The International Journal of Psychosocial Rehabilitation

Halfway House: An Alternative to Rescue the Rights and Citizenship of the Mentally Ill Person.

Edna Paciência Vietta, MD
  Professor from the Department of Psychiatry and Human Sciences of the
School of  Nursing at Ribeirão Preto- University of  São Paulo.

Toyoko Saeki, PhD
Department of Psychiatry and Human Sciences of the
School of Nursing at Ribeirão Preto- University of  São Paulo.

Darci de Oliveira Santa Rosa
Doctorate Student from the Interunit Program of the
School of Nursing ar Ribeirão Preto - University of  São Paulo.

Lúcia Aparecida Ferreira, MA
 School of Nursing at Ribeirão Preto- University of  São Paulo.

Citation: Vietta, E.P., Saeki, T., Santa Roas, D., & Ferriera, L. (2000)  Halfway house: an alternative to rescue the rights and
citizenship of the mentally ill person.  International Journal of Psychosocial Rehabilitation. 5, 19-28

Abstract:  This work analyzes the halfway house as an alternative psychiatric assistance and important means for practice of rights and citizenship of the mentally disabled. Based on the experience of interns at a halfway house belonging to the psychiatric hospital of Ribeirão Preto, state of São Paulo- Brazil. It rescues part of the evolution of the psychiatric assistance from the Mental Health Movement o the Desinstitucionalization proposal. The goals and the indication of the halfway house are recovered placing them in the context of the Brazilian Reform. The proposals and studies of the Psychiatric Reform in Brazil began in the 80s, becoming enhanced at the First National Conference of Mental Health held in 1987 with the bill 3657/89 presented by Paulo Delgado disposing the progressive extinction of the Brazilian psychiatric hospital. Among other things, the proposal suggests internal democracy of the services and institutions, including new standards of services that have the patientís citizenship as its fundamental premise, involving the rupture with the institutionalization paradigm. The project indicates the halfway house, among others, for the chronic patients. As a result, we decided to investigate the experience of interns at the halfway-house with the following goals: 1) to obtain references about the experience of the interns in a halfway-house; 2) to collect from the declarations the aspects that reveal this as being an opportunity to practice the rights and citizenship of a mentally disturbed person; 3) the analysis of the aspects within the context of the Psychiatric Reform Proposal. Methodology: Sample: Nine (9) ex- patients living in Two Halfway-house. Focusing interview: focusing on the experience of living in the halfway house guided by a guidebook consisting of five (5) straight questions to obtain the reports. Analysis: with the material at hand we proceeded with the process of Thematic Categorization. Results: The subjects were satisfied with the halfway house. They accuse the hospital assistance for the lack of freedom, respect, slavery and stern discipline. They consider the halfway house a pleasant place where they are free and respected as people. Conclusion: The halfway-house is an appropriate place to practice freedom, individuality, and independence, where the mentally disabled can fight for their rights and citizenship.

Nowadays in Brazil and in the whole world we have noticed a new act of criticism to the asylum and hospital centered model for treatment of the mentally ill person, considered a hectic and old-fashioned system as it has justified segregation, prejudice, disrespect to the rights of citizenship of those who suffer from mental disorders, or even those who vary from the behavior considered normal.

Deinstitutionalization certainly is a process to be started irreversibly in the whole world and must be properly replaced by more human, less humiliating, less violent, more therapeutic alternative institutions.

In the rest of the world theories and alternative practices for the asylums have been happening mainly after the Second World War as show the following acts: Therapeutic Community, Community Psychiatry (in the USA), Anti-psychiatry (England), Sector Psychiatry (France), Democratic Psychiatry (Italy); in Brazil these acts have just become outstanding after the democratization of the country and the reformation in Italy.

The act for reformation organized by BASAGLIA supported by the Radical Party in Italy promoted the complete revocation of the psychiatric legislation in force, assuring the absolute suspension of every form of institutional control over the insane people and insanity. This act had effects on politics on in May 13, 1978 the law 180 is approved and is named after Basaglia.

