Print version ISSN 0034-8910
Rev. Saúde Pública vol.42 n.1 São Paulo Feb. 2008
Bernadete Maria DalmolinI; Maria da Penha VasconcellosII
de Enfermagem. Instituto de Ciências Biológicas. Universidade de
Passo Fundo. Passo Fundo, RS, Brasil
IIDepartamento de Saúde Materno Infantil. Faculdade de Saúde Pública. Universidade de São Paulo. São Paulo, SP, Brasil
To asses how people with mental disorders experience their special needs and
interact with the community in public urban places.
METHODOLOGY: The research was performed in the city of Passo Fundo, Rio Grande do Sul, Brazil, using ethnography as the theoretical methodological approach. As of the study of one subject, the objective was to understand what characterizes people as mentally sick and how the adversities of their mental picture do not prevent them from building circuits, paths, and social networks with the urban space.
RESULTS AND CONCLUSIONS: It was identified the subjectivity processes of subjects in the spaces of the city. Since health services recognized these individuals, it is possible to create interventions which are more suitable to their special needs.
Key words: Mental health. Anthropology, social. Ethnopsychology. Qualitative research.
Named in psychiatry as mental disorder, experiencing intense psychiatric distress is understood in the present study as the manifestation of psychological characteristics in the life of individuals. Mental distress involves a set of elements that make it, be it neurological, physiological, social, cultural, religious, philosophical or economic causing intensive psychological distress to patients. This type of manifestation has results in the history of the personal and family life and in the network of social relations, thus going beyond the punctual moments that characterize the more specific situation of crisis. That is, mental disorders are in a complex field of knowledge.
To assess the problem of mental disorders, it is important to highlight that psychological distress is always followed by the possibility of subjective productions that may be resources for facing adversities from getting sick.
Aiming at changing the recommendation of keeping these individuals in continuous surveillance, and, therefore indoors, the objective of the present study was to understand how individuals in psychological distress experience public urban spaces.
The ethnographic method was used to present the path of a patient called Beija-flor,1 as of a research previously published.²
The choice of a methodology depends on the research object, field work, and how the theme will be approached. Trying to broaden the understanding on psychological distress, Anthropology was used, with contributions that could be closer to the dynamics of these individuals, helping to learn about the codes that were still little known, the way of life, the arrangements and rearrangements of a special situation, to break with inattentive and prejudicious views that still guide the technical view in the field of mental health.
Based on the experience in health services and in education institutions, it is possible to realize that in real life, people want to lead ways, create strategies, and produce knowledge that, generally, is not known or valued by professionals dealing with them. When these people go to health services, they seem to know their rights, and what will and will not be valued in that place. This is the reason why they act according to what is expected from them, not making their own resources explicit and masking their potential.
Alternatively to the institutional discourse of Psychiatry on mental disorders, we have tried to get nearer to the point of view of suffering individuals to have a broader understanding of the problem of psychological distress and using interpersonal relations as a guide to the path. The option for ethnographic approach would be useful due to its tradition in studies that favor understanding cultural patterns.
During the present research process there was a concern with the theoretical production of Magnani³ because of the closeness between the object people in situation of severe psychological distress and their studies on the everyday life and the ways of sociability in the cities. This author has studied the meaning of social relations "up close and within", as opposed to "homogeneous" approaches of the social life that hinder understanding the specificities of action of the social actors in their multiple spaces, forming approaches that provide a "far away and outside view".
As a particularity of Anthropology, the Ethnographic method:
"[...] cannot be confused or reduced to a technique, it may use several according to the circumstances of each research: it is a way of approaching and apprehending [...] the nature of the explanation using Ethnography uses as a bases, an insight that enables to use data seen as fragments, scattered information, lose evidences, in a new arrangement, that is no longer the native arrangement but which starts from it, take it into account, coming from it, and not the one used by the researcher when it started" (Magnani3 2002, p.17)
To write the Ethnographic work, Brandão1 points out to watch out not to "freeze the interpersonal life in the social structure", because what you lose is more than the experience of the everyday life:
"[...] we also lose the understanding that the logic of the structure of the relationship between family, relatives [...], neighbors, between productive individuals and/or owners, between bosses and employees, men and women, between us and between us and the others, there is not only within but in between the threads of these social institutions [...] through which people work, have, produce, have children, inherit etc., but also with other threads that form lives within, outside, aside, or against the official organizations of the society, it creates the systems of life, the symbols and meanings of the other side of the social life itself." (Brandão1 1995, p.138)
The city of Passo Fundo, (RS), where the study was developed, despite being a middle-size city, also suffers the consequences of urbanization in big cities. Thus, the logic of their social relations as of the private codes and specific paths can only be understood in the everyday life, going deep into the cultural universe that gives sense to it. Thus, the complexity of these spaces "is no longer an operational totality ", and it is necessary "to establish mediations between the level of experience of the actors, and of broader processes ", in a way to obtain some kind of order between the specific practices and the behaviors that were seen.³
Challenge of the field research
Field work started in December 2001 and was finished in September 2002, the district chosen was Vera Cruz, located in the city studied. In this stage, more general observations on the dynamics of the district and of the people were obtained through informal conversations and visits to map references of the place. In a first stage, observations were performed in residential areas, on streets with greater concentration of committed people. Information about this concentration of committed people was obtained using an official list of mental patients. Then, we tried to get closer to people, to establish relations that would give meaning to the investigation later.
