In this abstract, I discuss a psychoanalytic framework for understanding loss and grieving in Salvadoran patients. The framework is inductively derived through years of practice with patients. I begin with a presentation of case types and then describe concepts of “biosimilar”, the horizon of continuities, and the assemblage as they relate to the case types. These concepts provide a theoretical reference point upon which I have inductively come to understand and structure treatment for grieving patients.

Cases

I will begin by describing cases regarding death, and a few characteristics that people present after loss. The type A cases are related to violence, suicide and lost people (or “disappeared”), which are very common types of loss in the Salvadoran context. The type B cases are related to illness and ambivalent loss, which are also very common types of loss in the Salvadoran context. When I refer to ambivalent loss, I am referring to people who died and their relatives had no explanation from a medical-forensic point of view. Type C cases are related to age and the idea of “normal and acceptable death”, and in this case, are typically surrounded by religious and spiritual rituals.

Case A1

The death of a 13-year-old named “L” who was murdered in front of his friends. This involved kids entering their adolescence in El Salvador. The school reacts to this death by implementing a few rituals, specifically involving Catholicism. But his closest friends react different- they knew him close enough to know that he and his family were not catholic. At the funeral, one of the kids who saw the murder gets close to the coffin and sees his friend, as he describes “dressed like a vampire with a catholic cross on his chest”. It is the first time in his life that he sees a dead person. Less than a week later, the boy feels what he calls “the need to search” for his friend, and he starts to learn how to draw cartoons, to play videogames, and to become violent and physically aggressive with the people around him. Three months later, the boy has chest reactions “similar to asthma” when he plays sports, and he also feels pain in his chest. When becoming an adult, he explores two careers that are linked with the abilities and areas that “L” had during his lifetime: “graphic design” and artistic drawing. As an adult, the boy talks about “L’s” life through him, sometimes with contentment, but other times as a conflict.

Case A2

This case (by suicide) is about a young man and his mother. A man, referred to as “T”, at the age of 35 with chronic pain in his back, decides to commit suicide. The mother finds him lying dead in his bed with a note. Different reactions emerge from the situation. First, his twin brother feels relief because his brother is no longer in chronic pain. But the mother, after a period of three weeks, starts to behave differently, with her first reaction being sadness, crying and other behaviors associated with grief. She then starts to practice singing, and reading about Pachamama, which was her son´s artistic and spiritual practice. She refers to the situation as a “way of understanding him better”. Two months later, the mother starts to feel chronic pain in her back and spends most of her time in bed medicated. She speaks about having the certainty that when she got older both of her twins were going to be professionals, and she will be a grandmother. The actual situation is abnormal, because instead of her twins burying her, the situation is reversed.

Case B1

A 39-year-old man gets sick suddenly in his office. His co-workers try to help him, they call an ambulance, but by this time his wife (who is 6 months pregnant) is at the scene. She follows the ambulance with her husband, and twenty minutes after getting to the hospital he dies, without anyone knowing the cause of death. After ten months and other experiences that include the death of his father and the wife eventually giving birth, she starts listening to her husband's favorite music, expressing her husband's philosophy of life, and having more daily physical energy like her husband used to have. She starts going out with her husband's friends and spending more and more time with his family. As the widow describes it, she feels that the husband lives through her. One year later, some of the behaviors and beliefs of her father start appearing in her, and she delves into Marxism and ideas of revolution, which pertained to her father’s studies. This becomes an issue because her husband and her father had very different ways of seeing life, especially with regard to raising children. Then she says that the hardest part is to find balance among both in her life, because sometimes she feels like her father and other times like her husband, and their goals and way of life were very different.

Case C1

After years of suffering from lupus, an 84-year-old woman dies. Her daughter has been taking care of her the last couple of years, and after having lived as a catholic the daughter starts to practice Buddhism, which was a major part of her mother’s spiritual life. She also begins to feel the need to eat her mother’s favorite meals and to dress like her, sometimes wearing her mother's old clothes. She develops a close relationship with her mother’s cat, which dies from obesity and a urinary tract infection. One month later she starts eating more and gaining weight, apart from having her mother's routine, she is now having health issues related to minor urinary tract infections. She describes her life as comprised of her mom’s routines and seeing her mom through herself in the mirror. She also incorporates the cat's routine into her own, and she enjoys staying close to the places the animal used to be in the house, and sometimes she says that she feels like the cat because now she is no longer friendly with people and is starting to get ill as the animal did.

A “Biosimilar” Approach to Grieving

In this paper, I am developing the notion of a “biosimilar approach to grieving” which employs assemblage theory to understand psychological cases of grieving and loss. When I refer to a “biosimilar”, I am referring to a biological entity, organism, or behavior that, in response to a “loss-activator” and a “duel-active principal,” searches to be equivalent to its reference. This search is presented in its repetition and concentration of efforts to become the original biological entity, which I refer to from now on as a reference biological entity, which may be human or non-human.

