Psychosocial rehabilitation in Brazil:
the impact on everyday life
Alice Hirdes, M.D.
Psychiatric Nursing Teacher at Universidade Regional Integrada do Alto Uruguai e das Missões
Campus de Erechim. Master Degree in Nursing. Support: FAPERGS. Rua Maranhão, 653/21
Centro – Erechim/RS/Brazil – 99700-000 email@example.com
Luciane Prado Kantorski, PhD
Psychiatric Nursing Teacher at Universidade Federal de Pelotas. PhD in Nursing. firstname.lastname@example.org
Hirdes, A. & Kantorski, L. (2003) Psychosocial rehabilitation in Brazil: the impact on
everyday life. International Journal of Psychosocial Rehabilitation. 7, 81-89.
Acknowledgements: This work is the result of a Master’s Dissertation supported by FAPERGS.
This article describes the centralization of the therapeutic work on the aspects of everyday life of the users’ mental health service, emphasizing psychosocial rehabilitation, while a social practice geared towards the rebuilding of identities and possibilities for mentally ill people. This study was developed at the Mental Health Community Center in São Lourenço do Sul/RS, Brazil, the so-called "Nossa Casa", taken as a practical mark in a new way to approach mental diseases. This research consists of a qualitative study in which we make use of the Marxist referential, with the dialectical materialism as a theoretical substrate in order to interpret reality. The instruments used were semi-structured interviews with ten persons from the mental health staff. The thematic analyzed consisted of the centralization of therapy work on the average users’ life aspects focused by the interviewees, such as the possibility of searching autonomy and citizenship.
The scenery of the study:
This study was developed at the Mental Health Community Center, São Lourenço do Sul/RS, Brazil. The mentioned institution is characterized by offering integral attention to mentally ill patients, through a network of attention services to mental health. This institution started to be structured in the year 1988 attending the initial necessity of taking care of mentally ill patients in town. The Mental Health Community Center comprises a mental health network, as follows: Psychology and Psychiatry Ambulatories; "NOSSA CASA" – CAPS - Psychosocial Attending Center and the parent-cell of the project; Therapeutic workshops; a Psychiatric Unit at the General Hospital; Children and Adolescent House; "Nosso Lar"- protected home. The network is accredited by "Sistema Único de Saúde" (SUS) and gives attendance to the rural and urban population of the municipality. The mental health service runs daily, from Monday to Friday, through interdisciplinary teams. The emergencies are attended at the local hospital, which is the entrance door for hospitalization cases. In "NOSSA CASA" the daily average number of users is from 25 to 30 patients. The number of attendance is about 1.300 patients per month.
The users of the Mental Health Community Center comprise patients with mild to severe mental disorders – neurotics, psychotics, those discharged from psychiatric hospitals, organic psychosis. The average time for internment in the Psychiatric Unit is approximately 10 to 12 days, a considerably short time, because as soon as the patient shows improvement on the reasons that took him/her to the hospital, he/she is then transferred to "NOSSA CASA". In this place the remaining time is discussed with the team, and also factors and facts which were relevant for the current situation, such as his/her familiar situation, social network, employment, among others.
"NOSSA CASA" team is composed by one nurse, two nurse attendants, eight therapeutic attendants, a psychiatric doctor, three psychologists, one home economist, two general service attendants, one cook, one driver and one office boy. One of the authors (A. H.) used to work in this duty for 10 years as a therapeutic attendant, as a nurse and as an administrative coordinator.
The Mental Health Community Center is aimed towards the community mentally ill patients under the perspective of psychiatric reform, and focuses on: (i) permanence of patients in their own environments, them patients to remain closer to their families and social environments; (ii) integral attendance to meet individual needs; (iii) the respect of individual differences; (iv) rehabilitation practices and social reinsertion.
This is a qualitative study that uses the Marxism referential, the dialectic materialism, as a theoretical background for the interpretation of reality. Abstracting the question negation-overcoming for the referential of psychosocial rehabilitation from the dialectic conception, we considered necessary to deny the assistance reality of the individuals with mental problems centered in the model of the damage, in the deficit towards the rescue of centralization of the focus in the abilities, and the search of work to reach the aims of psychosocial rehabilitation, citizenship and quality of life.
