A life story and an institutional path: youth, medicalization and social distress1
Ana Paula Serrata MalfitanoI; Rubens de Camargo Ferreira AdornoII; Roseli Esquerdo LopesIII
IDepartamento de Terapia Ocupacional e Programa de Pós-Graduação em Terapia Ocupacional, UFSCAR. Address: Universidade Federal de São Carlos - Departamento de Terapia Ocupacional. Rodovia Washington Luís, km 235. São Carlos, SP. 13565-905. <email@example.com>
IIDepartamento de Saúde Materno-Infantil e Programa de Pós-Graduação em Saúde Pública da Faculdade de Saúde Pública da Universidade de São Paulo, SP
IIIDepartamento de Terapia Ocupacional e Programas de Pós-Graduação em Educação e em Terapia Ocupacional da Universidade Federal de São Carlos, SP
A life story is presented for analyzing the manifestations of an individual path in dialogue with the elements the young people's lives in popular groups. It focuses on the discussion of social equipment in the production of the senses, places and suffering of some people's lives, which causes processes in which "diseases" and medicalization are generated from social problems. Based on the assumptions of ethnography researches, the path of a young was tracked for four years throughout her experience with social services that focus on infant and youth care, and mental health. It is considered that social politics should intervene in youth under a broad comprehension of the social problems; and also the area of mental health care, in connection with the social sphere, must take care of the suffering situations without the homogeneity of the needs, translating it into an iatrogeny and medicalization of the social.
Key-words: Youth, Life Story, Social Services, Iatrogeny, Social Medicalization.
Life trajectories are woven in the combination between individual elements from their microcosmos and the macrosystem defined by the context in which they are inserted (Meihy, 1998). They cannot be separated from the relationship between culture, socioeconomic situation and life's private universe.
Based on the presuppositions of ethnographic research, bringing the studied theme to everyday life, as proposed by Goldman (2006), we aimed to analyze the particularities of the individual trajectory of a young girl who belongs to popular urban groups.
We circumscribe popular urban groups to the structure of the social division of labor. Thus, we qualify as "popular" people coming from groups of "workers", that is, agents who, in the social practices of labor, occupy a certain place in the economic sphere, as they depend on the sale of their labor. They range from paid workers who have a "stable" job to those who perform precarious activities and even those who experience structural unemployment, since they configure the "totality of social work, the working class and the world of labor" (Antunes, 2003, p. 98, italics in the original)2.
In the construction of a perspective of analysis of the popular issue, it is important not to circumscribe it only to the economic category; the sociocultural dimension should be added. Both dimensions are apprehended as mechanisms that organize daily life, submission and resistance, observed by behaviors, ways of life, language, among other elements (Bourdieu, 1983).
Thus, the life story presented here is about a popular young girl, the daughter of workers or people excluded from the labor universe, who have a sociability and a daily life marked by the connection with their social position. Some elements are presented, highlighting the role of the services and of the social policies in the direction given to certain paths in that girl's life. Our focus is the discussion about the objective, responsibility and influence of the social equipments on the production of meanings, places and suffering in some lives.
Cynthia3: social suffering and institutional paths
Cynthia lived in the city of São Paulo with her family. Her father was a Paraguayan. She was the youngest daughter and she had two sisters. When she was eight years old, she went to live with her paternal grandmother and her father in Paraguay. She returned to Brazil when she was twelve by means of a referral of the Paraguayan justice and went to live with her mother in the city of Campinas (state of São Paulo). The alleged reasons were that she had been sexually abused by her father and her grandmother did not have the means to raise her. These facts were reported by Cynthia, by her mother and by the documentation sent by the local justice. Cynthia also said that her father went to prison because she "told what he had done", showing concern for this event. When she came back to Brazil, her mother had married again and she had had a baby. Right after Cynthia arrived, her mother had another daughter, in relation to whom Cynthia expressed great affection.
In Campinas, Cynthia used to go out and walk the neighborhood. She was known in the neighborhood's social services and also in the healthcare center. She had a foreign accent, mixing words in Portuguese and Spanish, an apparent frailty and a need of contact with people, expressed by her constant search for contacts and company in the services in which she circulated.
