Therapeutic Listening: a work instrument at the service of mental health?
Alice Hirdes, M.D.
Psychiatric Nursing Teacher
Universidade Regional Integrada do Alto Uruguai e das Missões. URI
Campus de Erechim. Mastership in Nursing.
Member of WAPR
Brazil. E-mail: email@example.com
Hirdes, A. (2003) Therapeutic Listening: a work instrument at the service of mental
health? International Journal of Psychosocial Rehabilitation. 8, 37-46.
Acknowledgements: This work is the result of a Master’s Dissertation supported by FAPERGS.
This article approaches the question of relations established between the team and the users and intra-team, as factors that facilitate or make difficult the interventions in mental health. The thematic analyzed consisted of the centralization of actions having as its base a therapeutic relationship, as well as the importance given to therapeutic listening and to be present as a therapeutic instrument in everyday experiences. 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 illnesses. This research consists of a qualitative study in which we make use of the Marxist referential, the dialectical materialism, as a theoretical substrate in order to interpret reality. The instruments used were semi-structured interviews with ten individuals from the mental health staff. It was concluded that intra-team relations and integration are decisive for de-institutionalization, which implies transformation of the professional roles in institutions, as well as centralization of the therapeutic work in the listening and in the validation of the user’s identity appear as a work style of the Service.
The scenery of the study
This work was developed at the Mental Health Community Center of São Lourenço do Sul/RS. The institution is characterized by offering integral attention to mentally ill individuals, through a network of services of integral attention towards mental health. This institution comprises the following services: Psychological and Psychiatric Ambulatory, Center of Psychosocial Attention – “NOSSA CASA”- CAPs, the mother-cell of the project, Therapeutic Workshops, a Psychiatric Unit in the general hospital, Home for Children and Teenagers, “Nosso Lar” – Protected Home. The network is accredited by SUS – the Brazilian Health Public Service – and gives attendance to people from the urban as well as the rural areas of the city. The purpose of the service is communitarian attendance to mentally ill individuals under the perspective of Psychiatric Reformation. This is emphasized by the permanence of the person in his/her environment, integral attendance aiming to meet individual needs and the practices of social reinsertion and rehabilitation.
This is a qualitative study which uses the Marxism referential, the dialectic materialism, as a theoretical substratum for the interpretation of reality. Abstracting the issue of negation-overcoming for the referential of psychosocial rehabilitation from dialectic approach, I consider necessary to deny the assistance reality of the individuals with mental disturbs centered on the model of damage, deficit, toward the rescue of centralization of the focus on the abilities and the search of work to reach the aims of psychosocial rehabilitation, citizenship and quality of life. The interviewees are identified in the text by letter “A” and the number of the interview (for instance: A1, A2, and so on).
In this area I approach the relations established between the team and the users, and the intra-team. The centralization of actions, having a therapeutic relationship as its basis, is very concrete in the exposition of the actors, as well as the importance given to therapeutic listening and the fact of being present as a therapeutic instrument in everyday experiences. The assistance practice permeated on the responsabilization by mentally ill patients is evidenced by the interviewees’ speech. Negotiation, attention, respect, affection, validation of identity and freedom are seen as therapeutic processes that lead the users to an increasing in the quality of life.
The biggest referential, the biggest instrumental of this is the human relation. And for that, there must be good human relations of all work structure. If there is not, it does not work. It gets much harder. So this was the original idea of the creation of a service that is named “NOSSA CASA”. When the house is “NOSSA CASA” we are citizens inside it, and there is a flattening of hierarchies. This is the biggest secret (A1).
Through the speech, it is possible to notice the centralization of work in human aspects, regarding patients as much as employees. The flattening of hierarchies remits to the freedom of weaving suggestions, comments and interventions by the whole team. This flattening is a concrete reality; however it can be understood by at least two forms. Firstly, as a real horizontality in all instances, contemplating the aspects of doing and administrating the care. Secondly, I visualize that this flattening of hierarchies, many times, was used to fill in brackets regarding the physical presence of professionals, mostly the technicians. There was a technical necessity that the professionals present in “Nossa Casa”(technicians and non-technicians) could keep up with the attendance and the resolution of demands that were presented. In this case the flattening comes from an external necessity, related to making, the practice. In sum, it is a flattening derived from the convenience and/or necessity.
