Discursive construction of social representations expressed by seekers of psychosocial healthcare services in Brazil

Abstract

Background:

The current paper discusses the results of a study realized with 66 seekers of 12 psychosocial healthcare services (CAPS) in Brazil, by investigating their social representations.

Aims:

Throughout a quali-quantitative approach, unstructured interviews have been conducted and focused on two themes: one related to mental suffering and another to the CAPS itself.

Method:

The data were processed adopting the Iramuteq software for text-mining-analysis.

Results:

Out of the findings emerged four lexical classes due to the discursive representation of: (1) CAPS (39.7%); (2) social life (29.7%); (3) family (13.6%) and (4) medication and care (17%), where the utterance NÃO (NO) occupies a central position. Accordingly, the NO is associated with ‘not there’ and ‘not here’, contrasting the care provided outside the CAPS, represented as inhumane or inadequate, to that provided inside the CAPS, linked to feelings of ‘not being discriminated, mistreated and unrecognized’. The underlying social representations expressed in the interviews show an opposition between what was experienced outside and what was experienced inside the CAPS.

Conclusion:

The care received in CAPS units is the expression of a new psychosocial paradigm in a process of implementation, focused on participation and interdisciplinarity, as opposed to the biomedical paradigm focused on the disease.

Keywords

Social representations psychosocial healthcare services deinstitutionalization mental health

Introduction

The aim of the current paper is to discuss the social representations of a group of people who seek the Centers of Psychosocial Attention – CAPS in the Federal District to receive care for their psychic suffering. In this study, the participants are called demanders and not users to highlight that they not only are trying to enforce a right to which they are entitled, but also that they are expressing a demand for support, aid or relief for psychic suffering and a wish to care for themselves. Caring for oneself is a process of psychosocial elaboration and also of inclusion in society and in everyday life.

The Social Representations Theory was chosen to define the object for this study in the interaction dynamics of heuristics, empiricism and hermeneutics, considering that the participants’ statements are inserted in a very particular history of being in the world while considered crazy and discriminated against both culturally and socially.

The first part addresses with the issue of mental health and psychiatric reform, the second deals with the concept of social representations, the third explains the methodological design and the final section presents and discusses the results.

Data were collected through unstructured interviews, preceded by a sociodemographic profile of the participants. Content analysis was carried out using the Iramuteq software (Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires), which groups the words in a text corpus – the set of interviews – highlighting the words that appear more frequently and that have more associations with each other.

The research universe comprised twelve CAPS units; six of them are CAPS Alcohol and Drugs units, accounting for thirty-six participants, and six CAPS Disorder units, from which came thirty participants. The results show that the social representations of this group of people express an imagery of seeking relief from suffering in a context of many social, economic and cultural disadvantages. At the same time, the social representations regarding the CAPS are anchored in meanings related to welcome, care and respect.

The life of the demanders interacts with a broken family, low income, poor schooling, collective transportation or walking and a deficient service network.

Mental health in the psychiatric reform: the construction of the CAPS

Discussing mental health requires taking into account not only the individual characteristics of behavior, but also their insertion in a particular cultural, social and political context. Mental health is a matter of public health, culture, social relations, scientific-professional paradigms and social representations of madness, in all their complexity.

The biomedical-political interventions in this field focus on the analysis of behaviors that disturb current society standards, noting that this disturbance is perceived according to what is considered normality, acceptance of order. Basaglia (2005) calls this conception ‘looking of deviance’. According to this model, the segregation of those called mad or fools, at home or in institutions, was imposed with the creation of mental hospitals, asylums as places of separation of those unreasonable from the others called normal, rational animals, distinguishing the insane as someone not like us because he would have lost his reason or his judgment. Fool is that who acts inconsistently, without meeting social norms.

The so called ‘Basaglia Law’, regarding healthcare policies for psychiatric diseases in Italy was enacted in 1978, after a longstanding and controversial process. Its aim was to promote a global change of the way severe mental suffer should be considered and faced. In Brazil, however, a law granting for civil and humans rights of people with psychotic distress has been established only recently, namely in 2001 with the Law 10.216. Indeed, there has been a general refuse of such a new perception of psychiatric diseases, culminating in a harsh conflict of interests between the biomedical model and the pharma industry on one hand and the psychosocial model on the other. Finally, there have been great advances in psychosocial care, once the Basaglia-Law has been established. Notwithstanding, controversies between both models continue in several countries like Argentina or France (Murekian et al., 2018).