The dynamics of the district was characterized: who dwellers were, getting to know the people identified as mentally sick, establish the first contact with them and their relatives, understand the more general behavior of these individuals in public spaces. Matching this information, the observation network and that of possible future informants was formed. This stage was discontinued after the set of information was exhausted.
Local categories were established enabling a first cut where we could capture, according to dwellers, those who were "outsiders", "nuts", "lunatics". More objective relations with the institutions offering treatment were also identified, especially with those for mental health care, which stood for more visible therapy practices.
The existence of circuit, defined by the set of institutions and therapy practices, triggered by the individuals of the study when searching for health care: general health services (emergency, general hospitals, public drugstore), mental health services (psychiatric hospitals and day care services). In addition to these institutions, there were other "supporters" (district attorney and public office) in this network of protection to the rights of these people, which are strategies to guarantee the access to supplies and health services, as well as free medication, pension and other social rights.
After characterization of the social environment and support institutions, the paths of individuals identified in the place as experiencing severe psychological distress were assessed. Each person is a "complex unit",4 with unique threads of social affective and institutional connections. This provides different experiences; they can experience chaos and reorganization, rupture and connections, existence-suffering and health in a continuous process of interaction and retroaction.
Paths are expression of the subjective production which enable that an individual experience different ways of perceiving and interacting with the world. Thus, the paths, as built and achieved choices in the connection of individual and social dimensions, indicate particular situations (people, circumstances, memories), and it gives the support so that people in severe psychological distress can use the spaces, interact with the other people, achieve the desired situations and go back to the places that support and welcome them and make them autonomous. However, there are also, within these paths, the "non-choices", that is, the situations they have not lived or wanted, but that are part and present at the same time in their lives. This pressure of being the subject in some situations and being subjected to something in other, sometimes building "escape breaches", other times accepting what is no longer meeting their needs, is alive and part of the everyday interpersonal relations of these individuals.2
Observing the routines of the five informants of the main study,2 the field work gained a new dynamics, increasing the diversity of the spaces and practices, searching for the senses forming each path. When he was not committed, Beija-Flor spent the day on the streets.
The analysis of the people with whom he related to and the strategies Beija-flor used, occurred progressively, as a result of the articulation offered by the research and of our reflections when we met him. Based on the theoretical reference, when we synthesized the data the next steps were indicated, keeping as assessment unit, the relations and the socio-affective and cultural practices which were the experiences of the people in psychological distress.
The study was approved by the Ethics Committee on Research of Faculdade de Saúde Pública da Universidade de São Paulo.
ANALYSIS OF THE RESULTS
First hints of the path
The systematic observations on Beija-flor, his ways and activities developed enabled to understand how he built connections or performed small services with affective characteristics, as well as how he established institutional relations that meet his needs, shaping his paths in the space of the city.
In the first months of the research, Beija-flor was mentioned by district dwellers as a typical case: "here we have Beija-flor that is nuts". At that time, he was committed. According to reports of his mother, he has had convulsions since he is six months old, and he has always taken a lot of medication due to the intensity of these convulsions, an when he was nine he was really bad. "I have always used medicine, only medicine, for 40 years". For 14 years now he has been admitted regularly to the Psychiatric hospital of the city, and it was not possible to determine how many times he has been admitted (with an average of 45 days of hospital stay). According to his mother, he "spends some days at home and then he has to be admitted again. You know how Beija-flor is: he is not easy, because he is not humble. He gets into trouble on the streets, people nag at him, and then he 'gets crossed' easily. He does not disturb anyone, but if people say something he gets nervous".