She presented some episodes of "aggressiveness", moments of rebellion when she did not comply with the adults' orders, threatened to break objects and, mainly, went to the streets, to walk, even when physically impeded, according to her mother. In one of these situations, when she was fourteen, her mother called the emergency medical service, and Cynthia was taken to the psychiatric sector of a hospital in the city, where she was hospitalized.
We can interpret this moment as a critical event experienced by Cynthia, according to the concept of Kleinman, Dass and Lock (1997), as the young girl acquired, as we will see, knowledge that accompanied her throughout her story, marked by that event of suffering. With it she began attending mental health and psychiatry services, as well as using psychotropic drugs, which will bring fundamental characteristics to her trajectory. Since that moment, she was marked by these healthcare equipments and could not interrupt this connection in her path.
After being discharged, she was followed up at the outpatient clinic in the same place. The psychiatric sector had not made a closed diagnosis because it argued that, firstly, she was an adolescent, under formation; her characteristics could change and she could develop or not a psychiatric condition. Afterwards, it argued that the great affective, social and cultural privations observed in the girl's life story might be confounded with some set of symptoms which, in fact, would represent a problem of another nature and not a mental illness. Thus, the administered medication aimed at the aggressiveness symptoms and at anxiety control.
One day, after this event, she went out with her two-year-old sister without telling her mother. She spent the night roaming the streets with the little girl, whom she liked so much. On the next day, when she came back home, her stepfather, the father of her sister, threatened to kill her, because he was worried about the small child. Motivated by this episode, Cynthia returned alone to the street and headed spontaneously to the outpatient clinic of the mental health care network, which was connected with a local University, where she had recently begun to be followed up, and reported what had occurred. She was received by the reference team; concerned about the episode, the team decided to refer her to a shelter whose function was to be a provisional home for those who cannot be under the custody of their guardians, evaluating that it would be "dangerous" if she stayed with her family.
After the psychiatric hospitalization, Cynthia experienced another important episode in her trajectory: the entrance into social services, which followed her up from then onwards, during her entire path, and outlined important traces in her life. Under the sign of guardianship, due to the death threat that she had suffered, technicians decided to refer the girl to a place for protected sheltering, as opposed to family mediation. The posture that was adopted due to a concrete risk is evidently understandable, and the decision is supported by law, by the Estatuto da Criança e do Adolescente (ECA - Statute of the Child and Adolescent) (Brasil, 1990).
However, as Fonseca (2005) argues, there is a tendency to technify the popular family relations to the detriment of a capacity for the analysis of the "ways of life" rooted in that social class, expressed in their customs, languages and values. There was not a thorough analysis of the social representation of that situation in the family context, as the dynamics established there was not known, and the concrete threat made by the stepfather was not investigated, nor the place occupied by Cynthia in that family. Thus, it is possible to point out that the measures that were taken were precipitated and unfolded concrete facts in that girl's life.
This option composed, together with the hospitalization, a script of institutionalization and psychiatrization of the young girl, who had a family history that demanded attention and care, and was inserted in a peripheral context of little access to social services and goods. The demand for actions that attempted to understand Cynthia's situation was evident, without the need to take her, as the first step, to a shelter. Instead of the technical work, the focus should have been on strengthening and broadening the personal and social supports regarding Cynthia. The proposition of guardianship, together with the "punishment" of the family due to the situation that was triggered, weakened her family bonds.
Cynthia was referred to a shelter that provided assistance, mainly, for adolescents in street situation. When she arrived at the institution, her profile differed from that of the other adolescents who were there, as she had not had the experience of living on the streets. Due to her personal aspects and to her differences in relation to that context, she was constantly involved in fights and required continuous individualized intervention of the institution's professionals. She was not able to carry out the daily tasks proposed for everybody (like tidying her room up, taking care of her clothes, among others), except when some professional helped her. On top of that, she had a remarkable specificity: the use of psychiatric medication, administered by the local professionals. Such particularities generated discomfort in the institutional dynamics with the other adolescents, who questioned the reasons for her special treatment, saying that she was "mad", motivated by the observation of her unwillingness to perform the institution's tasks and, above all, by the continuous use of medication. She also had difficulties in performing personal hygiene practices and episodes of stink, resistance to having showers, contamination by lice, etc., were frequent. Thus, Cynthia did not make friends in the institution, did not interact much with her peers and maintained bonds "only" with the technicians. This was a recurrent fact in her life, as these data had been present since her arrival at Campinas, in the circulation through the social equipments of that territory.