Foucault (1995), in his History of Madness, shows that the history of the segregation of the insane already had antecedents in the Middle Ages, with the unreasonable embarking on the Ship of Fools, wandering from city to city, especially those on the banks of the Rhine. This Ship, according to a painting by Bosch, did not permanently anchor in any place, receiving aid and discrimination from the inhabitants. The painting also shows the madness as an expression of the joy of living and singing, at the same time as of thoughtless and risky acts.

This segregation was consolidated in the twentieth century with the creation of mental hospitals and asylums that became a place of containment and deposit of the insane, with treatment close to slavery: total deprivation of liberty, receiving electric shocks, humiliation, sedation. Arbex (2013) reports this dehumanization in mental institutions. Nise da Silveira rebelled against this practice after World War II, when she began working in the psychiatric hospital of Engenho de Dentro in 1944. In 1959 she implemented art therapy workshops, contributing to the development of a process of expressing ‘images of the unconscious’, catalyzed by affection, as opposed to the model of medical power centered on medication and biological intervention, for example with lobotomy (Mello, 2014).

In addition to his criticism of the segregation of people with mental illness in Italy, Franco Basaglia (1985) established a new anti-asylum paradigm, with substitutive services to the asylum, formulating a policy of community inclusion and coexistence of those called insane. Law 180 of 1978, known as Basaglia Law, ordered the closure of all mental hospitals, in a process known as psychiatric reform or deinstitutionalization, which begun in Gorizia (Northern Italy), with the opening of the hospital and the participation and integration of patients in the community, until the total closure of the institution.

In Brazil, the proposal for an anti-asylum law had a long, 12-year process of discussion in Congress, with strong pressure from drug-prescribing psychiatry and mental hospital owners, in opposition to pro-mental health movements such as Mental Health Workers and to family and civil society organizations (Amarante, 2015; Passos, 2009; Vasconcelos, 2016).

These groups organized a counter-hegemonic mobilization to denounce the asylum, the ‘economic sector of madness’, which includes pharmaceutical companies and hospitals. The anti-asylum struggle also implies a critique of a disease-centered paradigm, the construction of a new paradigm centered on the production of health in an open environment, with services replacing the asylum.

The formalization of the CAPS was established by Law 10,216 of April 6, 2001, which provides for the rights of people with mental disorders and overhaul the mental health care model. Prior to that date, the cities of São Paulo and Santos already had implemented these services. It should be noted that the Law affirms the rights of the insane, prohibiting all discrimination and ensuring interdisciplinary care in open health units, preferentially aimed at their social reintegration. It establishes that hospitalization should be a measure of last resort. It represents a paradigm shift from hospitalization to care in open environments, with responsibility shared with families and the society (Hirdes, 2009).

CAPS, furthermore, have lower costs, compared to traditional hospitalization, offering at the same time important results for the prevention and care of mental health. Significant changes for the quality of life of these healthcare seekers, despite focussing on the reduction of psychiatric symptoms, constitute the central mission of CAPS (Andrade and Bonadiman, 2014). The traditional psychiatric hegemony, instead, still maintains a clinical and political approach, mainly interested in pharmacological treatments of mental health.

The process of creating substitutive services in mental health aims a deinstitutionalization, and not just a de-hospitalization. According to Basaglia (2005, p. 176), ‘medical ideology serves as a shield for political judgment’, and deinstitutionalization seeks care rather than cure, in consideration of the individual’s uniqueness. Even in the CAPS there is a risk of perpetuating stigmatizing conceptions about mental illness – viewed as dangerousness or requiring medicalization – which are anchored in society and even among professionals (Barbosa et al., 2018).

CAPS are the only available alternative to access mental health care for the more disadvantaged social classes in a country of harsh social inequalities such as Brazil. Recoveries in public hospitals only reduce acute crises, but only CAPS offer psychosocial attention, although the limited numbers of existing services cannot satisfy the general demand. Access to psychiatric drugs is available with a medical prescription and is generally free, but often not available. The number of hospital beds, despite a recent rise of financial resources, is still poor. Asylums, otherwise, resulted in a progressive rise of mental disorder, along with dehumanizing conditions as shown by the dramatic example of Barbacena (Arbex, 2013).

Silveira (1981), in addition, encountered a lot of troubles during her attempt to propose more human approaches of psychiatric treatment (Silveira, 1981). Finally, the Law number 10.216 defined an epistemological and political change according to people with mental suffer.