Family problems were constant and always because of disbelief and putting down everything he did or said, together with the admissions, always, against his will. These admissions were not justified by the worsening of his health condition; they only aimed at taking him out of the streets using the excuse that he "ran the risk of hurting himself". Admissions provided family relief, because in the hospital he was well "taken care", according to his mother. Statements of the relatives on the information not only highlighted the dynamics and the present agreements in this episode but also showed the memories of those living this process:
(Brother): "You like going out so much, why don't you want to go to the hospital?" Beija-flor raises the tone of his voice and talks to the interviewer: "If people take you to a place, roll you up and do not let you go, what would you think?" The brother insists: "But don't you want to go at least to the reviews?" "Reviews, reviews" Beija-flor talks back. "They have already taken me to review and they let me there for more than I can remember. I have never seen a review with 30, 60 days."
Beija-flor refers angrily to hospitalization and keeps talking more than the others: "The hospital is very hard because there you cannot want something." At this time, more nervous than usually, he asks: "Please, if we cannot stop talking about the hospital I won't talk anymore."
The house of Beija-flor's family, even though it is his reference place, the place where he lives, is an ambiguous place, where he has shelter and food, but relations of protection and closeness that would make him want to go back there when far away are not established. He longs for dawn to continue his journey in a more fluid space, with more flexible rules, where he can bare his life and expands himself the streets.
Ethnography of the city space as freedom
The contact with Beija-flor occurred mainly on the streets. He was always suspicious that the presence of researchers was to commit him to the psychiatric hospital. He walked very fast through the streets and his stops were very quick. His contacts and stories were private, and, sometimes, a fantasy, demanding extra care in the observation to respect a limit to be discovered at every situation. The question posed was: What is this space that makes him come back so eagerly every day?
In one of the meetings, Beija-flor presented a living strategy that, in his opinion, did not cause him greater problems: "I don't like 'disturbing' anyone, I stay a little and then I go!" Aware of the moments when his presence was not pleasing, he created defenses to avoid enemies: he used what was interesting to him quickly and then he left looking for new sets.
For an inattentive perspective, gathering the scenes of the every day life of Beija-flor seems meaningless, surreal, marked by excessive wandering. But it is in this intensive physical activity, difficult to follow, and in the amazing condition of finding him in different places, with several settings (real and imaginary), that he had the possibility of giving some sense to his existence. There was a "link" of the every day scenes with its subjectivity, especially in trying to preserve and act the subject that expresses, on the surface, his need for a life where the beautiful, the attractive, and the desired are constantly searched for, and in small doses.
Beija-flor's feeling of belonging to that community gave him the authority to a kind of control of what happened in the neighborhood, expressing also values and aspirations of the place. Maybe, the need to feel "like" the others suppressing the things that disturbed most dwellers.
Police officers were his interlocutors (and friends). Many times when he felt his most familiar space "threatened" by unpleasant situations, he would look for the police: "he comes here to the pay phone and calls the police for anything", said other interlocutors of the research. Beija-flor, however, knew very well the situations that threatened good behavior of the district, such as "smoking marijuana and stealing". Once, he felt the smell of marijuana and he said: "look at that, it is disrespect to you". And he left complaining walking fast towards a pay phone to call the police.
Following the every day life of the district, establishing what can and cannot be accepted, making the link with the local authority that should keep the order and take care of safety, was a recurrent attitude of Beija-flor, even if, many times, the repetition of these gestures was not considered. "The police officers do not care anymore", the community leader said.3 Additionally, Beija-flor has also become a kind of messenger of the city or of the district as the community leader Jairo reports.
The street and the different aspects of the cities, on the edge of the district, were sceneries that created meanings giving rise, in reality or in his imagination, to the dream of the achiever, smart guy, that took advantages and was not surrounded by anyone or that when restrained, he built new scenarios since the street offered several possibilities.
There was an episode that a girl was approached by a police officer, probably due to the suspicion of drug use. He watched the scene, waited for the police officer to go away, saying that he knew she was innocent, although he did not know her. He told her to call him if necessary and calmed her regarding the police officers, saying they were his friends. He went to the police officer, shook his hands, made a scene and obtained from the police officer a sign of "nice guy, a friend" picturing him as a good guy.
He got onto the bus and said: "I was protecting the girl, she needed it". Some of Beija-flor's paths were clear regarding his intentions. In his own words, he "clocked in" on the entrance, break and exit of schools to see "beautiful girls", adding that the morning was better because the girls were older.
Beija-flor said he went to a school where his cousin studied to defend her from a supposed boyfriend that, according to him, was not accepted by her mother: "So, I'll go there and if I have to, I'll do it. Doing it is scaring him, making him let her go".
A little bit after seven o'clock in the morning, he was already walking on the sidewalk bypassing the district school. Near the gate, he talked to the police officer who stayed in the school, stood next to him and stayed there for some minutes still watching the students getting inside the school. He gave a policeman a paper and then went to his family's house, it was time for breakfast.
