic process is important to be noted, not for the sake of standardization, but to have a sensitive eye for nodal points that are similar and at the same time different. At first, Heitor confidently reports that he had no problems at all, and then he talks about an effort that gives us an idea of constancy in preserving the people he loves. I think about the impossibility of continuous efforts without flirting with some problem. This does not seem to be restricted to the experience of oncological treatment, as Heitor himself expresses “since always” and “I always tried”. If there is effort, at some point it becomes fatigue. There is an indicator of emotional dullness that seeks as a means to not reveal his insecurities and fears, a desire to demonstrate security. It is in this aspect that the development of a space dedicated to the individual becomes pertinent. Dialogue is the essential tool for the personification of this space, so that the person can create an authentic and reflective context of subjectivation possibility, with the psychotherapist as the facilitator. In the meantime, it is also possible to have a representation of his subjective configuration in the relative stability of the production of subjective senses of how to act in the world when faced with a destabilizing situation. Heitor prefers to protect others from his anguish rather than share it for fear of the effects on others when expressing his vulnerability. Cancer is a disease whose diagnosis is characterized by predictive stigmas, capable of generating subjective senses that corroborate a dominant passive social subjectivity in relation to the disease. It is in this social subjectivity that Heitor lives within his family framework. However, he has a different attitude towards the diagnosis because he has got no restrictions to talk about the subject. Heitor exemplifies this in a situation that occurred at home:
Heitor: I was never afraid of it at all. I wasn’t anxious, I never questioned it, I never had any problem talking about it. So much so that when we found out, this cancer being the second one, my sister was at home and she said: ‘Guys, please everyone leaves, so that my mother, my brother and I can talk’. I got angry and asked her to call everyone back, that there was no reason for all this.
The participant expressed some irritability in his voice when recounting this memory, stating that there was no need for everyone to leave. We can construct an indicator of non-victimization in the diagnosis, due to Heitor’s attitude in asserting himself in front of his family. At this point, there is a marked ambivalence, which gains intensity due to its emotional nature. Heitor does not want to reveal his insecurities, his anxiety, his questions. Each story, each memory evoked, is followed by a request and an appeal. Heitor tries to co-opt me; he tries to make the space for dialogue similar to the world he experienced with his mother, sister and friends. In his emotional numbness, he does not want to be part of the world of the disease, he does not want to be seen as helpless, he does not want his world to stop because of the disease, he wants to continue living as if the disease were not present, so that he does not look at himself with the same eyes as others and feel his own insecurities. People who go through this experience end up in processes of great isolation a situation enhanced by the people in their social circle who do not know how to deal with the situation very well.
Furthermore, the indicator constructed corroborates the indicator of family care and protection, since the articulation of both is what seems to support a position of non-victimization in the face of the diagnosis. As Heitor himself indicated the need to be well so that his home could be well. The social subjectivity of Heitor’s family context is configured in his individual subjectivity that generates subjective senses that mobilize him to place himself in this social subjective configuration as an agent of change and control so that his mother and sister become less worried and disrupted expecting that they will accept the treatment process more naturally.
Humans are unpredictable and active in their subjective productions, always generating subjective senses in their social spaces, which enables them to change themselves and the context in which they live. It is important to emphasize that this change is not something immediate; on the contrary, it is a mediate process, full of implications. In Heitor’s case, preserving this context is linked not only to issues involving the family, but also to his role in this family. It is not cancer that makes people retreat because of its own harmfulness, but rather the way in which this experience is subjectivized. This shows us the importance of dialogue in order to open the possibility of a reflective and singular context. In Heitor’s case, so that he can have a space that allows him to feel his insecurities, anxieties, fears and helplessness.
Heitor began to talk about his father, who had passed away a few years before. As he spoke about his father’s characteristics, an atmosphere of admiration and great influence emerged in dealing with life’s adversities.
Surveyor: Do you live with your mother?
Heitor: I think I accepted this burden more [...] because when my father passed away, he was the peacemaker at home. He was much more of a leader. I think he had this mindset of mine of projecting good things [...] Sometimes I think of my father as a role model. Of course, I would change a few things.
In this dialogue, it is possible to understand the articulation of the previously constructed indicators: non-victimization and care for the family. Considering that during the conversation, Heitor shows great admiration for his father, to the point of wanting to take on the paternal mantle and assume his striking characteristics. Memories of his father become subjective resources to produce new ways of experiencing the diagnosis and other life situations. He assumed the role of the responsible person who seeks to alleviate and resolve the family’s conflicts. The relationship that Heitor had with his father was very significant, to the point of impacting his individual subjective configurations.
