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[pt] O presente trabalho tem como objetivo investigar a problemática do trauma a partir do paradigma inaugurado pelas contribuições teórico-clínicas de Sándor Ferenczi, e que foram, posteriormente, desenvolvidas por Michael Balint e Donald Winnicott. Para isso, na primeira parte desse trabalho, apresentaremos as noções de trauma, nas perspectivas teóricas de Sigmund Freud e de Ferenczi, destacando as suas principais diferenças. A partir da compreensão ferencziana do trauma, abordaremos as principais modificações técnicas propostas pelo autor. Essas modificações serão tomadas como base para discutirmos, na segunda parte, a maneira pela qual Balint redefine a teoria sobre os primórdios da constituição subjetiva, principalmente, a partir das definições de amor primário e de falha básica. Essas concepções implicarão em uma revisão da técnica psicanalítica, no sentido de reconhecer e manejar fenômenos clínicos que remetem aos momentos iniciais de subjetivação. Na terceira parte, apresentaremos a compreensão de Winnicott sobre a experiência traumática, entendida como reação às falhas ambientais, assim como a compreensão de seus efeitos no processo de amadurecimento emocional. Além disso, discutiremos a maneira pela qual Winnicott define o espaço analítico, o manejo das regressões e o uso das interpretações. Por fim, na quarta parte desse trabalho, destacaremos, a partir desses três autores, alguns elementos que podem ser tomados como coordenadas teórico-clínicas para pensarmos a especificidade de uma clínica do trauma. / [en] Our investigation aims to research how the notion of trauma was described in Sándor Ferenczi s works and to relate his contributions to Michael Balint and Donald Winnicott s later developments. To achieve this objective, in the first part of this investigation, we will introduce the notion of trauma in both Sigmund Freud and Ferenczi s works, aiming to highlight their key differences. We will then discuss the main technical adjustments proposed by Ferenczi. Based on this discussion, in the second part, we will investigate the manner through which Balint redefines the early moments of the constitution of subjectivity, based mainly on his notions of primary love and basic fault. This new approach will lead us to a revision of the psychoanalytic technique, whereby the identification and clinical handling of clinical phenomena are referred to the early moments of the constitution of the ego. In the third part, we will discuss Winnicott s understanding of the traumatic experience, conceived as a reaction to environmental flaws, as well as the effects that these flaws will have on the process of emotional maturation. We will study the manner through which Winnicott defines the analytical setting, clinical handling of regressions in analysis and the use of interpretations. Finally, in the fourth part of this thesis, we aim to extract, from these authors, key elements that could be used as theoretical and clinical references for defining the specificities regarding the approach of cases pertaining to early trauma in psychoanalysis.

[pt] A presente dissertação propõe-se a realizar um estudo teórico, a partir do referencial psicanalítico, sobre a sensorialidade no processo de subjetivação e na clínica. Dialogaremos com a noção de sensorialidade desenvolvida por Alberto Konicheckis, que a compreende como a multiplicidade de experiências psíquicas que decorrem dos órgãos dos sentidos. Trata-se de um conceito complexo e ambíguo, que está situado em uma zona de entrecruzamento entre o dentro e o fora, o eu e o outro, o íntimo e o compartilhado, já que o sensorial é despertado pelo encontro do corpo do bebê com os objetos externos. Compreendemos que a sensorialidade tem primazia na primeira infância e que a constituição psíquica parte de processos sensório-perceptuais e rítmicos coconstruídos entre o bebê e seus cuidadores de referência. Este nível de registro da experiência segue presente ao longo de todo o percurso de subjetivação, sendo dinâmico, mutável e passível de instabilidades. Desse modo, a pesquisa também buscou contemplar os diferentes arranjos sensoriais que permeiam a trajetória do sujeito, com seus riscos desorganizadores e suas potencialidades de ampliação subjetiva. Além dos reagenciamentos que acompanham o viver, ainda destacamos descontinuidades provocadas por intrusões violentas da realidade externa, que podem quebrar o ritmo de vida do sujeito e que interpelam ao sensorial. Considerando que a sensorialidade é um elemento fundante do sentimento pessoal e que segue tendo um papel vital para a continuidade do ser, apontamos a relevância de a clínica psicanalítica atual alargar o trabalho com o sensorial e de dar a devida atenção à dimensão arcaica e infralinguageira na relação analítica. / [en] This research aims to carry out a theoretical study, regarding the psychoanalitic framework, about sensoriality in the subjectivation process and in clinical practice. We will discuss the sensoriality concept developed by Alberto Konicheckis, who understands it as the multiple psychic experiences that arise from the sense organs. It is a complex and ambiguous definition, located in an intersection zone between the inside and outside, the self and the other, the intimate and the shared, since the sensory is awakened by the contact between baby s body and external objects. We understand that sensoriality has the primacy in early childhood and that psychic constitution starts from sensory-perceptual and rhythmic processes co-built between the baby and its reference caregivers. Such experience record level remains throughout the entire subjectivation course, and is dynamic, changeable, and liable to instabilities. Thus, this research also addresses several sensory arrangements that permeate the subject s life, considering their disorganizing risks and their potential for subjective enlargement. In addition to the transformations inherent in living, we also highlight the discontinuities caused by invasions of external reality, which may break the rhythm of life and challenge the sensorial. Whereas sensoriality is a founding element of personal feeling and continues to play a vital function in the continuity of being, we pointed out the relevance of current psychoanalytic clinical practice in expanding the work on the sensory and paying attention to the archaic dimension of the analytical relation.