The path of the study
We recurred to the definition of psychosocial rehabilitation produced by experts from several countries and compiled in a document called "Declaration of Consensus in Psychosocial Rehabilitation" which states that psychosocial rehabilitation is a process which facilitates the opportunity for the individuals – who are prejudiced or disabled by a mental disorder – to reach a great level of working independence in the community. This implies both professionals and users to improve competences and introduce environmental changes in order to create a better quality of life possible to people who experiment a mental disorder, or have a mental deterioration which produces a certain degree of inaptitude (WHO/MNH/MND/96.2).
The instruments used were semi-structured interviews with ten integrants of the mental health team. An official letter was sent to explain the thematic of the research requiring collaboration in the phase of interviews. Thus, the conventional directions started and the subject was discussed in meetings of the team. After the testing of the instrument (the interview itinerary) the ten semi-structured interviews were performed with the workers from the Mental Health Community Center, such as, psychologists, psychiatrics, therapeutic attendants, nursing attendants and workshop instructors. As a delimitation criterion, the individuals were selected among the employees working for, at least, five years in the institution. The interviewees are identified in the text by letter "A" and the number of the interview (for instance: A1, A2, …).
This thematic area contemplates the actions of the individuals, in their the everyday service and the importance attributed to the different practices of psychosocial rehabilitation. The user’s conception, while a person not as a nosologyc adding leads the actions for intervention centered in the individuality of each human being. The approach in everyday life aspects constitutes itself in attendance practices implanted in the service. The practices considered consistent with the philosophy of doing but not ruled on the traditional model are addressed. Dissociation between illnesses and person is evidenced, and also the centralization of practices toward the person, without disregarding the aspects concerning the treatment.
Centralization of therapeutic work in the aspects of users’ everyday
The practices of everyday life are the first step for psychosocial rehabilitation of the individual and, mostly what makes one a citizen… When we give a person a treatment we treat things differently than when we treat a diagnostic. This is the practice of this service. To treat people, citizens. With identification card, address, family (A1).Goldberg (1996a, 1996b) emphasizes that in front of the patient we cannot place ourselves a priori in the knowledge of the object. He illustrates that with the psychiatric clinics, in which he always tries to learn with the patients’ disturbs, not to reproduce them. He also suggests that the centralization towards the symptoms constitutes itself the referential adopted in institutionalized models, which reduces and includes the patient in standardized behavior, independently of the presented psychosocial characteristics. The clinics, according to the author, based on institutionalized models, admits typifying the manifestation of diseases, while a strategy to reach the specificities. However, he emphasizes that only an operative and an ethics clinic will be able to establish differentiated therapeutic interventions.
We understand that the new services should correspond to a renewed clinic, with differentiated treatments, and where concomitantly or in sequence, therapeutic projects that contemplate the psychosocial needs of the involved people be developed. This is what might effectively bring a person to be a citizen. It is important to point out that the projects cannot constitute themselves as models built from professionals, but built collectively with the most interested people: the users.
According to Saraceno (1999) the services are constituted as a variable that has influence on the rehabilitative process. The author points out the capacity of the service in looking after all patients and giving them possibilities of rehabilitation as a high quality service. He states that the services, which do not offer these possibilities, generate intervention hierarchies and those who are less qualified are excluded from the process. Saraceno (1999:96-97) points out that a high quality service should be permeable and dynamic, with high internal and external integration "… a service where the permeability of knowledge and resources prevail on the separation of them", and in which the organization is "oriented towards the necessities of the patient and not the service".
We understand that internal and external integration is due to the movements which transpose the treatment and the psychosocial rehabilitation. This integration will be possible and concrete if professionals visualize the importance of no dissociation, and assume both the treatment and the rehabilitation. The idea of this proposal faces a resistance that is sometimes established in everyday services: the treatment given by some and the rehabilitation by others.
In "Nossa Casa", most of technicians are detained on the treatment and on the formulation of rehabilitative proposals on intellectual level, while non-technicians make the proposals to work on a practical level, that is, a separation between who provides treatment and who provides rehabilitation prevails. The attempts of re-approximation occur through meetings of the team, where specific cases are discussed individually, and where a rescue and an integration of both treatment and rehabilitation are approached.
Bandeira (1994), analyzing the importance of communitarian infrastructure in the social re-insertion program, in a controlled group evaluated during three years, concluded two essential aspects for the increasing of successful probability of mentally ill patients social reinsertion, such as, quality of the program, where the basic abilities for everyday life in the community is included, individualized follow-up and attendance to patients in crisis. The second aspect is concerned to the quality of home environment. Patients’ active participation in the activities of the house, the establishment of objectives, individualized orientation is included in this item.