Deinstitutionalization should privilege the empowerment of people with psychological suffering, their relationship with their context, the construction of citizenship, a social place of respect and work, integrated into the territory in which one lives, in the perspective of freedom to be and live singularly as a person, not as sick or insane and discriminated against. It also presupposes interdisciplinarity, intersectorality and differentiated therapeutic practices, ensuring the social, labor and economic insertion of people who are disadvantaged due to their physical, mental and specific social conditions.

In this perspective, to care implies putting aside the feeling of strangeness towards the demanders, and the institutions should become familiar to them, a place of freedom, citizenship and social interactions. Institutionalization, in turn, imposes rules, exercises domination, configuring a power that denies otherness and subject people to established norms, to medical order and to social control.

The psychosocial and citizenship paradigm should not to be confused with de-hospitalization, medication at home, strategies for achieving a cure, a change in care technique or with replacing aggressive therapies with light therapies or hospitalization in general hospitals (Rotelli et al., 2001). Rotelli, in a deinstitutionalization perspective, affirms:

Mental health would be [a situation] in which a subject can exist with others and communicate through language, speak of himself and have his differences accepted, constitute himself in his partial uniqueness and partial communion with others, constitute himself and be constituted [in a situation] where inclusion/exclusion tension each other and are at risk, at the limit at which the other can contain you and you also can contain him, and together you may find a common feeling, a common practice, an interrelated project (2008, p. 54).

The process of deinstitutionalization involves de-labeling the insane and criticizing stereotypes and prejudices, that is, ‘considering him independently of the content of the label defining him. I relate to a person not for his label, but for what he is, and this also implies freedom, a break from bars, sedation and relations of domination’, according to Basaglia (1985, p. 26).

The discovery of freedom by psychiatry thus leads to the issue of mental health care outside the asylum. Still according to Basaglia:

In reality, there are still grids, keys, bars, gates, personnel with little technical, and often little human, preparation, but the question is still open: the destruction of the asylum is urgent and necessary, if not simply obvious (Basaglia, 2006, p. 26).

The establishment of CAPS units, essentially, implies altering the power relations between professionals and demanders, considering them subjects legally entitled to care and not objects of curative treatment. These centers respect the singularity and the way of being of each person, not functioning as a behavior control device.

The diversity of situations encountered in the CAPS requires an intersectional and pluri-professional attention towards the articulation of the various services, that need to be implemented, especially in episodes of acute crises. CAPS for mental disorders provide beds for acute psychical crises, but only for a generally limited time of 1 to 3 days. In addition, some CAPS offer home care services for follow-up observations. Furthermore, there are basic healthcare services and other social assistance centers, which, although with mostly poor results, usually collaborate with the CAPS. The CAPS psychosocial activities provide information and awareness, due of the specific needs and the real possibilities of attention, encouraging the seekers’ agency while facing their existential demands.

The aim of the current study, therefore, is to propose a multidisciplinary model of psychosocial interventions in order to cope with severe psychological suffer, specifically targeted for the Brazilian context.

According to Castaldelli-Maia and Ventriglio (2016), indeed, we do not pretend to reply entirely an European model of psychiatric reform, but rather to create a new conceptualization of what local specific treatments should consist in:

During his visit and in his series of lectures in Brazil in 1979, he declared that he would not want to prescribe a ‘European treatment’ for the problems of Brazilian mental ill-health, but would like to encourage Brazilians to think about the solutions to problems in this area (p. 411).

This study investigates whether demanders’ social representations of the CAPS take into account this paradigm of deinstitutionalization. The following section presents the concept of social representations and social representations of madness.

Social representations

Social representations do not translate into a structured vision of a body of knowledge or beliefs, but are a way of relating to the social world (Valsiner, 2015). They are, at the same time, the process and the result of social interactions in motion. They give visibility to the structure of society’s imagery and to its elaboration by a certain group or collectivity. They fit into a communication dynamic that takes into account the cultural context and the common sense. Moscovici (2013) identified the individual/society interaction occurring in a process in which the active subject (ego) communicates with the other (alter) about a social phenomenon (object) implicating, as Valsiner (2015) points out, both the endo-group and the exo-group, to a greater or lesser extent. Social representations are related to the imagination, the practical life and the culture, according to an already consolidated view on social representations (Apostolidis, 2017; Jodelet, 2015; Moscovici, 2012).

However, it is important to emphasize that social representations are associated with the affective dimensions of life in the implications of emotions, being cognitive-emotional in nature. Jodelet (2015) calls attention to the experiential knowledge, which can articulate scientific knowledge with common-sense knowledge, without disregarding religious knowledge. In this perspective, Jodelet (2015) considers that common sense is not homogeneous. For example, a CAPS demander is equipped with various kinds of information on social life, the internet, the psychiatrist, the social worker the psychologist, and their own uniqueness. Their representation of health/mental illness are not uniform.