After these episodes, Cynthia started to transit between stigmatization and real psychic suffering, occupying a place of difference, prejudice and social suffering, which was explicit in her living with street boys and girls, her group of peers at that moment, and also in her contact with some professionals and services.
Simultaneously with the admission to the shelter, she started to be followed up by a healthcare service destined to adolescents. Conceived as a Reference Center for Integral Care to the Adolescent's Health, it subsequently became a Centro de Atenção Psicossocial - Álcool e Drogas4 (Psychosocial Care Center - Alcohol and Drugs) focusing on children and adolescents (CAPSad-i). Its objective was to provide care for adolescents in social vulnerability situation, mainly those in street situation. It offered individualized and personalized care, which was viable due to the number of professionals that composed its team. Cynthia was followed up individually in this service for four years, and developed bonds with the entire team.
The process of institutionalization, freedom deprivation and stigmatization of a group, due to their illness, to the place in which they are to receive treatment, or other circumstances that have led them to an asylum, is thoroughly described by Goffman (1974), who emphasizes the perverse effect and the dynamics of identity construction in this role.
Therefore, the propositions of articulation between social and health policies should be viewed critically, without underestimating the possible suffering, but being careful not to "create" predispositions, prerequisites and predeterminations towards the label of "ill", "mad" or any other stigma. When we deal with the interaction between the theme of childhood and youth and mental health, it is essential to be careful not to produce stereotyped social marks that undervalue this population, mainly those who are already immersed in contexts of disrespect and prejudice. It is necessary to clarify the individuals' real demand concerning assistance to psychic suffering. Cynthia clearly demonstrated suffering and difficulties that needed care, strongly intertwined with her social condition and life history; however, they did not seem to determine a psychiatric condition.
Fassin (1998) approaches the encounter between public health and social space by means of interventions performed with the "urban figures of public health", that is, social situations that gain a place of intervention in health. The author exemplifies with the homeless (without fixed address, in French), drug users (approached by damage reduction programs), and periphery youths, among others, who are treated like "figures" and not like subjects.
The figure is, in fact, on one side, the exterior form of a body, like an appearance, seen as a more precise resignation, the person's aspect, which is expressed in his characteristics; on the other side, it is the visual representation of the thing that is situated in the world of art or in the domain of rhetoric (Fassin, 1998, p. 10)5.
With her characteristics and particularities, Cynthia presented an unstable adherence to the institutions she attended, coming and going without creating roots. This fact can be attributed to the precarious responses that the institutions offered her, because her demands submerged in the services' dynamics, which focused on the population of adolescents in street situation. With this, she started to establish a movement flow that was similar to her behavior when she was living at her home. As she could not find a social place to occupy, she circulated in other spaces. When she was admitted to the shelter, in contact with those who had lived on the streets, she started to make a circuit that included the central area of the city. Leaving the shelter without authorization, she went to the streets, with the purpose of visiting her family, professionals from institutions that she had attended and staying, in some moments, with other groups, more frequently adults in street situation; she seldom was among adolescents, which demonstrated her fragile insertion among them. At the moments in which she circulated on the streets, episodes of fights were common, followed by slight physical injuries, when she got involved with other youths, with adults in street situation or with intervention agents, like the police.
One of the vulnerabilities that she experienced in those occasions was in relation to sexual practices, a constant element in episodes of her trajectory. There were rumors that she had suffered sexual aggression on the part of adolescents in the shelter, and it was known that she used sex on the streets in exchange for food, a place to sleep in and affection. Cynthia did not speak directly about this theme. She only referred vaguely in her discourse to "a man" who gave her a place to sleep in; "a man" who regularly gave her food when she was on the streets; "a man" who had a dog and let her play with the animal; "a man who was good". Connected with this theme, Cynthia started suffering from syphilis, of unknown origin, and began to need intense care. She was followed up by the institutions she attended, by means of the professionals from the shelter and from the healthcare service (CAPSad-i).
Her trajectory exemplified the complexity of the phenomenon called sexual exploitation, combated by the guidelines of the Brazilian government (Brasil, 2006). Sexual exploitation, in the prostitution modality, approaches situations in which the child or adolescent is used for sexual purposes in exchange for something (favors, money, affection), practiced by an adult who benefits from this through a power relation (Leal, 2003). This definition fits the situations experienced by Cynthia, as they did not involve financial exchanges and were related to some type of consent on the girl's part, in her search for affection and social exchanges.