In Brazil, at the second half of the 70ís, the effects and announcement of these experiences are noticed and a time of intense accusation about the anti therapeutic and harmful conditions of the psychiatric hospitals. Reflection and consequent awareness about the psychiatric issue is started as part of the national issue. In 1984 Basaglia was in Brazil making some conferences about Alternative Psychiatry. New acts arise with professional, social and political mobilization. From 1987, debates about the situation of the psychiatric hospitals and mentally ill people interned in them increase and the movement becomes stronger and reaches the political milieu in an effective way.

In this context, the bill 3657/89 by the congressman Paulo Delgado comes forth suggesting the gradual extinction of psychiatric hospital like asylum and their replacement for other alternative social resources such as halfway houses, shelters, leisure centers, community centers, day hospital, night hospital, psychiatric units in general hospital and psychiatric emergency units. This bill is going through the proper procedures in the National Assembly and has been arousing warm debates of the Brazilian society on the character of the intended changes. It brings themes about the citizenship of the mentally ill people, limits of legal reformation and new models of care to the mentally ill person including the Halfway House which we will discuss in this study.

Halfway House according to OLIVEIRA (1989) is a human and efficient alternative to the treatment of the chronic patient for the following reasons: 1) It is a small institution which takes the patient from the anonymity of the hospital; 2) It replaces the Medical model by the family model, propitiating a better appreciation of the healthy part of personality; 3) It is a proper place for every chronically ill person where he can make use of his righteous areas; 4) It represents an opportunity of approaching the patient with his family and community through a comprehensive and cooperative approach which promotes the family interest in the patients.

The halfway houses in this study take part of a project created by a governmental psychiatric hospital in the region of Ribeirão Preto.

This project comes from the unfolding of a rehabilitation program called Therapeutic. Village whose patients, besides owning acceptable conditions of independence and self-administration, show the desire of breaking the bond with the institution.

Thus, the halfway houses model was created for, these patients in discharge conditions (and) who stayed in the hospital due to essentially non-clinical reasons but due to sequels of mistaken policies, whatever their reason is (lack of social and economic resources, social abandon and compromise of their productive capacity).

It is expect to offer ex-patients of the institution through the halfway house their real social integration and recovery of citizenship which would set them free from the State custody.

Nowadays there are three units like this two units for women and one for men, and the first one was opened in September, 1992.

This project counts on the effective participation of community since the halfway houses are managed by entities with funds from the government which are given to a civil organization hired by the government through selling or bidding at auction process.

Besides managing funds for the halfway houses, the institution which provides services is responsible for keeping an advisor whose responsibilities are: coordinate meetings with the residents; be an element of linkage between residents and hospital supervision staff; take part in periodic meetings to assess the staff and facilitate the development and maintenance of an environment which makes possible a good relation between residents and community.

The Psychiatric Hospital is responsible for offering technical support to the halfway houses which is made by a staff formed by the technical director, management director, nurse, social worker and therapist.

The social worker and the nurse make periodic visits to the halfway houses as well as take over the supervision of the advisor's work.

The halfway houses work in private properties located in a middle-class neighborhood of town, with complete substructure.

The houses are simple, of changeable size depending on the number of residents- about three to five residents. They are furnished end there are household appliances which enable their normal functioning. They are also provided with food and consumption materials for both residents and their maintenance.

It is important to emphasize that the residents receive a retirement income from the Benefit Program of Continued Assistance and the amount of money earned is managed by the resident and is used exclusively for personal expenses.

According to what was said before we chose the following objectives to develop the present study:

1) Obtain testimony of grasp of life experiences from the residents in a Halfway House.

2) Take aspects from the declarations which reveal the rescue of rights and citizenship of the mentally ill person.

3) Analyze these aspects in the context of alternative model of Halfway House.

Sample: Nine (9) ex-patients living in two Halfway Houses.

Method and instrument: Focused Interview: focusing on the experience of living in the halfway house guided by a guidebook consisting of five (5) straight questions to obtain the reports.