The importance of culture in the social representations’ elaboration was strongly emphasized by Moscovici (2012), who pointed out that it is not a natural phenomenon, since it involves beliefs, knowledge, sensations, language, as well as the culture’s own rationality. The common sense is a mix of scientific and common information, not individual, of the context and the post-scientific society, and may comprise conflicting representations, in transformation.

For Moscovici (2012), the theory of social representations investigates transformations and their relation with the communication context; the images, the languages and references reduce the distances between groups by means of a knowledge crossbreeding. That which is most stable, stabilized and profound in a representation is what anchors it. At the same time, they are symbolic and indirect, but are also in movement. The images become familiar, objectified in cultural references, thus these elements can be seen as the constituents of the representation. Moscovici (2012, p. 54) points out that ‘to represent means to transform into symbol or mental content the given realities’, gaining the trust of the group, since ‘a group has a fiduciary value of trustworthiness among its members’ (Moscovici, 2012, p. 57), adding that ‘if it is true that belief does not govern the scientific knowledge of reality, it is, however, what confers to that knowledge its character of reality’ (Moscovici, 2012, p. 92).

The concept of social representations is different from the concepts of social perception and social cognition because it expresses the impossibility of dissociating its reality aspect from its mental or symbolic aspect, taking into account the common sense that categorizes the social world. The representation of madness is a social construct and may be associated either with the demonic and exorcisms or with the inability to live, but at the same time it can mean a different way of knowing and opposing the way of life of the dominant social order, which is also submissive (Rotterdam, 1508).

Jodelet carried out a research on social representations of madness in the 1970s in a community that welcomed and housed the insane, observing that madness was considered as either a disease of the nerves or a disease of the brain. The first representation led to practices that were more aggressive and the second to a more welcoming approach (Jodelet, 2006). Madness was seen predominantly as a malfunction in life, regarding oneself and other people.

In the psychiatric perspective, the classification of a mental patient refers to a medico-biological paradigm, to a disorder diagnosed by symptoms scrutinized by a specialist with biological power/knowledge, who speaks from a place of power, expressed in a specific dress code and in devices for the diagnosis of and intervention in the lives of other people.

In the case of madness, it is necessary to take into account stereotypes, prejudices and discriminations related to what is considered normal/abnormal. It is necessary to take into account the dominant concept of the biomedical model, which puts mental illness in opposition to normality.

In this way, in the dominant paradigm, being mentally ill is to be abnormal or even to appear abnormal in the eyes of the scrutinizer, as diagnosed by the established medical authority. The concept of normality is historical, cultural, medical and political; establishing power over the other. Canguilhem (1978) points out that the concept of normality should be adapted to the subject’s way of life, which can be in opposition to the dominant way of living and understanding. In turn, paying attention to the singularity breaks with the normality of the average taken as standard, as a rule, with what is considered dominant.

The concept of normality contributes to the naturalization of the dominant order as if it were the perspective of everyone, disregarding diversity, which makes the normality itself paradoxical. What is different, therefore, can be normal.

In the context of health/mental illness, several representations of the same object can coexist, as in the confrontation, for example, between the dominant medical-psychiatric perspective and the psychosocial view that criticizes medication and hospitalization. This approach to mental health and related social representations led us to question the beliefs, meanings and knowledge that the CAPS demanders elaborate regarding the context, care and suffering that they experience in a society that at the same time discriminates against and welcomes them.

Material and methods

The method of this study is qualitative, elaborated in a process of methodological triangulation using a socio-demographic survey of the participants, research field diaries and unstructured interviews on the demanders’ psychological suffering and the care provided to them. The respondents agreed to answer freely to our request: Talk about your suffering and about the CAPS, respecting the sequence of responses.

Sixty-six interviews were conducted in twelve CAPS units of the Federal District with the free and informed consent of the participants. The study was approved by the Ethics Committees of the Federal District’s Health Department and of the Catholic University of Brasília (CAAE: 50964415.3.0000.0029).

The methodological design took into account the diversity of the CAPS Alcohol and Drugs and CAPS for Disorders. Six of each modality were chosen; 36 participants were from CAPS-AD and 30 from CAPS-Disorder. The interviews were arranged with the staff of each CAPS unit and were authorized by the respective managers. The meetings with the demanders were unstructured, ensuring a welcoming rapport between researchers and participants. First, interviewers requested information on the participants’ socioeconomic profile.