Supported by these facts, the healthcare service that followed her up administered contraceptives to her on a monthly basis. Cynthia was always informed about the procedure and, sometimes, she resisted it. After a persuasion process performed by the professionals, she ended up accepting the medication, with a few exceptions. It was administered regularly until she was eighteen.
Worried about Cynthia's unstable movement of permanence in the shelter and the risks to which she was submitted when she was on the streets, representatives of agencies for the defense of children's and adolescents' rights decided to transfer her to an institution that was considered to be more adequate to her profile. She remained in that shelter during almost five months, with constant comings and goings. Cynthia was transferred to a provisional home6, so as to wait for referral to another place.
Cynthia had been in this provisional home for one month when she had a crisis, a nervous breakdown, according to the local technicians, and was referred to the psychiatric admission service of a general hospital, connected with a University of the city. More than once, she was submitted to physical and chemical restraint procedures and was hospitalized for one week. Due to this, the technicians who followed her up, searching for more specialized care, discussed the possibility of seeking a place for the adolescent in another city, which had an institution for adolescents with psychiatric disorders. It was a traditional psychiatric institution, characterized as an asylum, which had a child and adolescent wing for children with serious psychic disorder. This solution was justified by the increase in the guardianship and care that needed to be provided for Cynthia, in an attempt to take her out of the streets and of the risks to which, in their evaluation, she was submitted in these situations; moreover, it was justified by protection, contained in the law (ECA), supported by lack of knowledge about the reality and universe of the total institutions, in the asylum model. Some professionals, however, because they were familiar with the reality of mental health care and of the statutes in this field, were radically against the proposition. They resisted the proposal and questioned the "career of mentally ill patient" that was being established to Cynthia, and her institutionalization, perhaps irreversible, that might occur with that hospitalization. She still did not have an effective diagnosis and some technicians thought that she did not present any mental illness, no psychic disorder, "just" behaviors and suffering deriving from her life story.
In Brazil, mental health care is accompanied by the discussion about the Psychiatric Reform, based on the model of deinstitutionalization and community assistance. It is based on the Italian experience of opening the institutions (which started with the closing down of the San Giovanni Asylum, in Trieste, in the 1970s), impelled by Basaglia (1985) and by the proposition of Democratic Psychiatry (Rotelli, 1994). However, when we are dealing with practices beyond the field of health, like that of the social services that provide assistance for children and adolescents, the experiences in this area, and even the knowledge and appropriation about mental health discussions and proposals, are absolutely incipient. Moreover, they show important frailties in the executed actions, as well as the reproduction of the paradigm of isolation of the population, an element that is present in the asylum model (Goffman, 1974). Lack of knowledge about the mental health field, its treatment models and difficulties regarding its transformation, may have led the social services professionals to propose Cynthia's transfer.
As it was not viable to refer the case to another municipality, it was decided, once more, to indicate her return home. For three years, professionals from different services discussed with Cynthia's family about her homecoming. According to the services' records, the threat that had been made by the stepfather seemed not to be true, due to his characteristics and relations with the family. The mother was inserted in a social program to complement the family income, which was, effectively, a concrete problem. In parallel with the executed measures, technicians from different services discussed the frailty of the bonds between mother and daughter, and the fact that the mother blamed Cynthia for what had brought her back to Brazil: the sexual abuse practiced by the father. With this dynamics, the conditions for her return to the family were evaluated as precarious.
However, due to the impasse among the assistance network professionals, as some of them defended Cynthia's referral to a psychiatric institution and others, mainly professionals connected with the psychiatric reform, rejected this option, an articulation with her mother was attempted so that the girl could be discharged from the hospital and from the psychiatric infirmary. Finally, it was agreed that she would return home and receive intensive home monitoring provided by the health professionals. As a result of the agreement, she stayed at home for some weeks and, when she recovered physically, resumed her circulation between the streets and her home.
The debate about the procedures to be applied and the "protection" provided by the social services for the target population is necessary, mainly in this encounter between social demands and health demands. Social suffering can, as in the trajectory of Cynthia, be classified as psychic suffering and develop as a social production of madness, as the public social responses to suffering are insufficient and ineffective. Under the discourse of protection and guardianship, the girl was taken away from the care of her family and referred to psychiatric follow up, but there was not a consensus about the real clinical need.