Saraceno, Asioli & Tognoni (1997) highlight the attitude of integration of the team as one of the several variables that determine the infirmity and/or the efficacy of the intervention. These variables, related to the organization and to the style of the work of the team, can be either favorable or unfavorable. They point to an integrated team as a favorable variable, that should have the following characteristics: distribution of power, importance of knowledge, clear and non contradictory communication; discussion and planning of the work, socialization of knowledge, self-criticism and periodic evaluation of the results. Among the factors that obstruct internal integration, the authors point out the practical separation between the different professional roles, the differences as to the levels of empowerment and cultural aspects of the professional roles, and the conflicts and frustrations among the members of the team.
I understand that “good human relations in all work structure” remit to relations not only among the users, but also over all among the technicians. What I could apprehend is that many new services meet serious difficulties and tensions among the technical team, commonly in relation to dispute of power regarding the coordination of these services.
In some cases the teams de-structure themselves (or are de-structured), seriously compromising the work developed. And while the professionals dispute power between them, the users are forgotten. That is, the service, constituted a priori for the user, ends up being a stage of dispute by the technicians, who should provide the care. Thus, the disintegration of the team constitutes itself in a variable that favors for the development of the infirmity, compromising the efficacy of the interventions.
According to Saraceno (1999, p. 95-96):
A high quality service should be a “place” (constituted by a multiplicity of communicative places/opportunities) permeable and dynamics, where the opportunities (that is, the resources and the negotiable occasions) are continuously available to patients and technicians. In fact, if from a service (of a fraction of it) the “endowment of “opportunities” is established in a limited dimension and once for all, the result will turn into a progressive blindness of that part of the service in relation to the attributions that he does not have [ ] the passage from “space” to “place” is a complex process that is concerned not only to the architecture but most of all to relations among people (affective and of power).
Other authors such as Ribeiro & Teixeira (1997, p. 336) point out that the disputes among professionals conduct to “sterile antagonisms and to political/epistemic disputes by knowledge/power, besides contributing for the fragmentation of subject-object of their interventions”. Despite the changes that have been processed in the country regarding assistance to mentally ill patients, the authors question “if the assistance effectively given has been transformed concretely toward the ethic values of our times”, independently of the theories or adopted techniques.
I would like to add Basaglia’s inquietudes (1991), where he emphasized that it is not the redefinition of the institution regarding structural terms, through new schemas, that will guarantee that the actions will be therapeutic, but the relations that will be established inside the new assistance organizations.
I understand that the new services should be attentive for possible (and concrete) contradictions that might co-figurate in its interior. One of these contradictions refers to the discourse about the practice not to be suitable to the practice developed in many cases. It seems apparently easy to theorize about a good human relationship, however, I question: will this relation be operationalized in practice? Or it will get lost in the meanders of the power?
Basaglia postulates that the contradictions of the real should be dialectically experienced. He points out that if the contradictions were not ignored or postponed, in an attempt to create an ideal world, but faced dialectically, the community would become therapeutic. He highlights that, for this comes true, possibilities and alternatives must exist. Only this way the dialectic would exist.
It can abstracted that different authors call the attention for the relations established between people – professionals and users in the services, highlighting the importance of explicating the contradictions, as pointed out by Basaglia. Our concern while professionals, must be directed to the questioning of our praxis, in order to our everyday practices effectively correspond to practices ethically suitable with the philosophical principles adopted.
We have something in common, which is the … the humanization of the service, that is to make him a person that can live again inside the community, to find his place, and that a person might live a happier life than the one he was having so far. I believe that these practices that we use … they come to what we think … which would be ideal for the human being. To receive respect, to receive the affection of the people and … I believe that the time has showed us that … these people somehow got to get reorganized (A8).
This speech is related to the human relationship established with the users. However, the individual under study makes a concrete reference to the practices developed, mentioning respect and affection. These attitudes certainly should exist in a good service of mental health. However, they cannot be constituted in the only alternatives offered. Undoubtedly the users need affection e attention, but they also need interventions that might provide concrete transformations in their lives.