The interviews respected the pace and freedom of the participants. Two themes were used to elicit responses, in an unstructured manner. During the interviews, the researchers mirrored the participants’ comments, in an empathic replica, reflecting the speech back to them so that they could further interpret and deepen the issues. Therefore, the interviews are interspersed with reflections and expressions addressing again and again their histories.

This survey, despite involving just 66 participants, covered a large diversity of intersectional factors regarding both CAPS-services and their seekers. Accordingly, the sample has been recruited, by considering different typologies of either the healthcare seekers, such as residential area and socioeconomic aspects across the whole Federal District (a macro-metropolitan area of approximately 50 square kilometers and over 3.5 million inhabitants). The findings, emerged out of the current study, showed the discursive processes, throughout the participants described their most ego-syntonic and in-depth representation about CAPS services during their everyday life. A full publication of the interviews can be made available as supplemental material.

The critical and dialectical analysis of the themes was based on the corpus systematized by the software IRaMuTeQ R - Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires (Ratinaud & Marchand, 2012), which classifies the co-occurrence of words in a set of texts by their frequency and by their association with each other, allowing a statistical analysis of text units and tables associating individuals with words.

IRaMuTeQ can generate various kinds of results; we selected for this article the word cloud, generated by a simple factorial analysis, which aggregates words and organizes them graphically according to its frequency. The dendrograms or word trees are generated by a Descending Hierarchical analysis (DHA) of the lexical repertoires, evidencing the associations between the occurrences and their absolute frequencies, considering their proper placement in the (con)text. For more details, see Hochdorn et al. (2018).

Results and Discussion

First, Table 1 presents the participants’ profile, highlighting the greater presence of males, especially in CAPS Alcohol and Drugs units. Next, we discuss the profile in more detail.

Table 1.

Profile of CAPS-DF research participants.

Variables	All CAPS		Man		Woman
Variables	No.	%	No.	%	No.	%
All CAPS	66	100	42	63.64	24	36.36
Type of CAPS
AD	36	54.55	27	40.91	9	13.64
Disorder	30	45.45	15	22.73	15	22.73
Age groups
19–29 years old	7	10.61	4	6.06	3	4.55
30–39 years old	13	19.70	9	13.64	4	6.06
40–48 years old	14	21.21	10	15.15	4	6.06
50–59 years old	23	34.85	14	21.21	9	13.64
60–65 years old	8	12.12	5	7.58	3	4.55
72 years old	1	1.52			1	1.52
Time attending the CAPS
Doesn’t know	2	3.03	1	1.52	1	1.52
Up to 6 months	18	27.27	13	19.70	5	7.58
6 months–1 year	9	13.64	5	7.58	4	6.06
1–2 years	10	15.15	5	7.58	5	7.58
2–5 years	16	24.24	12	18.18	4	6.06
More than 5 years	8	12.12	4	6.06	4	6.06
More than 10 years	3	4.55	2	3.03	1	1.52
Education
Primary school dropout	30	45.45	21	31.82	9	13.64
Primary	4	6.06	2	3.03	2	3.03
Secondary school dropout	7	10.61	5	7.58	2	3.03
Secondary	10	15.15	5	7.58	5	7.58
Some college	7	10.61	6	9.09	1	1.52
College degree	4	6.06	2	3.03	2	3.03
Graduate degree	2	3.03	1	1.52	1	1.52
No formal education	1	1.52			1	1.52
Not informed	1	1.52	1	1.52
Personal income
Less than min. wage	19	28.79	11	16.67	8	12.12
1–2x min. wage	14	21.21	9	13.64	5	7.58
2–5x min. wage	6	9.09	5	7.58	1	1.52
5–10x min. wage	1	1.52	1	1.52
More than 10x min. wage	1	1.52			1	1.52
No income	23	34.85	15	22.73	8	12.12
Not informed	2	3.03	1	1.52	1	1.52
Housing
Alone	13	19.70	10	15.15	3	4.55
With a partner	4	6.06	3	4.55	1	1.52
With parents and siblings	3	4.55	2	3.03	1	1.52
In an institution	9	13.64	8	12.12	1	1.52
Other	37	56.06	19	28.79	18	27.27

Table 1 shows that there are more male participants (64%) than female (36%). We did not aim equal gender participation, since the interviewees were spontaneously selected, respecting a minimum of five demanders per CAPS unit.