Another point that was present was the continuous administration of drugs to Cynthia. It was realized that, during almost one year, when she was not given the medication on a regular basis, in comparison to other moments during which she received intensive medication, the characteristics of her symptoms did not cease and she maintained exactly the same behavior, with some crises of "aggressiveness", which had been accompanying her for years. Therefore, technicians and services started to question the pertinence and efficiency of the drugs that were administered to her.
We observed that, as a result of the technical actions of diverse professionals and services, Cynthia experienced a process of social medicalization, identified in her insertion in psychiatric care and in the administration of drugs, which "can be seen as the progressive expansion of the field of intervention of biomedicine by means of the redefinition of human experiences and behaviors as if they were medical problems" (Tesser, 2006, p. 62). By considering her suffering an illness, it was possible to camouflage the question about the cause of the manifestation of those symptoms, treating it as an exception, as a "case" of psychiatry among those who live on the streets, without remembering the reasons that had led her to the streets: technical interventions, and, furthermore, without explaining that the experienced social suffering demonstrated lack of perspectives and answers.
Taught to forget, underestimate and disqualify the autochthonous knowledge for the interpretation and handling of experienced illnesses and sufferings; taught to search in the biological cause and in the chemotherapeutic/surgical treatment the solution for all the problems; taught to expect from the specialist and from the complementary examinations the elucidation and the cure for everything. (Tesser, 2006, p. 70)7.
When she was seventeen - which means that she had been receiving assistance from the social services for three years -, Cynthia returned to the shelter due to a judicial decision, because she had definitively lost contact with her family and was living on the streets. Her mother moved to São Paulo again, without informing Cynthia nor leaving her new address. The initiatives related to reestablishing the bonds with her family did not bring positive results, and ended up producing the complete loss of the family references to which she had returned when she arrived from Paraguay. The judge formally registered that, if the adolescent did not adhere to the shelter and to the treatment in the healthcare service, the CAPSad-i that she already attended would determine her admission to a psychiatric unit.
As she would be eighteen soon, the services' technicians became worried about the situation of her majority. What should be done when she became an "adult"? Which services would be able to continue assisting her? The services she attended were restricted to adolescents, that is, they could not provide care for her after she turned eighteen. To what autonomy could Cynthia resort to manage her life?
In view of the lack of social services that assist youths, mainly those with some degree of social suffering and with demands of individualized follow up, the technicians decided to refer her to a Centro de Atenção Psicossocial - CAPS (Center for Psychosocial Care)8. There was a consensus about the fact that Cynthia did not present a condition of psychosis, the major profile of CAPS; nevertheless, the need of constant and intensive care was clear, and there was no option of places that could provide this for the adult population. This CAPS was integrated into the local policy, in one of the first municipalities that underwent the process of psychiatric reform in Brazil, as can be seen in the history of Campinas (SP), which offered care technologies concerning the principles and guidelines of the regulations of the mental health field. Meetings were held before the beginning of Cynthia's assistance, so that the professionals could learn about the specificities of the case and could provide different care in relation to the profile that predominated at that place.
Even though these measures were taken and the institutions complied with the principles of humanized assistance and fulfillment of singular projects, it was necessary to "frame" the girl in a symptomatological perspective of the mental health clinic so that she could receive some level of care for her social suffering. Only from the place of the illness, even though it was never diagnosed by a specialist, did her suffering achieve some level of sheltering, with strong implications to her trajectory.
The pain and the illness, which have social recognition in the cultural sphere, enabled a place of social existence, in the "art of suffering" (Tesser, 2006, p. 64), to the detriment of a non-place occupied by poor youths, radicalized in those who live on the streets, in a position of social "remains" (Castel, 1998). Cynthia had to ascend to madness to have the right to continuous and individualized follow-up and assistance.
The paths she took in the social services directed Cynthia's life and strongly characterized it in her entire story. This trajectory exemplifies the absence of the universalization of social rights and the experience of an "inverted citizenship" (Fleury, 1994), as only through the culturally recognized condition of the disease could she access the right to care. However, the situation promoted the girl's framing in the universe of madness.
