Similarities and differences arising from accommodation and care issues in half-way houses: qualitative approach
Similitudes e diferenças nas temáticas que envolvem a moradia e o cuidado nas residências terapêuticas: abordagem qualitativa
Hudson Pires de Oliveira Santos Junior 1; Dulce Maria Rosa Gualda 2; Maria de Fátima de Araújo Silveira 1.
1 Universidade Estadual da Paraíba, PB, Brasil; 2 Universidade de São Paulo, SP, Brasil
Abstract: In seeking to build new knowledge so as to transform patient service practices performed in the field of mental health, as laid down in the Psychiatric Reform guidelines, this study has set out to gather statements from professionals and residents of half-way houses providing therapy in order to understand what similarities and differences there are between them on various accommodation and care issues arising in this service. This is a qualitative research study, which collected data by means of systematic observation, a field log and semi-structured interviews, conducted with 10 professionals and 07 residents of the Serviço de Residências Terapêuticas (Half-way House Service) of the municipality of Campina Grande, Paraiba. The result was that the statements indicate that these community residences provide a quality service, which reflects a tendency towards humanization, and one which is offered in an intermediate space in which citizenship can be achieved by those being discharged from asylums. As to the activities of the professionals, the study observes that the work process has provided the team with a means to manage care in a way that is substantially different from the technician approach which occurs in hospitals. As to those suffering from mental disorders, they start to regain ownership of a space from which they have long been estranged, that is to say, their homes, how to live at home, and how to live in a city. They have surprised everyone by their ability to (re-)adapt to and (re-)gain the urban space.
Keywords: mental health, mental health services, assisted living facilities
Resumo: Na busca de construir novos saberes para transformar práticas assistências produzidas na saúde mental, como preconiza a Reforma Psiquiátrica, este estudo objetivou unir falas de profissionais e moradores das residências terapêuticas, para compreender o que elas têm de similitudes e diferenças acerca das diversas temáticas que envolvem a moradia e o cuidado neste dispositivo de atenção. Trata-se de uma pesquisa qualitativa, cuja coleta de dados ocorreu através da observação sistemática, diário de campo e entrevista semi-estruturada, aplicada a 10 profissionais e 07 moradores do Serviço de Residências Terapêuticas do município de Campina Grande, Paraíba. Como resultado, os depoimentos sinalizam que estas residências prestam um serviço de qualidade, refletindo uma tendência à humanização, sendo um espaço intermediário para alcançar a cidadania dos egressos de internações manicomiais. No que se refere à atuação dos profissionais, observa-se que o processo de trabalho tem proporcionado à equipe um modo de conduzir o cuidado de forma menos tecnicista do que ocorre no hospital. Em relação aos sofredores psíquicos, estes começam a se apropriar de um espaço que há muito lhe tinha sido seqüestrado, que é o lar, o morar, o habitar uma cidade, surpreendendo pela capacidade de (re) adaptação e (re) apropriação do espaço urbano.
Palavras-chave: saúde mental, serviços de saúde mental, moradias assistidas
Introduction
Towards the end of the 1970s, the care practices undertaken in psychiatric hospitals in Brazil were questioned, which culminated in the emergence of social movements, amongst which the Movement of Workers in Mental Health (MTSM in Portuguese) and its struggle for a society without asylums was prominent. The outcome of this struggle for human rights to be respected and for better conditions in the health system enabled Public Policies on Health supporting mental health to be reformulated. This started with the passing of a law, Law 10.216/01 otherwise known as the Psychiatric Reform Law(1).
Such changes in the health system provided a characteristically beneficial background propitious for significant transformations of knowledge in the health area, particularly in the field of mental health, in which a system of substitute facilities for psychiatric hospitals, deemed extra-hospital, were created which were coherent with the international advances recommended by the World Health Organization and Brazilian Legislation on the Sistema Único de Saúde (Single Health System)(2).
Under these criteria, there arose the network of substitute services for providing mental health services, made up of the Center for Psychosocial Care (CAPS in Portuguese), the Center for Living Together and Culture, Beds in general hospitals, the Emergency Psychiatric Unit and the Service of Half-way Houses, deemed as community Residences providing Therapy (SRT) in Portuguese .