Regarding the type of CAPS, there are more male participants from CAPS Alcohol and Drugs units (64%) and more female participants from CAPS Disorder units (63%). The age groups most represented are those aged 56 to 61 years (18%), 36 to 44 years (17%), 51 to 55 years (15%) and 46 to 50 years (14%). Forty-seven percent of the participants are between 46 and 61 years old, young people between 16 and 30 years old are fourteen percent and the elderly over 62 years old are seven percent, with a lower presence of men between 36 and 44 years old.

Most participants have been attending the CAPS between 6 months and 5 years. Schooling is predominantly limited to incomplete primary education, but women have a higher percentage of secondary education graduates. Low income is prevalent for both men and women. The percentage of men living alone (24%) is greater than that of women (13%). Some of the men attending CAPS Alcohol and Drugs units live in institutions.

In summary, the profile of the research population indicates that they come from low-income social class. People of the upper class seek private or health plan services.

The following is the word cloud generated (Figure 1), whose aggregating nucleus of occurrences is the word ‘não’ (no/not). The words closest to this nucleus are the ones that are most associated with it; letter size also shows this association.

Figure 1.

Word cloud generated by IRaMuTeQR.

The word ‘não’ appears at the center of the word cloud. Deepening the interpretation and analysis, including the interviews’ content, the ‘no’ is associated with ‘porque’ (because), ‘falar’ (speak), ‘aqui’ (here) and also with ‘lá’ (there); the outside and the inside of the CAPS units, as demonstrated by an analysis in depth of the discourse. That is, the comments contrast the here in the CAPS with the care there, outside the CAPS. The social representation of the ‘here’ is associated, in the word cloud, with ‘ficar’ (stay), ‘falar’ (speak), ‘vir’ (come), ‘saber’ (know); ‘there’ is associated with ‘só’ (alone), ‘casa’ (home), ‘trabalhar’ (work). The following comment may illustrate the representation of the CAPS:

‘There are a lot of things, the CAPS helped a lot, it really helped a lot. If it was not for [the CAPS] here, I'd had already killed myself,iIf it was not the staff here. The girls helped a lot [with their] messages, a lot of talk, [they hear us] talk, give advice’ (P1).

In other comments, the opposition between there and here appears. Because here in the CAPS:

"I have no complaint," "I’m not ashamed to open myself," " not a thing is missing," "[there is] no financial resources, but I continue," "[they] do not discriminate against me," "[there is] no prejudice," "here we find a basis to start over," "but there is no place here for everyone" (P1).

While there, outside the CAPS: ‘there is no entering the hospital at night’; ‘there they do not vent;’ ‘there I'm not human’; ‘there I did not understand’; ‘there they did not accept my sick daughter’; ‘I could not take it anymore there’; ‘there was no family there’; ‘there in the public [health services] system, [they] do not offer help’.

In short, the word ‘no’ has a positive meaning when associated with the CAPS, expressing the idea that if these places did not exist, people would be in a worse condition and subject to an even greater suffering.

These opposing representations express an experience of cultures and contexts that are significantly contrasting or still being formed, since, as Moscovici (2012) points out, opposing cultures exist in the same social context, or as Bourdieu (1994) points out, there are different habitus in the same field. Thus, the culture in the CAPS is distinct from the culture of care outside the CAPS, which still marked by a biomedical perspective. The CAPS’ culture is still polarized between the biomedical perspective and the psychosocial model, but with a trend towards open and person-centered care rather than the closed environment of disease.

The dominant institutionalized culture is permeated by the view of madness as a disease that can be treated, or as a stigma that is assimilated in the relationship with the demander, considering him incapable or even a ‘non-human’ subject, as expressed in the statement quoted above. On the other hand, the culture of deinstitutionalization that is under way in the CAPS changed the way of treating the demanders, now with welcoming and good treatment, in their perception.

The social representations express an experiential knowledge (Jodelet, 2015) of the everyday care, either in the CAPS or outside it, manifesting a path bifurcating in two opposing directions. According to László (2015), the social representations of collective history and memory are constructed in a narrative closely associated with a group identity shared in significant contexts common to group members.

Next, we present the classification shown by the dendrogram, the results of the descending classification analysis of the meaning units, detailing the most significant words in the responses of the demanders participating in this research.

Content classification in a dendrogram

The following graph (Figure 2) shows the co-occurrence of words elaborated by the Iramuteq software, with four stable classes: class 1 is related to the place of care and contains 39.7% of the content units; class 2 (29.7%) is related to the demander’s interaction with society; class 3 (13.6%) can be defined as relations with family and daily life; and class 4 (17%) shows the relationship with treatment and clinic.

Figure 2.

Word classification according to co-occurrence.