Saraceno (1999) alerts that, in the internal integration of a good service, organizational and affective strategies should be contemplated. He highlights that the permeability of the resources and the knowledge should surpass the separation of them. I understand that this stage should constitute itself in the ideal to be reached by the services. The movements in the services, when conducted towards organizational and affective questions concomitantly, would lead to dialectic overcoming. The same way, when the conflicts and the contradictions were dialectically worked, and not occulted, the discontinuity, the appearing of the new, would be promoted, and the explicitation of the contradictions will conduct to qualitative improveness that will process changes in the real life of the services.
… And I think that, in my opinion, the most important is … we talk with all these people … here in the house … I am speaking about the user now. Talk to him a lot of conversation, a lot of conversation with the people, no need to impose anything, it must be like that, that must be like this, or like that. I think that … of course everything has its limits, isn’t it? But a lot of talk, I guess so. (A2).To talk and to give attention are seen as interventions that result on the strengthening of the users. The negotiation with the users is established through “no need to impose anything”. However, the interviewee states that sometimes there is the need to establish limits. The establishment of partnership with the family is seen as a positive factor, by the possibility to listen to what the family has to say about the user. Commonly this kind of intervention leads to a unique language, through which professionals and users establish a common approach. This leads to positive results for both, that is, families and users. Once the user will not receive information and different management, the family, on its hand, will feel supported by the team.
These people need a lot of attention. And it is this kind of attention that makes them to stay, as I said, they, they, have the courage to face the world that suddenly they have lost, I don’t know the reason … now they have … most of the people who talk to us have got their families and … and give their opinions too. So, this kind of thing, not to be only locked or interned, under medicine, things like that, this kind of thing does not help much (A2).
The interviewee has a clear understand that the confinement, the reclusion and therapies centered in psychopharmacology itself do not bring results for rehabilitation. He expresses lack of knowledge on the possible reasons that led users to get mentally ill. This statement corroborates with what was evidenced in the analysis of Wetzel (1995): the non-technicians would not need to know the scientific knowledge for their practices. Non-technicians realize this as a limiting factor, at the moment in which the knowledge is limited to some professionals.
I understand the importance of extending the knowledge indiscriminately to the employees. I highlight that the adoption of this behavior would only bring consistency to the interventions done. This homogeneity, kept the proportions, should not result in empty academicism and formalism, but attend demands for the practices not to become fragmented. As approached before, the knowledge is directly linked to power. The analysis of these relations becomes important in order to establish the understanding of this knowledge/power centered in the hands of few “enlighten” individuals. It is established, then, the distinction between intellectual and manual work. The knowledge constitutes itself in the only way of emancipating the human being.
The group is … that user’s stuff, he opens his heart, I guess this is one the things … the important thing is to know to listen. I guess this is what they have. You sit and talk and discuss. And they tell you about their lives and you listen to. That is a benefit to everyone (A4).
The hand to hand, the contact, the talk, that really close thing … very closely, to listen to people, is not simply someone who takes a kind of medicine, that is a number … That is a person who has some difficulties that we … can sit and talk to him/her, to listen to what this person has to say (A5).Listening represents, under the professionals’ conception, a benefit for the users because of the attention, availability of time, individualization and the other to be able to talk freely, to talk about his/her life, his/her fears, necessities and difficulties. This is visualized as highly therapeutic. The differential is to treat the “person”. This implies to welcome the user in his/her subjectivity.
The fact of listening to the other, freely, is for Dewald (1981) a unique experience, in terms of significance and value. The author points out that the non-therapeutic relations are based on giving and receiving, in which it is implicit that each participant should showed himself/herself interested by the other. On the contrary, in the psychotherapeutic situation the exclusive area of interest is the patient, his/her difficulties and problems. He highlight that it represents a privilege to have someone who listens to us and treat us with attention, respect and interest.
Andolfi (1996, p.71) highlights the availability as an important element to listen to verbal and non-verbal language. Listening, for this author means also the construction of a suitable and functional interaction. This is characterized by an external space (the setting) and the mental, internal space. The author highlights the importance of the silence in the therapeutic listening, conceptualizing that “listening means to suspend one’s own propositions and to allow the access of everything that comes from the other”.
Another important listening element, considered by Dewald (1981), is the therapist’s capacity of empathy, expressed through his/her capacity of in putting himself temporarily in the patient’s place, when he manifests his thoughts and experiences. And through this experience to understand the meaning behind the material manifested by the patient.