Procedure: After permission of the institution, some visits were carried out in the halfway house in order to establish a friendly relation between the research worker and the residents. A previous meeting was done in every halfway house to explain the objectives of the interviews. It was informed that the participation would be voluntary and secrets would be kept. The research worker stayed in the halfway houses part time for a week to obtain the reports. The halfway house advisorís room was used. The research worker was at the residentsí disposal in order to interview them whether they accepted to take part in the research. All the residents (9) - four (4) from one halfway house and five (5) from the other - showed up to be interviewed using a guidebook consisting of five (5) straight questions regarding to their lives in the halfway house. The interviews were recorded with the residentsí permission aiming to obtain accuracy of results. The reports were classified according to the steps suggested by GIORGI (1985) adjusted by Vietta (1995) as follow: 1 - Careful reading of the overall content expressed by the patient in his report in order to understand its meaning in the global structure; 2 - Texts reexamination aiming to identify units of speaking, understood as locutions of effect on the thematic context; 3- Description and classification of aspects which show contents agreement from several reports expressed by different subjects and looking for what seems to be constant in everyoneís speech; 4 - Organization of locutions or their meanings in categories; 5 - Thematic analysis of these groups and general contents.

Analysis of reports

The question "How do you like living in the Halfway House". For the residents the halfway house is an excellent, calm and peaceful place. They hope they can get over this situation and they state that,

"It is gook and much better. Here we are fine, we can work peacefully and happily".

"It is peaceful, a harmony, I am happy now, I think I can get better here".

The residents feel free and get more autonomy and freedom with responsibility.

"It is good to live here, we have freedom, I do my laundry, everybody does his laundry, Graça makes the meals, cleans the house and I walk freely on the street".

"It is calmer and free, it is funnier and better. We can walk around and nobody annoys us".

The residents express satisfaction when their individuality is respected and their feelings of ownership are protected.

"It is peaceful, everybody has his stuff, we get by more freely".

"It is very good. I am learning how to take care of what belongs to me".

Being allowed to get out of the halfway house for a day makes the residents foresee a future life and look for financial stability.

"We have retirement income, we will get a minimum wage, but I am thinking of getting a job, making more money and live with my girlfriend".

"It is very good, I would like to meet any relative of mine one day, but not to live with him, just as a friend, but I donít want to keep on living here".

According to the Universal Declaration of Human Rights, article 13 "Everyone has the right to freedom of movement and residence within the borders of each state". In the Citizenís Manual the practice and delight of all the social, political and civil rights of people are protected including the right to come and go (movement) guaranteed to everyone in the whole national during peace time, since there is no strict prosecution against them or they are in the act of crime. The problem of the mentally ill person in Brazil is the disrespect to his legal condition of citizenship. The word which we use to express citizenship is entirely impressed by the universal rational tradition that identifies citizenship as the complete practice and possession of what every man would have in common: rationality. That is why the mentally ill person, seen as insane, is excluded from citizenship. Actually the citizenship condition of the mentally ill person is impressed by the paradox written in the citizenship statute of the mentally disturbed person indicating that the negative influence of this social condition does not involve the faculty due to political and care or merely conjuncture reasons, but due to structural reasons established during the historical organization of the mental disorder figure. Based on the terms used in the mental disorder, the social removal of the mentally ill people was authorized as well as deprivation of the other social rights, that is, his entire citizenship condition. The Halfway House rises at the moment of proposals of changes with an alternative of rescue of this condition.

The reply to the question "How does the Halfway House work?" makes clear that the environment of this community is designed in order to help the development of the residentsí potentialities, that these residents are stimulated to try increasing responsibilities, try new attitudes and behaviors and develop their social relationship.

It is obvious, through the reports that every resident is reliable and they are aware of the task to keep the community environment. It is also obvious that the local community starts contributing to the support of the Halfway House.

"Everybody does a kind of housework, everybody helps because the house belongs to everybody".

"Everybody does a kind of housework, Graça prepares the meals. The remaining people help do the cleaning".

"Everybody feels free, Dalva does the shopping, the Spiritual Center based on Allan Kardec in front of here helps with the remaining chores".

"Everybody is responsible for something. Dalva does the shopping, takes care of the rent and gets nervous about the mess. We have meetings for explanation on what we are supposed to do and to reprove the residents who do not accomplish their duties or scream".

In response to the question "Do you have any complaint about the Halfway House?" if so "Have you ever thought of going back to hospital?"

"No, only if I have any problem (crisis) and they take me there by force".