Class 1 refers to the social representation of the CAPS. As already mentioned in the word cloud, it is a representation associated with ideas of a good place, people meeting, participation, welcoming, being happy, having nothing to complain about and a place where there is affection but also activity. It is a place to work in a group, in workshops and for which you are thankful.

The following two statements by demanders of CAPS Alcohol and Drugs state that the CAPS is a place of peace and care. The first is from a 56-year-old woman, and the second is from a 46-year-old man:

‘Look, the CAPS is a place where people rest a bit. I talk to other people more intelligent than I am. I feel at peace in here’ (P3).

‘It has a good side and a bad side. The good side is the care staff, the nurses, the doctors, the staff, the health workers, sometimes the guards, the cleaning staff. They are super polite. It's bad that when they put people in, they do not evaluate people; anyone may come in. Thieves, murderers, rapists, armed robbers, all kinds of people may come in. I have no complaint’ (P4).

The good side is the welcoming and the bad side is that everyone is admitted. As for the CAPS Disorder, it is also possible to observe a feeling of improvement and being welcome in the words of a 71-year-old woman:

‘Thank God. I'm not well yet but I’m better than I was, I'm fine, thank God . . . And I’m receiving a very good treatment, I have nothing to complain about in any way: the doctors, the employees . . . Because our family is very small, it's just me, my daughter and my son . . . [They are] a very attentive staff, they even have a lot of patience, so I have nothing to complain about . . . She leaves early, and make her coffee and I’m still in bed. So, this coming to the CAPS it's good for me because . . . if I stay at home I'll just be asleep’ (P18).

Class 4 is strongly associated with class 1 and is related to the use of medicine, the consultation, the doctor, the psychologist, the prescription, the treatment. The CAPS is also represented as a place of good treatment. According to the words of a 59-year-old woman attending a CAPS Disorder unit:

‘I've never been treated the same as in here. I've never continued a treatment because I could not take it just like in here. I always needed a treatment but I thought they’d be going to keep talking about me, you know . . . Like, they would put me in a place of crazy people, I don’t know, [that’s what] I understood . . . Or I had the disease and I was afraid to know that I was sick, I did not understand it. But not here, I do like it here’ (P32).

A 38-year-old man attending a CAPS Alcohol and Drugs unit states that:

‘The CAPS, to me, is a very good place, there are people being treated here, the treatment here is great . . . I already said to the professional that here I was even able to start pulling this thing out of me . . . When I enter I feel a headache; soon I’m thinking of doing foolish things . . . I can’t stay in a closed place and in an open one either . . . I do the car wash, and I already can stay. The group is nice, the group is nice, the group I’m in is calm and tranquil, this car wash group. Sometimes I took part in the soccer group’ (P15).

Classes 3 and 2 are interconnected. Class 3 is related to the family and to housing. Class 2 is related to social interactions, social life and the violence of society. The participants’ families functions in various ways, but they are important to all, as expressed in their references to mother, father, son, brothers, to home and housing and also to events such as marriage and death. Several participants mentioned their place of residence. Class 2 words speak of eating, taking, killing, beating, fear, clothing and also of buying, giving, weapons. These words stand out in the following statements. The first, from a 45-year-old man attending a CAPS Alcohol and Drugs unit:

‘I’ve already tried, I already thought about killing myself when I was younger. Inside the police station I thought about killing myself, too, but every time I just remembered my mother. I thought: I can’t kill myself because I have to prove my innocence. Thank God. God saw that I was right, the judge talked to me, ordered only to do service - how do you say? - community service’ (P1).

The following statement of a 70-year-old woman attending CAPS Disorder speaks of the fear she feels and the problem it causes:

‘Look, this is something that I really do not like to talk about, because it was so horrible, something that I had never experienced in my life. I got to be like that and I was afraid of things. I didn’t want to leave my home. It seemed to me that I was not going to get well anymore, you know, and it was a really bad thing. It was exactly . . . this problem then . . . my daughter said “my God,” a psychotic thing, a thing she talked about then’ (P18).

The analysis of these results shows that the social representations of the participants in the research are deeply associated with the living conditions of this low income population and with the context in which they live, finding in the CAPS a welcoming interaction. As has been observed, social representations are marked by the discrimination against the insane who are afraid of themselves and also of causing problems to others.

The CAPS Alcohol and Drugs welcomes people who live in a situation of violence and aim to state their innocence and establish good family relationships.