Bezerra Filho (1987), analyzing the situation of psychiatric interview at the level of ambulatory attendance, describes important characteristics of the students’ listening compared to the diagnostic attitude. The author understands that the diagnostic attitude of the interviewer prevails in the teaching of clinics psychiatric practice, in detriment of an attitude of listening. He points out that a mentally ill patient, in his interpersonal relations, experiences invalidation of psychosocial identity, mostly when this patient is in an adverse social-economical context. Thus, in the process of listening, the patient is given the opportunity to realize himself as an individual, through the validation of his/her speech without discrimination, as a protagonist of his own history.
I consider that the real therapeutic involvement demands availability, interest, time, affection, and sensibility in the establishment of therapeutic relations. Without these minimum requirements, hardly the aspects concerned to psychosocial rehabilitation of the users, the way I conceive, will be accomplished in its totality. It matters, over all, an attitude centered in listening to the other, which reveals to be different from hearing, a physiologic function that demands a neurological constitution. In listening, we place ourselves in the objective external space and in the subjective internal space of the other, through an attitude of participation, of sharing the experiences, as well as being present in silence. Silence might acquire different meanings. I mean here the silence which denotes an attitude of acceptation, empathy, comprehension, establishment of a relation of trust. I consider these attributes fundamental substratum for the evolution of a rehabilitative project. “And, ‘to de-psychiatry’ the knowledge of psychiatric patient means not only release him of the limits of a diagnosis but also try to look for (re) meeting him while an individual of his own history” (Bezerra Filho, 1987, p. 123).
While the traditional practices transformed the mentally ill person into an object (and his body), new perspectives break up, in which the subjectivity is reintegrated with the social body of mentally ill patients. This consciousness about the importance of these interventions produces overcoming movements of the state of object in which the patient was relegated. And, corollary, the reconstruction of a physical, subjective and social body.
I think that … I think it is this respect we owe them … as citizenships. The respect we owe for the member of the family who comes here to ask for help …because suddenly it is just to treat, give medicine, leave the patient like he is or put him in the hospital, if the attendance is not well given, we go there, to see what is not good (A6).
Well, the first thing, …, is that we are concerned to treat mentally ill patient as a person that … deserves all our respect, all consideration, and … it is a relationship based on sound sense, in an affective attitude, … and more, worried about … the emotional of the person, that he/she has a, a … a little of happiness, to bring a little of … of encouragement for this person, and I think this leads to … to a positive thought that … that helps people (A5).
The respect to the user and his family is visualized through a concern and active responsibility of the welfare of both. A differentiation is done between symptomatic treatment, hospitalization and everyday accompaniment of the user in the service. The respect to the family is expressed in welcoming the mentally ill person. And, when feasible, this welcoming is not restricted to listen to him/her empathically, but to produce concrete actions that might change the context of life.
Respect, for Andolfi (1996), comes from the valorization of dignity and the unity of each human being. Respect transmission derives from a genuine sensibility and consciousness of the human being. Actions do not become valid if these components are not present. Respect is realized through the attention given to the person. The availability of the therapist is manifested through the importance given to the interlocutor’s problem and the respect given to him. The author highlights that the differentiation of the symptomatic behavior of the individual represents a signal of respect for the client. Through this behavior, which remits to not reduce the individual to the symptoms that he presents, positive aspects and potentialities of the individual are revaluated. Thus the author understands that on one side there is a person and on the other a symptomatic structure, as separated entities, in virtue of the individual’s complexity to be much wider than his problems. Another dimension of the professional’s respect, approached by the author, refers to the respect to the client’s problem, when suffering and difficulties are realized, from the evaluation of the gravity under the client’s perspective e not from prejudiced evaluations of the professional. This respect is expressed, as a last resort, when responsibility regarding actions performed occurs, differentiating those that are the therapist’s competence and those regarding the client.
This active responsibility, sometimes, seems to exceed the limits considered adequate, when it results in excessive protection by the team, as characterized in the following speech:
They always feel very protective by us, and then, from that, we have to start to show them the world outside, how it is, what their necessities are, and what they need to do to feel well in their own houses. The necessity to work to have a better level of life (A10).