We try to make our patients to retake their lives closer to reality, as much as possible. We try to make them retake some daily activities that they have lost, sometimes, because of the illnesses. Activities like personal hygiene, …, shower, shaving, nails, hair, in order they get their vanity back. Besides, we try to retake some activities with them, some in the kitchen-garden, who have already done this kind of work, others in carpentry, others in protected factories… To try to look after their own houses, to take care of their own lives, to have leisure… (A9).Through the talk it gets clear that the centralization of therapeutic work firstly begins on the difficulties installed with the illness, in relation to the development of activities people can do in their everyday life. That is, common elements of a person’s everyday life are worked, which for people who have disabilities or are handicap are not really common, to gradually open the options of intervention. The rehabilitation process has its beginning in everyday activities, such as to take care of their own body. Then, the aspects concerning activities developed before the illnesses are worked on. The work runs from a protected context to the occupation of real spaces in the community. The users’ priori abilities are considered and reinforced, and the disabilities are worked.
Bandeira (1998), searching psychotics’ social competence, through social validation of specific abilities, regarding verbal, non-verbal, paralinguistic, of expressivity’s components and abilities of solving problems, concluded that the higher difficulties happen in relation to the verbal component and problem solution. The aim of the author was to evaluate the training of social competence of mentally ill patients, compared to a reference group of their own community. According to Bandeira’s (1998) review of literature, the results of social abilities training improved the level of social competence and decreased the number of patients’ re-hospitalization. The author understands that the efficacy is higher when many components and several social situations are worked. She also highlights the importance of including the practices performed in the natural setting where the patient is inserted.
From this research we can apprehend the importance of recognizing the environment in which the individual is inserted, so that the formulated proposals be coherent with the social environment and its demands for mentally ill people. We understand that the environment contextualization, the culture in which the person is inserted works as a thermometer in determining the validity and importance of the aspects to be focused in the training of social competence.
When a person is treated, his/her inter-relations, way of dealing with the family, with the work, with the house, with the recreation, with that entire are treated. What is good for myself is good for the employee and is good for the patient. The traditional practices many times forget this. From the point of view of clothing, name, housing, of all these concepts which are very important for us and that become important in the model of psychosocial rehabilitation, where we first rehabilitate the person, his/her working conditions, then his/her condition out of the treatment. (A1)The work also appears as a rehabilitation factor on the interviewees’ speeches. It is important to highlight that this is not as accessible to mentally ill patients as it seems to be. This is a reality which cannot be denied, mostly if we consider that São Lourenço do Sul is a small town, with relative difficulties in work market for the "normal individuals". This reality is not different from the reality in other cities, with similar population characteristics. Regarding big cities, difficulties will certainly be bigger: firstly, the dispute for job is bigger, and, secondly, small centers probably take advantage regarding protected work.
We have mentioned a situation that has been characterized as a protected work: daily patients followed by an attendant used to go to a big workmanship, which was going to be repaired to be a branch of a supermarket in the city. These users, in a protected policy, worked effectively on civil construction. Businessmen who welcomed the proposal followed the whole process. The work for mentally ill patients, besides the challenge which represents, needs primordially discussion on mentally ill patients’ rights and the recognition of these rights by society.
According to Saraceno (1999, p. 131) "… the work is identified as an "instrument" of rehabilitation, subordinated to healing and, successively, as an indicator of success of the healing itself, thus, a return to normality indicator".
Some authors like Cohen (1990), Ciardello and Bell (1991), Pitta (1996), Saraceno (1999) and Pratt et al (1999) have deeply discussed about the work while a promoter of psychosocial rehabilitation having in one’s mind the possible benefits acquired in the personal, relational and communitarian context, deriving from there. The occupational rehabilitation (vocational rehabilitation), principally in the Anglo-Saxon model of psychosocial rehabilitation, is explicit as a central principle of the process. In the pragmatic model, people are requested to produce in economical terms. In Latin American countries, a focus has been given on the rights of mentally ill patients. This is a basic necessity to be worked with society. Without this previous understanding from society, the effective occupational rehabilitation will not have chances to be materialized as a right, but as a concession.
Rehabilitation, according to the interviewees, is divided into distinct moments in which "… first we rehabilitate the person, his/her work condition, then his/her life out of the treatment" (A1). Goldberg (1996b) points out that treatment and rehabilitation are in dissociable. He states that for a patient to be rehabilitated it is necessary to offer continuous treatment.