After some months at the CAPS, according to the local team, she had an acute crisis and had to be submitted, for the purpose of restraint, to a high dose of psychiatric medication. It was suspected that living with seriously ill patients, together with her internal suffering for being abandoned by her family, and not having perspectives for the future generated the referred crisis. As side effects, she put on substantial weight, some of her movements became slow and she had periods of intense salivation. In this same phase, her hair was cut very short. This haircut is very characteristic of these populations.
Based on the analyzes performed by Goffman (1974), we can say that Cynthia underwent an institutionalization process that unfolded during her adolescence and in the passages through the justice, social and health services, including the psychiatric ones, which culminated in the acquisition of bodily and attitude characteristics of the group in which she was inserted and to which she started to belong.
Then, Cynthia had another crisis at the CAPS, attacked users and professionals and caused material damage. The service sent her to a hospital of the municipal health network that offered psychiatric hospitalization, and she stayed there for approximately four months. The hospitalization represented her return to the hospital context and to the intensified contact with people in psychotic crisis. As a result of this fact, according to the local technicians, she learned stereotyped behaviors and, in one occasion, she attempted to commit suicide by hanging herself, without a real danger of being successful.
The hospital's professionals, in an attempt to make Cynthia's discharge viable, searched for alternatives for her insertion and financial support. They requested a benefit of the federal government directed at people with incapacitating deficiency for independent life and work. She received this benefit after being examined by experts who concluded that she was unable to manage herself autonomously. With the possibility of receiving a financial resource, the team looked for a space where Cynthia could live. They rented a room in a boarding house downtown - the girl's first experience of living alone.
It is important to highlight the team's commitment to their patient's discharge, reflected on actions so that Cynthia could lead her daily life and continue to receive care. The enrolment in an income program, enabled by the articulation with professionals from a psychiatric hospitalization service, configured a situation that could open perspectives to that girl's trajectory.
Besides her placement in a boarding house and the acquisition of financial resources, she started to be followed up by the psychiatric service of the Healthcare Center of the region in which she now lived.
To organize her daily life, she was taken back to school, in the modality fast high school diploma program, and she also started attending workshops for the production and sale of handcrafted objects. These workshops were targeted at individuals with psychic disorder.
Cynthia remained approximately three months in this project (of dwelling, health follow-up, education and work). Subsequently, she abandoned the workshops and went to the shelter in which she had stayed longer to ask if she could live there again. She was provisionally received by the local directors, who did not have judicial authorization to assist the girl, as she had turned eighteen. At the shelter, she said that she had been sexually abused by the owner of the boarding house in which she lived and due to this she had to leave the place urgently. To us, she said that the owner "controlled" her life and she did not want to stay there. In this way, she changed the propositions that had been presented to her, according to her interests.
Fonseca (2005) argues that it is important to emphasize the positiveness of the sociabilities developed in popular groups, without focusing only on lacks and shortages. In this sense, Cynthia, in several moments, acted to weave her paths, as in the situation described above, resorting to a fact that she knew was impressive to try to stay in the place she had chosen, joining real possibilities and personal options. This regards "thinking about the way of life as a historical phenomenon, the result of certain economic and political circumstances, providing proof of the creativity of individuals acting in partnership" (Fonseca, 2005, p. 58).
Also in that year, she concluded the Primary School and participated in the party that was held for the graduates of that period. She was very proud of her achievement and invited many technicians from different social equipments, leaving nominal invitations at each service and asking people to give messages to those who no longer worked at certain equipments. She articulated her personal network, formed by the technicians from the services of assistance for children and adolescents, including them as her guests in her party. Subsequently, she continued with her studies.
Months later, she moved to another boarding house, where she stayed for another period of time, always demonstrating the need of intensive monitoring to manage daily life, organize her space, to practice personal care and other activities of this nature. Some time later, as a result of another crisis and another psychiatric hospitalization, she was referred to a therapeutic residence for patients with serious psychic disorder, guarded by healthcare professionals.