In the speech a paternalist attitude is evidenced, which becomes to be noticed by the professionals, when they recognize the necessity of a bigger independence of the users. To help, to get, to arrange are verbs that denote this situation. Even if one of the factors involved is economical difficulties of some users, I understand that an empathic attitude without being paternalist might be established and to accompany the user in the process of emancipation. I agree with Pitta (1994), when she states that the Centers of Psychosocial Attention should not be more than a passage place. The author points out that these services should always preserve non-permanence as a characteristic, but to welcome people when they need.
The attributions and limits of the professional, the user and the family were commonly discussed in the meetings of the team. While some defended a position considered more paternalistic, others assumed a position turned to the necessity of the user to face and to conduct his life. I understand that there must be neither an excessive paternalism nor an absolute non-responsibility. The attribution given only to the user concerning the failure of some interventions, the non-responsibility, results in a very comfortable and convenient attitude for the professionals. We should provide help during the way, always visualizing the process of emancipation of the user. The sensibility to visualize/understand these movements might constitute in the differential between responsibility and paternalism.
It is not the big workshops that make the service better; I believe that are the small things done everyday, taking care of the user. It is the shoulder that, that permits … permits the person uses in case of sadness. It is the word the person needs to hear to feel better. These are rehabilitative processes. To see the other as a human being and not a number or a figure that, by chance, came to our service. No, this person is a human being that according to his potentialities, his necessity might use one or another … another rehabilitation process (A8).It can be observed through this collocation that the attitudes considered relevant for rehabilitation are the welcoming, the listening to the other, and treat him as a human being. The interviewee recognizes that it is not the workshops that make the service better. Maybe because she recognizes that the workshops might constitute in entertainment places not in rehabilitative ones
I agree and recognize the importance of care, affection and welcoming. However, I consider that these are (or should be) intrinsic characteristics of the services of mental health that work under the context of psychiatric reformation. I visualize the necessity of, maintaining these characteristics, performing movements in the sense of performing real transformations in the life of the users, through the breakage of entertainment and the establishment of resources exchanges. In another way, the standardization of everyday activities that reproduce behaviors is promoted, creating chronification and blindness of the professionals regarding this problem.
I consider, just as Saraceno (1999) and Rotelli (1990), the necessity of breaking up with the entertainment and the necessity to practice de-institutionalization in any place, not only in the closed institutions. If the new services, countersigned in new practices, do not daily exercise rethinking their strategies in an open and clear way, might reduce rehabilitation to an attitude only affective to the users. This kind of attitude is, undoubtedly, important, however, it does not constitute itself in the only axle to be worked in rehabilitation. This question could be considered as a subjective question that involves rehabilitation. Nevertheless, I consider necessary to re-dimension the rehabilitation in the objective questions, the work in the axles house – work – social relations – family. To work both the objective and subjective questions simultaneously, in order to reach dialectic overcoming.
There is a great resistance in systematizing the actions from individualized therapeutic projects, as if systematization were an unnecessary bureaucratic impediment. I understand that individualized therapeutic projects should not be considered as merely normative processes, but as a set of norms and strategies that direct the actions. I understand that the lack of these projects compromises users’ rehabilitation at the moment in which a set of strategies designed and upon them it is possible to evaluate the actions established for each user does not exist. Without this criticism, Psychosocial Attention Centers might constitute as permanent places, in which patients spend the day in a number of activities and go back home in the evening. The biggest difficulty, in this context, is leaving from a protected place. A project where rehabilitation is contemplated in a short, medium and long term might stop the “forgetfulness” of keeping a user indefinitely in the CAPS. As referred previously, these places should be characterized as passage places.
Saraceno, Asioli & Tognoni (1997) affirm that therapeutic measures (psychopharmacology, psychotherapy, rehabilitation techniques) cannot be employed in an isolated way, without the due psychological and social contextualization of the patient as well as the organization and work style of mental health service. The authors emphasized that any therapeutic intervention should be part of a project that contemplates some features, such as: planed by the whole team, with clear and well defined objectives, performed by all members of the team and modifiable through the evolution of the results.
Saraceno (1999) raises the importance of the evaluation of actions in order to be able to identify which ones are relevant for the treatment and rehabilitation. In the absence of knowing which of these actions were really projected and developed, this evaluation is practically impossible. The author highlights that, when a set of interventions is successful for the user, the professionals signal them, and they attributed them to this or to that intervention, without clearness and evaluation. Thus, I highlight again the importance of minimum systematization of the services. I understand that the respect for the user also derives from the respect which his specific project is dealt with, unique of rehabilitation.