The element of “absence” is relevant to be highlighted in the dialogue process. Sometimes, it can transform certain motivations that give meaning to the person’s actions. An interesting aspect is that Heitor had not yet mentioned his father, even though he mentioned his family several times. When making an analogy, it seems that the mother is related to subjective feelings of duty, responsibility and care, while the father is an ideal to be achieved. This point demarcates his affective logics of subjective functioning that resonate with his subjective configuration of the way he is and lives his experiences in the family and in other social spaces. The figure of Heitor’s father appears during the dialogue when there is an absence of inputs of organization, security and serenity. Characteristics that make him remember, and are subjectively associated with, the image of his father.
Another important issue is to contextualize the term “memory.” In the context of psychotherapy, mnemonic processes are not just an image and iconographic reproduction. Mnemonic processes are connected to the network system of subjective senses that are related in people’s plots in such a way as to express a subjective quality in the content of what is said and reproduced. In the present case, we can understand that Heitor, when describing his father, evoked positive elements that he would like to maintain and overshadowed aspects considered negative. We perceive in Heitor’s subjective productions the connection with the analogy of his father, an ideal to be achieved. In other sessions, Heitor spoke of these negative aspects only by stating “he was a little rigid,” however, he did not denote any aversive or worthless appearance. Therefore, a fine detective perspective is not appropriate here to reveal the truth of these facts, but rather to seek to embrace the emotionality that is expressed in order to guide the subjective senses that calcify the way of being and seeing one’s world (
In the following sessions, Heitor expresses information that refers to his position as a “problem solver” in other areas of his life. He explains his interest in volunteer work in hospitals, with homeless people and teaching classes for illiterate elderly people. These are jobs that he began before undergoing cancer treatment and that he continues to do today. This dialogue was explored in an informal context.
Surveyor: I would like you to explain more about this.
Heitor: I have done it and I still do. I was teaching classes for older adults. I participate in an organization that collects a lot of donations of clothes, toys and everything. And they set up a store [...] I have already participated in the Laces of Joy. The organization where you participate by dressing up as a clown and go visit the hospital.
That day, the topic of work came up, because at the time our discussions seemed to be too focused on the issue of diagnosis. So, I asked him about his experiences as a lawyer, and he bent his head and said, “I took on some small cases. But I had difficulty adapting”. An embarrassed smile took over his face and his words were uttered at a different pace than usual. There was a brief moment of silence and he said, “But I had some cool jobs”. It was at that moment that I wanted to remind him of his volunteer work that he had mentioned in an informal moment.
Soon after that, the subjects seemed to become independent, one emerging from the other, from philosophy, literature, history and mental health. Time seemed not to comply with the laws of nature and we had created our own time-space. This is the difference between just communication and/or conversation and a process of dialogue. A kind of “trance” that suspends, at the moment we are emotionally engaged, our physiological needs and our spatial orientation.
Heitor’s mother is a pragmatic woman who doesn’t care whether or not he enjoys working as a lawyer. The important thing is to work, “even if it’s 24 hours a day” (sic). Subjective social productions in relation to functionality and productivity mark social roles in our culture, and so people who do not incorporate these requirements may be subject to judgment regarding their mental health, for example. In the works of
Heitor’s movement towards an independent path is notable. His subjective productions seem to delimit his space and the desire to preserve it, in the family context, in the group of friends, in my relationship with him and in volunteer work. However, if he appears to create spaces of intelligibility, what reasons have restrained Heitor from doing the same as a lawyer? Law in the Brazilian scenario, historically and culturally, is characterized by social subjectivities of economic power and control of norms.
At another point, Heitor describes the consultation with the psychiatrist recommended by his doctor because of the intense experience he had been through in the Intensive Care Unit.
Heitor: I went to the psychiatrist and said that I was planning to study for a public servant admission exam. The psychiatrist said that I couldn’t make any plans, because I was an oncology patient. I should only hold on to three things: family, friends and religion. She also diagnosed me with an International Statistical Classification of Diseases and Related Health Problems – Intensive Care Unit, which was about escaping from reality.
It is possible to think that Heitor, despite the limitations imposed by others, still produces subjective senses in relation to having a job, starting a career, being independent and having expectations for the future. This implication is linked to the constructed indicator of non-victimization. The psychiatrist, on the other hand, is trapped in the dominant social subjectivity of processes universalization and standardization that limit him to his disease. In this scenario, it is possible to understand that the expression of subjectivity goes beyond attitudes, behaviors, actions and language. It is interesting that the professional at no time, according to Heitor, opens up a possibility for dialogue regarding his interests. Much less, did she consider asking what had happened for him to be there in front of her.