We understand that the initial treatment of productive symptoms is the first intervention to be done. Within a broader perspective, we consider the diagnosis of this person’s life extremely important, and the subsequent establishment of a therapeutic project from the context in which the person is inserted. They must be sufficiently flexible to incorporate changes, and to possible re-dimension. We highlight the necessity of readingthe context within a change of optics. Usually this reading is done over the deficits, the negative aspects. To emphasize the forces, the health aspects, is an important transition in the treatment and rehabilitation process is as well as the notion in unsociability of both of them.
Liberman (1998) states that the programs of communitarian support serve as environmental protectors, through the reduction of harmful effects of the critics, absence of support, social and emotional over involvement in vulnerable individuals. According to the author, communitarian support might strengthen the protective effects in the training abilities of chronic mentally ill patients. The author points out that the learning of abilities to solve problems, conversation and vocational abilities, and self-help abilities, within a communitarian support context, capacitate the vulnerable individuals to establish realistic aims and to promote clinical and social aspects. Communitarian participation is viewed as the responsible for the decreasing of recurrence and for a suitable social adjustment. As well as the learning for changes and to solve problems of everyday life.
I am going to quote some examples that we use in our everyday life… we have here a big group which we take it to play soccer; there are two schedules and gymnasiums and take these people. So, about fifteen people we always take (A2).The using of collective spaces in "normal" times is a current practice in the service. Sports here are also an aggregated factor, which provides entertainment and leisure. The fact of arrogating legitimately social spaces, is not a concession or a favor, it is a conquest that was reached over the years. Not always the establish relations with the community were like these. If by one side there were requests for a kind of assistance which would bring resolution and put an end to revolving door, initially the fear, the preconception and the stigma raised barriers, walls, which were thrown down along of the time.
We also have leisure activities. Soccer, we go to the community to play. We have a choral, which makes presentation in several places, here, in the city, and also out of it… we have …tickets, leisure excursions with them, and journeys to the beach. We go to "Rei Clube" to play snooker, ping-pong, among other things… (A9).
Morgado & Lima (1994) comment upon the models of de-institutionalization, having this process in countries like the United States, Italy, Canada and England as the basis for its analysis. Regarding the United States, they refer to the process of de-hospitalization. This understanding, however, cannot be conceived as de-institutionalization, since in this country this practice was reduced to de-hospitalization. The authors point out five serious consequences of de-hospitalization, such as: abandonment of critical patients, high rotation of patients – characterized as revolving door, non-monetary cost by mental disease, problems with justice/police and policies of de-institutionalization movement.
Although not agreeing with the analysis of Morgado and Lima (1994) regarding de-institutionalization (de-hospitalization), we agree with the authors in relation to the characteristics of a good mental health model. Two pre-requirements are considered essential for the implementation of the program, which are: acceptance of the program by the community and the preparation of human resources. Regarding the acceptance of the program by the community, two aspects were characterized, such as the assurance of the participants’ objective conditions for the effective engagement in the activities, and subjective dimension of living in community with mental ill patients. In relation to the latter, the authors point out that this dimension is clear by its opposite, that is, the tendency to internment. Well-prepared human resources include the secure handling of basic pharmacology, focal psychotherapy and family therapy, communitarian psychiatric nursing and social service.
We understand that in the service under study these requirements were totally reached and even overcame in several aspects. In structuring the service, the community was always actively involved. This involvement was formal, when the presentation of the program to the alderman chamber and informal through the establish interactions with the community, such as, talking about mental health in several collective spaces (churches, associations, schools, means of communication), in promotions, in the invitations to the community in anniversaries of the institution, in the trade of vegetables from the kitchen-garden produced by the users to the community, in festivals, as well as the visits of the community to the house, firstly impelled by curiosity then by solidarity. This involvement happened through several ways, such as, through visitation of school children, aiming to know the service, and also by the work of professionals in schools to talk about mental health and insanity. These actions produced a favorable impact in the demystification of insanity. In the community, it was possible to observe clearly the dialectic jumping: from initial rejection – a house for crazy people located in a noble area of the beach – to projects developed with businesspeople in town.
In the analysis of the communitarian infrastructure formulated by Morgado & Lima (1994), it is evident that the community interactive context is central for the establishment of a good attendance system in mental health. The authors visualize the revolving door as the best indicative of communitarian assistance and the direct indicative of hospital assistance.
We agree with the authors and we consider the community engagement crucial for the formulation of any proposal of de-institutionalization. However, we considered a tendentious perception of the authors that, through the example of revolving door, want to make people believe that there are not available means to keep patients inside the communitarian structure. We understand that transformations occur, more concrete, in the micro spaces, through the deconstruction of a maniacal model strongly deep rooted in the professionals and the common sense. This means to take responsibility with the process of renovation, while the attribute to other organisms, results in non-responsabilization.