"No, I have no complaint about here, I want to stay here until I die (this patient does not have family)".

"No, Heavens forbid. I want to stay here until I can go out and live with somebody else or by myself in a house".

"Heaven forbid, Iíd better die. It is a mess in there. Anyway, nobody can control the insane people".

"I donít want to go back to the hospital anymore. We couldnít even talk. There is no use complaining. Here it is different, when we donít like anything the only thing we have to do is speak during the meeting".

The article 10 of the Universal Declaration of Human Rights states that "Everyone is entitled in full equality to a fair and public hearing by an independent and impartial tribunal, in the determination of his rights and obligations and of any criminal charge against him". The speeches of the residents are affirmative regarding to the disrespect of this right in the psychiatric hospital. The major complaint of ex-patients related to the hospital is the lack of freedom, oppression, abuse of authority and lack of rest.

"We are not free to do anything there, you have to do everything they order. You canít rest. We canít do what we want".

"We work like slaves there and we canít complain, sometimes we even starve because we canít eat out of the meal time".

"The only thing we do is work, we do not take a rest, we may rest only away from them. It is very bad for we canít run away".

"We canít even open our mouth to speak, we only work as slaves. The food is terrible".

It is obvious that the mentally sick person is disregarded in his rights, forced to do what he does not feel like and work when he is not up to. They complain about injustice and not having anybody to turn to.

In the Citizenís Manual, it is obvious the Right of doing or not anything, except when the law determines it in a different way. In the State of Right, every person is free to do or not to do or quit doing something if the law does not demand different form, ability or duties. Any act which forces somebody to do or quit doing anything when the law does not demand is considered illegal constraint. Hindering somebody to do something when it is allowed or ordered by law is an illegal constraint as well. Somebody who forces somebody or quit doing anything, if not by virtue of law, must be immediately arrested in the Act of Crime. If the co-author is an authority, "Habeas Corpus" would be appropriate.

Another right of the citizen is the respect to his body privacy. The patientís need for rest by the administration of medication and opposition to rest is an infraction of this right. Nobody can be subjected to torture or degrading treatment. It is know that mentally ill people take medicine which makes them sleepy and if they are hindered to sleep or rest, it is considered a torture. When an authority disobeys the body safety of a person it is considered abuse of authority. No member of a staff can take advantage of his position to torture, assault or force a person to go through a degrading treatment. The article 5 of the Universal Declaration of Human Rights states that, "No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment".

It is noticed that the halfway house shelters few residents, therefore, the staff can control more efficiently the medicine schedule which improves the conditions of the residents making the environment more therapeutic and manageable.

When asked "Has was your condition before coming to the Halfway House?" the residents answered that they got bad in hospital, abandoned and neglected, with proper medicine control.

"I went insane, I had dizziness, I felt lonely, I saw things. Here we have attention from the doctor, nurse, social worker and Dalva. Here I take my medicine at the right time. I donít feel dizzy and I donít see things".

"I heard voices, I walked around, I saw things, I couldnít work. Now the doctor has changed my medication and I take it according to his schedule. I am much better. In hospital I got worse because of the medicine. There I couldnít talk to the doctors".

"I really went insane, depressed, I didnít feel like doing anything. I just wanted to be lying, but they didnít allow us to lie down at daylight. I wanted to be alone, but they bothered me. Now I am better, sometimes I go insane, but when I am fine I help with the cleaning and I go for a stroll with Graça".

Dalva likes me, Graça likes me, Bertinília likes me. Do you like me?"

Most of the patients are psychotic who have been in hospital for over 25 years. Most of them have already been submitted to somatic therapies like electro convulsive therapy, with traumatic experiences of treatment.

"I had a good mental health, I worked at the Mercy Hospital, I took care of sick people, I gave injections, then I started getting worse, I ended up in a mental institution. I was submitted at least to 30 shocks. I have suffered a lot. Thanks be to God I am happy now. I am not complete treated but I can work and take care of my life. I ran away from my family. My father wanted to kill me. My father wanted to have sex with me. He had intercourse with me. I grew up and I was very ashamed of it. I didnít tell anybody. When I became a young lady I warned him I would tell what he did (she shows the scars on her breast). He attacked me with a knife. He was arrested. I became a whore and started taking drugs. I was arrested and taken to the hospital where I have been since then. I was submitted to many electro shock therapy sessions. My father hurt me so much. I think he is already dead. I feel protected here".