Chronic pain is common and a burden for both the individual and society. In chronic pain, the pain has lost its function as a warning system and instead has become a disease in itself. Neurobiologically, several areas of the brain are involved, but to gain a broader understanding of the long-term pain, the biopsychosocial model is the best starting point. In line with thisand many scientific studies since the late 90's, psychological factors have proven to be an important factor in the development and maintenance of chronic pain. Interdisciplinary multimodal rehabilitation programs (IMMRP) are the treatment currently given to patients with long-term pain in the specialized pain rehabilitation. When the IMMRP has been reviewed, patients have shown improvement over time, but it is not possible to say whether it is the IMMRP or which parts of the IMMRP that explain the improvement (1). In this licentiate thesis, I have studied the importance of psychological factors in the rehabilitation of patients with chronic pain. This has been done in three studies reported in three published articles. All the studies have been close to the clinic and have been performed on patients in the specialized pain rehabilitation care in Sweden. The first article studied the effect of the multimodal investigation (MMI). More specifically, it was investigated whether alliance building and feelings of validation in patients with chronic pain affected their acceptance of pain, pain management, catastrophic thoughts, and depression. This was performed in a "single case" study on six patients in MMI. The results showed that despite good alliance and sense of validation, acceptance increased only in one patient and no improvement was seen in pain management, catastrophizing, and depression. In study two, subgroups of patients with chronic pain were studied. The subgroup analysis showed that patients referred for IMMRP could be divided into groups with different profiles regarding emotional problems and pain avoidance. These profiles were important for how the patients relatedto their pain and the results of IMMRP. The results of the study can increase the understanding of which patients should be selected for IMMRP and how the treatment can be adapted to the patients' needs. In study three, opioid treatment in patients with long-term pain who were referred to IMMRP was studied. The result showed that opioid prescribing was common and 55% of the participants received at least one prescription for opioids during the two years after the first assessment. It also turns out that there was a connection between individual patient characteristics (especially pain and depressive symptoms) and opioid prescription. Understanding how individual patient characteristics relate to prescribing patterns and long-term opioid use is an important prerequisite for managing opioid prescribing and the basics for preventing overuse. Overall, this licentiate thesis shows that MMU has no therapeutic effect on patients with long-term pain. It also shows that patients with chronic pain are a heterogeneous group that can be divided into subgroups based on psychological characteristics. The subgroups, in turn, had different ways of managing their pain and absorbing the treatment offered. In addition, it emerged that opioid prescribing was common among patients with long-term pain and that there was a link between opioids and patient characteristics.

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Throughout the process of receiving healthcare, a patient is affected by several factors and processes. To just name a few, how long a patient must wait at the clinic, how friendly the front desk is, how the nurse treats the patient, how effective the physician is with his or her communication, what the cost of a patient's healthcare is, and how clean the clinic is all affect the patient's experience. When clinics excel in these factors, it promotes a favorable relationship between the patient and the clinic. Patients trust the healthcare provider and desire to continue attending that clinic when they need to. Unfortunately, not every clinic can succeed in all these factors. The purpose of this study was to investigate the relative importance of these factors in a patient satisfaction survey at a university health center.

In 2019, diabetes affected approximately 283,000 individuals, aged 20 years or younger, in the U.S. Due to illness symptoms (e.g., hypo/hyperglycemia) and disease-related complications (e.g., nephropathy), individuals report poor health-related quality of life. However, individual-level, family-oriented, and health care system factors may affect perceptions of a child’s overall health status. For example, beliefs of having spent enough time with the doctor may predict proactive health behaviors and perceptions of health. Overall health status may also be indirectly related to time spent in medical conversations. For instance, perceptions of shared decision-making (e.g., exploring pros and cons of treatments together) between families and providers may, in turn, foster family empowerment and resiliency (i.e., ability to adapt, cope, and overcome challenges) in the context of caring for a child with a chronic illness, with positive implications for perceived health status of their child. This study aims to examine the relationships of these variables. At the bivariate level, it was hypothesized that time spent in visits, shared decision making, family resilience, and perceived health status of the child would all be positively related. At the multivariate level, it was hypothesized that doctors working collaboratively with parents and family resilience would serially mediate the relation between time spent in medical visits and perceived health, such that more time spent with the doctor would be associated with perception of collaborative decision making and, in turn, higher levels of resiliency and better overall health status from parents’ perspectives. Utilizing data from the National Survey of Child and Adolescent Health from 2020-2021, this study examined survey responses from 369 parents of children with a reported diabetes diagnosis. Responses were extracted from a larger survey for questions related to time spent with providers in prevention focused visits, collaborative decision-making, family resilience, and health status of the child. Bivariate correlations and serial mediation analyses, per Hayes (2013), were conducted, covarying age, sex, ethnicity of child, health insurance, family structure, income, and education level of parents. Bivariate analyses showed some variables were significantly related in hypothesized directions (p < .05). In serial mediation analyses (10,000 bootstrapped samples), the total effect of time spent with the doctor on overall health status was nonsignificant (t = 0.7767, p = 0.4383), and the direct effect was also nonsignificant when mediators (i.e., collaborative decision making, family resilience) were added (t = 0.805 CI= -0.0044, 0.0122), indicating no serial mediation. Controlling for the effects of the other mediator, a significant indirect effect was found through collaborative decision making (t= 1.9181 CI = 0.0015-0.0940) but not family resilience (t = 0.9565 CI=-0.0059-0.478). This study demonstrates that collaborative decision making with parents mediates the relationship between time spent in preventative health care visits and overall health status. Changes such as policies that incentivize quality of care rather than number of billable visits, or establishment of patient centered medical homes, could support appointments of sufficient length that would allow for collaboration and, in turn, better perceived health status for those affected by diabetes.

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No description available.