After four years, at the age of twenty-two, the last time we were with Cynthia, she had the baggage of her experiences, of her formal inclusion as a patient in the universe of madness, with episodes of crises and psychic sufferings, and, consequently, she developed the personification of the pattern that is usually found among users of this services network. Obese, with short hair, residing at an assisted dwelling, she accumulated hospitalizations in crisis assistance and went through different psychosocial projects, since attempts of her inclusion in spaces outside the mental health network until the intensification of her care in it. The professionals continued debating the difficulty in handling her case and the doubt about her receiving mental health care. On her part, she continued negotiating possibilities, choosing where she wanted to be, rescuing and trying to weave networks of affection and belongingness, always connected with services and professionals, resources that she learned to access since her return to Brazil, when she was twelve years old.
In this trajectory, she remained fighting for life.
Cynthia's life story shows the frailty in sheltering social suffering, even within a juridical context of valuation of childhood and adolescence, like in Brazil, by means of the Statute of the Child and Adolescent (ECA). The social contradictions, aggravated by socioeconomic inequality, and accompanied by imaginary and cultural valuations in constituted paradigms, like that of disease, produce effects like the ones experienced by Cynthia, in which guardianship leads to a path of suffering and hinders the constitution of autonomy, which is expected to live the adult phase.
Her story shows the contradiction of the need of attention, the presence of suffering, of family abandonment and the institutional response, given by means of valuing a supposed disorder and her inscription in it so that she could continue to receive care.
In the midst of the contradictions of the assistances received in the services that she attended, Cynthia possibly experienced the creation of a mental disease, something that perhaps would not have happened if there was not the prerogative of juridical guardianship, which, theoretically, defends the right and enables the access to some goods and services. Certainly, it is an extremely relevant principle and the forms to make it viable need to be thoroughly discussed, considering the dynamics of the services and professionals involved, with the aim of revealing the unplanned practices. However, they are also the result of ongoing social actions. Between guardianship and autonomy, living the liminal phase of youth is articulated among different actors and possibilities of experiences, which are many times unexpected, like those that occurred with Cynthia.
It is important to emphasize that the discussion presented here, by means of Cynthia's life paths, does not focus on opposing the social and mental health services. It is necessary to point out that there are cases with complex issues, also on the streets, that require, of the services, answers in the mental health area. Cynthia's case, for example, showed the need of intersector actions, with interfaces in the field of mental health care, because, although there was a constant questioning about the existence of a psychotic condition, it clearly demanded psychic support and strengthening. Besides her, other cases could be given as examples, evidencing the need to think of alternatives in mental health to provide care for suffering situations, but without homogenizing a certain population group and without focusing on the production of a "mental illness" that would be characteristic of some poor youths.
There is, therefore, the challenge that the mental health interventions in the social sphere do not produce iatrogeny and medicalization of the social dimension, but provide effective care for those who need this attention, and develop other forms of giving shelter to suffering that do not produce individualizing explanations and culpabilities. In addition, these interventions cannot be reduced to an explanation about the "inadequacy" of the measures taken by social services professionals, as they, too, are products of the same order. Their actions produce unimagined results, like those in Cynthia's experiences.
I am concerned about the tendency of psychologizing or pathologizing problems. However, it is legitimate to think about and to have practices that attempt to correspond to the effects of the objective processes of precariousness over the subjects' general psychic condition. And it can be perceived that there may be a certain rationality in thinking that someone who does not have the objective conditions for his social independence has problems of suffering and, in the limit, undoubtedly, of pure and simple pathology. Therefore, heading in this direction seems to me a necessary amplification of the problem; the risk lies in reducing to psychologization and looking for the individual's weaknesses that cause or are the principles of the catastrophic situation in which he is. But I think it is evident that conditions of lack of social independence have psychic repercussions in terms of suffering or pathology. If the individual does not have conditions for his social independence, he may fall in a limit state (Castel, 2005, p. 157)9.
The dissociation between contexts, causes and implications of complex questions that are presented to public health nowadays may result in little effective or ineffective measures and in problems that are not tackled in the scope of the implemented policies and programs. The "new" demands that are beginning to be met in public health, like that of youths, challenge the field of social policies, with their different interfaces and inherent intersectorialities (Lopes, Malfitano, 2006), so that they start to modify intervention paradigms, models and methods, not being restricted to containing risks of diseases, but rather, consolidating themselves as a field that can effectively contribute to the promotion of conditions and expression of multiple life courses.
Nevertheless, it still is by means of social actions that some level of protection and care is ensured for many Brazilian children, adolescents and youths. Focusing on elements like those brought by Cynthia's story aims at enhancing knowledge about the existing dynamics, so as to emphasize the contradictions that are inherent in the social practices, without denying their need. Also, Cynthia's case highlights the importance of searching for adequate answers, that is, answers that are effectively of protection and care.