Through the interviews I could apprehend a certain difficulty regarding the description of the several rehabilitative practices used. While the workers of medium level point out some practices developed in a more concrete way, the technicians reported to the same practices in a wider, generic way. Here contradictions came up: the theoretical discourse not always corresponds to the development of its practice. The practices reported by technicians refer to those developed in the traditional paradigm: appointments, groups, meetings and the establishment of a human relation with the users.
I retake Kosik (1995) who, through the dialectics of concreteness, points out that the comprehension of reality only occurs at the moment the thought destroys the pseudo-concreteness. And under this destruction, relations like products of the man praxis are unveiled. The author highlights that the reality can be changed .as we produce reality, and when we get aware that ourselves produce this reality. The destruction of pseudo-concreteness, through which the thought dissolves the fetishing world ideal to reach reality, is obtained through the critics of praxis and the dialectic thought – which breaks the world of appearance to reach the essence.
We try to motivate them for … life, we try to orient them in the space of time … what else could I say … it is so wide the activity that we do there that, sometimes, we miss words to put it. At last, I think that basically, what is done, is done with care, it is touching, hugging the patient, which is what they need more, in these hard moments, of difficulties, of psychic suffering […] we motivate them, helping them, helping them in their everyday, and this takes time, and sometimes we get frustrated, but the answer comes (A10).
The interviewee above feels very compromised and takes active responsibility by this performance. Permeating all the process of the performed interventions, it is found an affective attitude. The interviewee sees this attitude as fundamental for the user in the hardest moments. The taking responsibility is expressed when he mentions the necessity to “motivate them for life”. This high level of consciousness, this takes responsibility by the user, brings a lot of frustration when the answers of the users are not those wished, over which the interventions were performed.
This is another side of the work developed with chronic mentally ill patients: the difficulties to satisfy to the demands designed by professionals. This takes to a feeling of failure, of impotence of the team, when, because several different interventions, the patient does not progress. I see the need to work the team, regarding these situations. On the contrary, this professional ends up assuming the failure of the interventions and, as the time goes, starts believing that it is not worth to invest on the user anymore, who has no conditions to get rehabilitated. Thus the user is placed aside and others, with “better conditions”, have the preference. Frequently we see professionals who formulate different explanations for that. This imposes a situation of acquiescence, of impotence, which might be contagious for the team, in its totality. This acquiescence, whether extended to the family, will corroborate to the hopelessness, normally already instituted by the chronic disease. I understand that the hope is the only blessing we cannot take away from the families, since there are many families and people that can only face difficulties of having a mentally ill member inside the family thanks to hope.
Saraceno (1999, p.95) approaches the question mentioned above, when he claims that a high quality service must include all the patients. According to the author, bad services are those that establish hierarchies of intervention to the patients, according to the logic that “those who cannot now, will never be able to”. Thus, they end up being excluded inside the service. It is important to highlight that, according to the author, it is the patient that finds difficulties to adapt to the rehabilitation program but this does not mean he cannot be rehabilitated.
The centralization of the therapeutic work in the listening, in a respectful attitude, and in the validation of the users’ identity, appears as a work style of the service. The relationship markedly human is considered as a rehabilitation factor for the users. I think that these differentials that are in the periphery of the actions, introduce qualitative improveness that are inserted in people’s everyday life. However, if these characteristics assume a central role, in detriment of other aspects; rehabilitation turns to be reduced to an affective attitude. Undoubtedly this is important, but it cannot be the essence of the work developed. Dialectic overcoming is reached at the moment in which subjective and objective aspects from singular demands of each person are met together in the same historical individual.
Some contradictions are identified such as the inexistence of individualized therapeutic projects and structural separation between who executes rehabilitation and who gives treatment. This was evident in the speeches of the interviewees. While therapeutic attendants and nursing auxiliaries reported to the practices concretely, on the speeches of technicians prevailed a generality. Deepening these questions remit to resistances produced and to the negation of this reality. This evidence questions deeply the role of the technicians, and the deriving relations of knowing/power. As pointed out by the authors of the Basaglia’s tradition, the de-institutionalization derives fundamentally from the changes in the established relations, which implies transformation of the roles in the institutions.
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