The responses to the question "What is a Halfway House?" the expropriation of the minimum rights and survival of the patients in this kind of institution is a confirmed.

"It is good because we have our house. We have arguments but we love each other".

"It is good here, everybody does what they are supposed to do, we go out together and we come back whenever we want to".

"Well, we werenít well treated in hospital. The other patients were nervous and had arguments with us. I helped with the cleaning. When I moved here everything has changed. I can sleep well and eat whenever I want to".

"We had no freedom and rest in hospital. We couldnít eat when we felt like eating let alone sleep well. Here everybody has his stuff, takes care of his things and everything is clean".

"We were in hospital, we worked like slave there and we didnít have anything. We got depressed. Here we do some job here or there and I already have money in the bank".

When you are not feeling well in the halfway house, you may rest. There is total freedom to do that. Dalva explains that it is not good to be in bed all the time, we must stay in bed only when we are not feeling well or when we are tired, sleeping too much is not healthy.

It is noticed that the awareness of citizenship, of being treated as person with respect is gradually conquered.

"We do some job here and there, I have already saved some money in the bank, the Spiritual Center helps us with the supplies. The only problem is that there are arguments among the women".

Problems are common, but they may be solved or worked out with a good conversation on behalf of the individual and group development.

"It is good, but some of us are not mature enough. Here there are arguments, lack of organization, but it is much better than in hospital. There are discussions because we can protect ourselves here. Once in a while Dalva (advisor) also helps us organize the house".

"It is good, it is like I was in my house. Our lives are calmer. It is different from the hospital. Here we can go out alone and make friends".

On being asked about "What has changed in your life after you came to the Halfway House?"

"Here I have a bed, a house, food, in the hospital I had them but it was confusing, nothing belonged to us. Here I feel that the house is mine and I can struggle for it and other things which belong to me".

"We have freedom, our lives have changed. When I was in hospital, I worked but I didnít earn any money. Now I already have some money in a savings account. I want to get a stable job".

"It was very good to come here. Everything has changed. I have another life. I was dead in that hospital".

"I got my freedom. I go to the primary care center by myself to receive the insulin injection and I take advantage of it to go for a walk, see people on the streets and talk to normal people. There we lived in dirty places, it was no use cleaning, it was a sty".

"We lived like slaves and even starved. It is different here. When we want to eat something we fix it ourselves. It is good to take care of everything".

In terms of the question "What are your expectations for the future?" the residents stated: assets, partner, job, occupation, money, peace and find their family.

"Have a house to live with my girlfriend, but just live, work and get a better life".

"Get a good job and work. I want to get money. I want to be respected in life".

"Live with my partner, alone with him, he doesnít want to get married. I want to have my belongings".

"Have a house, a telephone, money in the bank to live in Petrolina forever. I would like them to find he family in Petrolina. Poor, she cries a lot".

The Halfway House is an alternative of care that works as a resource designed to help the development of potentialities of ex-patients in a democratic and therapeutic environment where there is respect and accomplishment of human rights, as a result, the Articles of the Universal Declaration of Human Rights, respect to life, freedom and safety; some residents, besides their tasks, have already had a retirement income, fair conditions and protection against unemployment. As members of a society, they have social security and satisfaction regarding to social, economic rights which essential to their dignity and free development of their personality.

The Halfway House meets the several articles of the Universal Declaration of Human Rights because it does not hold its residents in slavery or servitude; the residents are not subjected to torture or to cruel, inhuman or degrading treatment or punishment; everyone has the right to recognition everywhere as a person before the law; everyone has the right to own property alone as well as in association with others; no one shall be held guilty of any penal offence on account of any act or omission which did not constitute a penal offence, under national or international law, at the time when it was committed no shall a heavier penalty be imposed than the one that was applicable at the time the penal offence was committed (that is, educational and therapeutic conversation); everyone has the right to freedom of opinion and expression; everyone has the right to rest and leisure and make proper use of spare time.

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