The episodes, trajectories, traces and moments of many lives that cross the dynamics of the services, among them, the healthcare services, are characterized in a pulsating, dynamic and lively way, changing quickly and weaving a tense configuration. This configuration shows, above all, the persistence in the ceaseless movement of life, in the search for new paths and other tracks; the creation of moments and experiences that put youths like Cynthia, in some way, in a deserved social and autonomous place.
It is in this stage of contradictions and on this string called 'life' that our characters-type balance, step by step, their trajectories, a source of energy to face the countless challenges of a world in which they seldom are the protagonists. It is in this 'tightrope', in this uneasiness, which can be so painful, that they show enchantment for life and for freedom, and also make us see the 'equilibrist hope' of finding other places that are more and more worthy and consonant with the complex plot of life (Dalmolin, 2006, p. 203)10.
Ana Paula Serrata Malfitano, the author of the dissertation on which this manuscript is based, was responsible for writing the text. Rubens de Camargo Ferreira Adorno, the dissertation's supervisor, contributed with the elaboration and revision of the text. Roseli Esquerdo Lopes collaborated in the discussions and analyses that were conducted, and in writing and revising the final version of the text.
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TESSER, C.D. Medicalização social (I): o excessivo sucesso do epistemicídio moderno na saúde. Interface - Comunic., Saude, Educ., v.10, n.19, p.61-76, 2006. 1 Translated by Carolina Siqueira Muniz Ventura.
2 All the quotations were translated into English for the purposes of this paper.
3 Only the name is fictitious and was chosen by the young girl in her collaboration with this study.
This report uses data from a research in which social services targeted at adolescents in street situation were monitored during four years, in Campinas - SP. These data derived from our contact with the adolescent and from records from different professionals and services that also followed her up. We started from the perspective of the social services and attempted to give light to the contradictions created in the process and in the dynamics that were experienced and to the social suffering produced based on them.
4 Mental Health Equipment that should "offer daily assistance to patients who make harmful use of alcohol and drugs, allowing therapeutic planning within an individualized perspective of continuous evolution" (Brasil, 2004, p. 24). It integrates the National Mental Health Policy of the Ministry of Health.
5 La figure, c'est em effet, d'une part, la forme extérieure d'un corps, ce qui en fait l'apparence, voire dans une acceptation plus précise, le visage de la personne, ce qui en exprime les traits et, d'autre part, la répresentation visuelle de la chose, que l'on se situe dans le mond de l'art ou dans le domaine de la rhétorique.
6 A shelter for children and adolescents with a period of permanence of, at the most, five days. Its focus was to provide assistance to special emergency situations and solve them by means of immediate referral. In this case, it frequently sent children to their cities of origin, when they were on the streets.
7 Free translation.
8 The CAPS - Centers for Psychosocial Care, composing the National Mental Health Policy, are "a place of reference and treatment for people who suffer from mental disorders, psychoses, serious neuroses and other conditions, whose seriousness and/or persistence justify their permanence in a device for intensive, community-based, personalized and life promoting care." (Brasil, 2004, p.13).
9 Mais je me méfie de la tendance à psychologiser ou à pathologiser les problèmes. Cependant il est légitime de penser et d'avoir des pratiques qui essaient de correspondre aux effets de ces processus objectifs de précarisation sur l'economie psychique des sujets. Et on perçoit qu'il peut y avoir une certaine rationalité à penser que quelqu'un qui n'a pas les conditions objectives de son indépendance sociale tombe dans des problèmes de souffrance et à la limite sans doute de pathologie pure et simple. Aller dans cette direction me semble donc constituer un nécessaire élargissement de la problématique, le risque étant de réduire cela à la psychologisation et de chercher dans la faiblesse de l'individu la cause ou la source principale de la situation catastrophique dans laquelle il se trouve. Mais que des conditions de non-indépendance sociale aient des répercussions psychiques en termes de souffrance ou de pathologie me semble évident. Si l'individu ne dispose pas des conditions de son indépendance sociale, il peut basculer dans des états-limite.
10 Free translation.
1 Translated by Carolina Siqueira Muniz Ventura.