Near the time people were leaving the school, there he was again saying he was a helper of sergeant F., who stayed on the door of the school. When he was asked what it was like to be the helper of the sergeant, he answered: "I stay here controlling, right? Controlling so that no one will pass through here! I give crosswords to the sergeant and he lets me stay on the gate." The paper (with crosswords) he had given the sergeant some days before was part of the deal, a strategy to be allowed to stay on the school gate for some time. This will let him look at the girls, be protected from "jokes" or unpleasant comments from the boys and feel, at least for sometime, as a member of that community.
Dating was part of his speech: "I'm coming back from my girlfriend's house, now I'm in love, but her father doesn't want us to date."
His walks to watch the girls expressed a need to feel like a man in front of the others (men and women) in a universe where male honor is also related to the ability to date, get married and build a family.
The emphasis on the interaction with girls and in possible affective ties mentioned by Beija-flor demonstrates his investment in a male figure that, in his cultural background, had a role to perform regarding women. As he was away of other social spaces of men such as bars, games, or formal work, that would give him other social bonds, the streets became his main territory to share codes, social and cultural values. The need for an existence mode, supposed to state male social functions, took him gradually to other spaces, such as a car dealer, and a gas station with a convenience store on the district.
Just as with dating, the work, where he said from his mind that he was released from, was part of his routine on the streets. The comments made by the family were always ironic when this subject came up. They did not consider that Beija-flor performed a job in the capitalist sense of the word. His mother said: "He sometimes helps a woman, but she gives him some cents that are almost worthless". According to him: "I work as an office-boy, I am an office-boy, and this is my profession." Nothing was more suitable for him than matching a job with his taste for wandering and creating his own rules.
Traveling his path, we could see that he performed regular activities for an old lady on the district, he would go to the supermarket, did street errands. It was a place socially built by him, with rules, duties and rights, more than a productive activity, it was the possibility for living together, for exchanging, that is, a way to associate with the codes of his context.
The choice for this methodological proposal "up close and within" as of the place of living was essential for this investigation, because it was possible to understand the local dynamics, mentioning the paths, understanding the arrangements and flows that come from the everyday life of the families.
According to the history of Psychiatry, "mad people" needed (and some of them still need) to be taken away from society because they cannot follow minimal rules for living, or because they cannot obey the rules of assistance. However, this was not observed in the stories of the individual studied. From the point of view of his relations with the city, using Beija-Flor as an example, we may say that they are not disturbing, aimless. On the contrary, they can live peacefully, establishing rules for their lives reinforcing their references with choices, and making this space vital for facing other moments of their existence.
When matching him with the sociocultural context, we could observe that Beija-flor tried to build a positive self image, trying to get away from the diagnoses of inability produced by the classic literature on psychiatric disorder and human distress.
It is important to understand the individual in a subjective and sociocultural context to enlarge inclusion, living together, freedom and identification with the others that are not sick; playing roles that are accepted in the sociocultural codes of the city. Wandering through public spaces enables the formation of a support network for affect exchange where he can do small errands and take part in the leisure spaces of the district that is little visible. The city is also a space that leads to conflicts which helps building strategies that can overcome the barriers created because of their differences.
This analysis reinforces the need to overcome the traditional practice on the health field that increasingly classifies, fragments, and transforms this distress process into a meaningless experience for those who live and suffer with it.
The present study presented the resourcefulness of the interdisciplinary dialog between social Psychology and Anthropology and the need for incorporating new theoretical methodological comprehension to understand more complex issues regarding Psychological distress.
1. Brandão CR. Partilha da vida. São Paulo: Cabral; 1995. [ Links ]
2. Dalmolin BM. Esperança Equilibrista: cartografias de sujeitos em sofrimento psíquico. Rio de Janeiro: Fiocruz; 2006. [ Links ]
3. Magnani JGC. De perto e de dentro: nota para uma etnografia urbana. Rev bras Ci Soc. 2002;17(49):11-29. [ Links ]
4. Morin E. Os sete saberes necessários à educação do futuro. São Paulo: Cortez/Brasília: Unesco; 2000. [ Links ]
Bernadete Maria Dalmolin
R. General Osório 2727
Morada da Colina
99010-140 Passo Fundo, RS, Brasil
The name has been changed for a code name of a Brazilian bird to keep the patient's
2 Field research was conducted with five individuals, four men and one woman, aged from 20 to 59 years old, diagnosed by the mental health service of the municipality as chronic patients in severe psychological distress.
3 Community leader and research contributor. He took part of the study giving statements about his neighbors in psychological distress. Because of the crises, he helped them and their families, taking them to health services, getting medication and/or being solidarity.