As Moscovici (2012) pointed out, a diversity of representations emerges depending on the group's trajectory and on the context in which it is structured. The CAPS Alcohol and Drugs participants are expressing a dependency on alcohol or other drugs and consider the CAPS as a refuge. The CAPS Disorder group identifies with the disease and considers the CAPS as a place of improvement and treatment.

As Apostolidis (2017) pointed out, the analysis of social life implies considering social representations as a practice that is reflexive and critical of public health care and the professionals who work in it. The author argues for the deconstruction of the prejudices against psychosocial care. The care provided in the CAPS is interdisciplinary and there is a representation of the interactions among the several professionals in action, related to this change in care procedures.

The representations are also embedded in the view that the demanders have of the different bodies of knowledge and of their own experiential knowledge, as Jodelet (2015) reminds us. The demanders’ experiential knowledge allowed us to observe, as in the word cloud, that there is a difference between the ‘here’ in the CAPS and the ‘there’ of other experiences of the mental health care system. The CAPS presents itself as a human or humane place, while other treatment facilities are represented as dehumanized. In these places, the social representation of madness is still anchored in discrimination, as emphasized by the predominance of the concept of normality (Canguilhem, 1978).

The issue of psychic suffering began to be better addressed in the CAPS with the adoption of the model of deinstitutionalization (Basaglia, 1985; Rotelli, 2008), which inspired the substitutive services to the asylum in both Italy and Brazil. The results of our research point to a participatory and interactive care in an open environment engaged in a process of deinstitutionalization, as opposed to the biomedical model of care.

Final considerations

From the narrative representations of the seekers themselves emerged a comparison between the efficiency of CAPS and other psychiatric healthcare services. CAPS, indeed, have been conceived as an alternative to traditional asylums, but there are still struggles to be solved, such as the capacity of public healthcare structures, among others. However, CAPS promote a combination of psychiatric care with psychosocial activities. This integration is perceived positively by the seekers, who also attribute to the pharmacological intervention a positive contribution in order to reduce mental suffer, while improving their adaptation to public and private life. Notwithstanding, the evaluation of mental health services in Brazil still constitute a major challenge (Ricci et al., 2020).

The demanders’ narratives brought to light the process of change occurring in the CAPS units of the Federal District, especially the change from the biomedical model to the psychosocial model of attention and care. This change was marked in the demanders’ narratives about their experiences, distinguishing on the one hand the ‘outside’ where other services were located and the ‘inside’ of the care in the CAPS.

This binary representation of ‘there’ and ‘here’ reflects the opposing paradigms of the traditional psychiatric institution, centered on cure and power, and of the provision of care centered on subjects and the process of social interaction in an open environment.

There are still obstacles for the total adoption of the psychosocial perspective in the CAPS, mainly regarding a greater interaction with the rest of the health care system and with a society in movement.

There is a consensus among demanders of various ages that there has been an improvement in their representation of themselves and of their social identity with participation in the CAPS. The demanders also have a critical view of the CAPS, which they see as needing an improvement in some operating conditions such as accessibility, funding and staffing, increased attention to security and the diversification of outside activities.

The method of listening to the narratives of the demanders was particularly rich in bringing to the fore their life stories and at the same time their opinion about the meaning of these experiences, highlighting the importance of what was remembered (László, 2015, White 2002). They were not asked to write their past life story, but to relate events in a free narrative approach. The participants' reports allowed them to express their life trajectories and their experiences with institutions, re-signifying their discomforts and dissatisfactions and how they are perceived in various contexts. In fact, contexts give anchorage to address problems.

Thus, one can see the madness differently according to a context and a paradigm of illness/cure or of singularity and way of life.

The CAPS, in the view of the demanders, are in a process of implementing a psychosocial, humanized and open-door approach, compared to the asylum or to a closed, medicalized, isolated and dehumanized treatment.

Access to mental health services, as has been mentioned several times along this paper, is still precarious in Brazil. CAPS is currently the only alternative for low-income populations. The current research, indeed, showed that nearly all participants of the study-sample claimed low education levels, low income and inadequate housing. High-income classes usually seek for private psychiatric services and can also pay for therapeutic insurances.

Supplemental Material

sj-pdf-1-isp-10.1177_0020764021991875 – Supplemental material for Discursive construction of social representations expressed by seekers of psychosocial healthcare services in Brazil

Supplemental material, sj-pdf-1-isp-10.1177_0020764021991875 for Discursive construction of social representations expressed by seekers of psychosocial healthcare services in Brazil by Vicente de Paula Faleiros and Alexander Hochdorn in International Journal of Social Psychiatry

Footnotes

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Alexander Hochdorn

Supplemental material

Supplemental material for this article is available online.

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