The dialogue becomes an invitation to reflect on phenomena that are simultaneously latent and tangential in the subjective processes of human life. The process of dialogue is to return the brush to the artist so that he can authentically paint his blank canvas again and be able to rediscover his own style. In the process of analyzing Heitor, it is possible to understand certain similarities that one would associate with the repeated brushstrokes of an artist, but which, as they are repeated, express different subjective senses. If we follow this logic, the professional wanted to take the brush from Heitor and paint on the blank canvas that was foreign to her in every sense.
Through this experience, Heitor was able to gain confidence and position himself, which allowed him to develop new subjective feelings as he lived through the disease. So, I asked him if anything had changed in the way he lived his life. Heitor stated:
Heitor: “I think this inconsistency is cool. I think if we knew, we would do everything wrong. It would mean redefining a lot of things, much sooner... As with cancer, no one can be in anyone else’s shoes. Maybe the clinic should even invest in this, right? It’s very subjective”.
In this excerpt, we can infer about the value given to the present moment of experience during the oncological treatment process. Furthermore, we are able to construct an indicator regarding the implications of existential colonization. It is interesting that Heitor in this dialogue expresses the value of the subjective as a way of promoting an ethical space in relation to the other and to himself, when he states that he is ignorant of what the other feels. The suggestion proposed by him becomes relevant due to the production of a space that promotes this singular rectification of the individual; the reasoning corroborates the construction of a psychotherapeutic space that is significant for this reality.
In this study, we can understand the complexity of this phenomenon of illness beyond the symptomatic issues of cancer diagnosis. The Heitor case described here shows us the importance of a welcoming approach by health professionals, as a way of facilitating the production of subjective senses that can express some dimension of safety and support. In this regard, we could perceive the social subjectivity articulated with the biomedical model, in the context of the Intensive Care Unit, generated from the production of subjective senses of objectification and lack of otherness in the face of the need for care.
In this case, the relevance of having an interrogative stance towards the understanding of health and the healthy being is also exposed. We saw that the ideal of health and its representations in culture, in social spaces and in individuals have their repercussions on the way the “sick” person is treated for the illness, for the control of symptoms, which culminates in a universalization of the care of the illness and an inhibition of subjectivity. The personification of the illness generates a hypotrophy of an existential and subjective plane of creating and accepting new ways of living life.
During the analysis, it was possible to construct and interpret elements that formed and organized Heitor’s individual subjective configuration in the face of his oncological clinical condition and his subjective resources to deal with this experience of illness. In addition, the foundations of the social subjective configurations of his family and health institutions were constructed and interpreted. Heitor’s subjective configurations have as their backbone a reproduction of the paternal atmosphere that flirts with security, emotional stability, with alternative reflective traits, of considering positive possibilities in situations of conflict, with ways of thinking that disassociate themselves from the victimization of the treatment situation and concern for caring for others, always placing themselves in a position of antithesis to the representation of the oncological patient. From his perspective, both the social configurations of his family and the health institutions groped for care in the face of a representation of the patient as an impossibility to live a life that fosters productions of exclusivity for the behavior of the disease.
The dialogue tool, administered throughout the conversational dynamics, exposes, through the indicators constructed in the analysis, a mosaic that touches on the importance of the dialogical stance. In the case presented, Heitor’s stance is constantly reactive to family and institutional imperatives regarding how he should behave in the face of his illness. When going through these social instances, he presented a feeling of lack of legitimacy regarding how he was living the experience of illness. In addition to feeling misunderstood, Heitor felt surrounded by control devices to the point of not wanting to feel enclosed in his own illness. At this point, the expression of the dialogic tool as a facilitator of new productions of subjective senses reinforces its relevance in this analysis due to Heitor’s desire traversed throughout his entire illness experience, from the moment of communication and discovery of the diagnosis, until his moment of synthesis regarding the appreciation of the singularity of the experience of cancer. Throughout his analysis, there is in the expression of his subjective configuration a desire manifested by the appreciation of a space that has no locus, the recognition of his singularity.
The relevance of the Theory of Subjectivity in understanding this phenomenon provides a perspective focused on subjective processes that are generally sidelined. The theory allowed us to understand Heitor’s subjective configurations and their development during the course of his oncological treatment and the subjective resources produced by him. This was possible thanks to the dialogic space built with the participant in an authentic way that provided an understanding of the relevance of dialogicity and the psychotherapeutic process as a phenomenon generated from the engagement of the investigator-participant dyad.
To this end, further studies are needed that value the production of this dialogic space as a psychotherapeutic space, especially in this context and theme of chronic diseases that increase in incidence every year. Therefore, it is very important to welcome the singularities that come with the experience of oncological treatment, with the aim of facilitating alternative emergencies in the face of the diagnosis for the development of current life projects.