In its search, the organism in its biosimilar state contains in itself the components that reaffirm the need for its constant search. One of them is the experience of the active principle, which in this particular case is the duel and the forms of assimilate the loss –activator–, and another, to find itself as an alternate version of the biological entity of reference. I contend that once the search commences, the biosimilar will be just a biological entity, but with peculiarities. One might be the minimum presence of his/her or its own identity as a reference entity, and another, that there will always be a search, a need to confirm and review its equivalence with the reference entity. That last state opens a wide range of possibilities (“mayanadi”) in the life of the biosimilar, which among a diversity of emotional responses, it may contain different degrees of pleasure and contentment, or displeasure and frustration.

In the biosimilar approach, I also explore two related concepts: One is the notion of bioavailability and the other one is bioequivalence. The first one refers to the influential or potential factors that are concentrated in the organism and then become a major part of the experience of loss, and these factors are entangled with the activator (loss) and the active principle (duel). They exist at different levels in the organism, from material to abstract levels that coexist no matter their nature, and constantly participate in the biosimilar context, sometimes as perceptual attributes and sometimes as behavioral responses. One example is the social beliefs that explain where individuals “go” when they die, the idea of a soul or a place to go after the cessation of their vital activity comes as a concentration of abstract information that is available for the biosimilar, and it reaffirms in the social/material world.

The second one, bioequivalence, refers to the relation between the biosimilar and the entity of reference; the nature of this relation can be material/affective/abstract/physical/social/psychological and not necessarily from the same species. It is possible to find examples between couples (humans), parenting, or humans and animals, even between species and non-living organisms such as places, communities or a house. From this approach, every link where there is the activator (loss) and the active principle (duel) needs a bioequivalence principle in order to take form.

The horizon of continuities

Further thinking and research in the aforementioned concepts is needed. In an effort to achieve a better understanding of a biosimilar approach to grieving, I place the notion in the context of what I call the horizon of continuities. This concept responds to the idea that an individual develops –in a prospective way– a panorama, a horizon where objects, places, purposes, sensations, affections and experiences that above all, are accompanied by the biological entity. In turn, they create a sense of certainty that they must be there. The horizon of continuities is the result of the construction of a universe of certainties that has as its starting point the worldview (cosmovision) and the cosmogony that surrounds it, and the world where it develops, which reaffirms or transforms these certainties. For example, the idea of a parent-child relation has at its basis the notion that the son or daughter will be alive when the parent dies. This way of thinking is part of the universe of certainties and creates a view, a horizon of continuities where the son or daughter bury their parents, and not the other way around.

The universe of certainties changes during the life of the biosimilar, and in some cases, it depends on the activator and in others on the active principle. It also may contain different degrees of pleasure and contentment, or displeasure and frustration. Depending on the situation, displeasure as in the A1 case, or purpose and conflict as in the B1 case.

Assemblage

Using the concept of the assemblage and the rhizome (Deleuze & Guattari, 1987), different links can be understood as connecting with and developing beyond the body. The idea of the assemblage allows us to think with the body-organism as being linked to the world through a network of original meanings, where perception can lead to the appearance of new elements.

Thinking with the concept of the assemblage offers a useful approach for exploring loss, grief and bereavement in the context of the biosimilar approach. Biosimilars emerge in assemblages as situated individuals’ network and interact with entities in the world. Assemblages allow for us to think about biosimilars not only as a response or a search, but also as emerging phenomena, by thinking about the possibilities where this form of search came from. Humans, for example, develop sorrow and grief in religious/spiritual/material/emotional contexts.

The biosimilar approach applied to cases A-C

Example: Biosimilar analysis on the type A cases

In case A1, the bio reference is teenager “L” and bioequivalence occurs in the school classmates and the friendships that exist among them. Bioavailability is the view of them getting older, such as the professional who subsequently develops his career as an artist. The universe of certainties is that everybody gets to be a professional, but most importantly it is that people die old. The horizon of continuities was first the view of friends getting older together, with couples, family and a career; now the horizon is to be an artist and to learn how to fight professionally. Biosimilar or the search to become the reference biological entity, is presented in drawing cartoons professionally, playing videogames, becoming violent and having an inexplicable pain in the chest.

In the A2 case, the bio reference is the young man (“T”), the bioequivalence is the mother/son relationship, the bioavailability is presented in the form of a certain view of the son as winner/professional/father. This is possible because in her universe of certainties, it is the mother who dies before their children. The horizon of continuities is the mother as a grandmother with her twins and grandsons, but now her horizon of continuities is to live with one son and the other one living through her. In this case suicide is presented as an activator, and duel and grief, the active principle. Biosimilar or the search to become the reference biological entity, is presented in singing abilities, Pachamama and other viewpoints that her son had, a sense of freedom that he always wanted, and the further back-pain condition.

References

Deleuze, Gilles & Guattari, Felix. (1987). A Thousand Plateaus: Capitalism and Schizophrenia. Minneapolis: University of Minnesota Press.

Notes

Notas de autor