Another thing is, for example, a patient who is willing to … I’m going to buy a piece of cloth. We go out with these people and go through the city, to the shops and we choose clothes for them, they will look … this fits on me, this one doesn’t… we help him/her to buy, with his/her money. Another thing we do, in the example of everyday life … we have a choral … it is a choral here in the house, but it is open for the community (A2).Small everyday acts are shared with therapeutic fellows, such as go shopping. These acts end in a routine practice which does not cause amazement to sellers and store owners. Very soon patients are recognized and identified by being from "Nossa Casa". This recognition is not just because of the "faces" of mentally ill patients, but because it is a small city where people know each other, and mentally ill patients lived and established relations with the population. These factors corroborated for the city to show itself as the best setting for the development of real changes, where through real situations, with their variables, the difficulties of the users can be worked out. This "real laboratory", in real life, is revealed to be the best school of psychosocial rehabilitation for the users and a learning for the team. I think like that, I think it is not only they do something in the workshops, you know, to sew, to embroider, etc. I think like that, … it changes the hygiene, that … think like take care of the house, we talk a lot about that with them (A3).The care with him/herself, through healthy and suitable hygiene habits, the management of the house and the several aspects involved here are discussed with the users. The making in the workshops appears as a non-priority factor for re-habilitation, firstly the capacity of performing everyday tasks appears, inserted in a specific context, because the latter two are seen as activities that change important aspects in the users’ life.
Another rehabilitated mechanism … is the self care… we try somehow to make the patient like any other human being that walks in our city … Anyway the hygiene, that is practiced by nursing, it is … it is one of the factors not only in relation to people’s health to keep clear, but also a rehabilitated thing, in the sense he/she doesn’t feel ashamed. Many times, when the crisis is over se feels the same way of any other person that is within the team that is going to the house (A8).
We rescue the differential between the entertainment and rehabilitation approached by Saraceno (1999). To do something is seen as a synonymous of entertainment, fulfilling the time, even if many times it is automatic, useless, repetitive and non provided of finality. In this context, the entertainment reduces the human being to a mechanic, stereotyped repetition of some activities, in order to fulfill the time, since inactivity is not tolerated.
We share Saraceno’s (1999) opinion regarding the search of disruption of entertainment in the services of mental health. This disruption must be approached in two fronts: the disruption of entertainment of the team which gives assistance and the disruption of users’ entertainment – who are the receivers of entertainment formulated by the teams.
And I think like that, that he/she in the workshop, he/she learns something. Because we have carpentry, we have upholstery, there are the packs, there are several workshops. And I think that he/she learns something, and I think this brings benefits for him/her … after he/she leaves here, even at home, if he/she wants to do something to sell or … I think this will benefit, the workshop itself (A4).The learning, in this context, starts being noticed in a different way from to do, of the entertainment. There is the being here and afterwards, to do something to keep him/herself. Thus, there is the idea of transitivity, the passage through the institution and the return to life he/she had before getting sick. Nossa Casa, after the users’ discharge, becomes a reference point in which they run to help when they need. Well, knowing the users, knowing their history, we start working on things they have missed because of their disease, for example: if he/she was a rural worker, we try to engage him/her in an activity in this sense … (silence). Always putting him/her inside its reality … helping, supplying, many times facilitating, the best way (A10).The centralization of therapeutic work having as its base the story of life and not the deficits, in the diagnosis, in summary, the disease is taken as a rehabilitated factor for the users. The respect to habits and these users’ culture and the reinsertion in their origin activity is evident. The respect to culture can be expressed, also, through simple everyday activities, such as, a home visit to a patient that only speaks German and/or ‘pomeran’ dialect by a worker who understands and speaks the same language, is a routine practice.
An activity that workers understand and express themselves in ‘pomeran’ is the therapeutic group in the rural zone. During many years one of the authors (A. D.) took part in this group. Because of the same language and culture, the users express themselves easily, naturally. To facilitate the best way does not mean to choose by the people. It means to help, to be present, in the choice of several possible ways and to provide support during the process.
Analyzing the data obtained, we learn that everyday life practices constitute themselves a priori in the service. The focus is directed for a responsible care, based on real appropriation of collective spaces. The rehabilitative process is centered in the individuals’ necessities and possibilities, in their life stories where previous abilities are considered and reinforced and the cultural context in which the person is inserted.
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