These half-way houses have the function of reducing beds in psychiatric hospitals and overcoming the chronic state of being "long-stay hospital residents", to which many patients had been relegated, because alternative accommodation for those who will be discharged in the future is implied, whether on account of the support required to ensure they remain outside mental health institutions or on account of the difficulty of reintegrating them with their families(3).
According to the Ministry of Health(4), in the last seven years (2000 to 2007) the network of half-way houses (TRs in Portuguese) has increased five-fold. In 2000 there were only 40 TRs in the country but this number jumped to 475 TRs in 2007, distributed throughout the national territory. However, this figure still falls short of the country’s needs, which are estimated to be 2,522 TRs(5).
The creation and operation of these residences are being widely discussed in Brazil. However, it is rare to find published studies that report on or evaluate both the scope and possibilities of these facilities, with regard to the challenges faced when residing in them.
Therefore, given that Psychiatric Reform is boldly trying to transform health care practices in order to construct new knowledge and, with a view to achieving this latter objective, the authors undertook this study. Their aim was not to confront, but rather to bring together what professionals and users have to say in order to understand what their similarities and differences are on various issues involving accommodation and care in half-way houses.
As to the implications for Nursing, it can be said that this study supports the construction of theoretical and practical support mechanisms that permeate the care of those suffering from mental disorders within the community, by focusing attention on the subject rather than the disease, an innovative and relevant fact, when compared with Psychiatric Nursing – the practice of which was to isolate the application of the psychiatric measures prescribed (the administration of pharmacotherapy drugs, restraint and so forth), all in the name of the pseudo order of the asylum.
Methodology
The study was undertaken using an exploratory and analytical typology, with a qualitative approach. One of the arguments for supporting the use of qualitative research is that this has a special approach for the study of small groups, which targets understanding the context in which the phenomenon occurs, besides allowing various elements to be observed within it(6), and therefore it is suitable for analyzing the practices of care and of the experience of accommodation in the Service of Therapeutic Residence.
Background to the Study
The study was undertaken in the town of Campina Grande (which has a population of about 370,000 inhabitants) - located in the interior of the state of Paraiba, due to the fact that this municipality is experimenting with and implementing measures for the de-institutionalization of people with psychiatric problems who have been long-stay hospital patients. This process began when the Ministry of Health established the National Program for Assessing the Hospital / Psychiatry System 2003/2004. One of the results of the evaluation was the declassification and de-accreditation of eight hospitals in the country, one of which was located in this town and which answered for much of the demand for mental health of the geopolitical region of the administrative area of Borborema/ PB. The intervention occurred with the de-hospitalization of 176 patients in April 2005 and ended in July of that year, with the de-accreditation of the hospital from the SUS Network.
Among the measures adopted to bring about de-institutionalization was a planned program of hospital discharges, which was conducted according to strict criteria. These demanded collaboration with families and the health services in the places that the patients came from. In a period of less than 02 months, this plan reduced the number of hospital "patients/ beds" (a total of 138), leaving only, 38 subjects who could now be considered "residents" because they had been there for between 02 and 30 years(4). They were transferred, shortly thereafter, to the Referral Center for Mental Health, currently the Emergency Psychiatric Unit and, gradually, in a planned way and after being evaluated case by case, they were accommodated in Half-Way Houses.
In the current scenario, the town of Campina Grande has an extensive network of substitute services: 01 CAPS II, 01 CAPS III, 02 CAPSi (children), 01 CAPSad (alcohol and other drugs), 01 Emergency Psychiatric Unit, 01 Center for Culture and Leisure, 09 mental health mini-teams in the Basic Units for Strategy for Family Health (ESF in Portuguese), 06 Half-Way Houses (03 male, 02 female and 01 mixed - men and women) and 41 accredited users in the Going Back Home Program(7).
Collaborators on the study
As the actors of investigation, there are 10 professionals who deploy their services in the team for the six half-way houses in the town and for the 07 residents of the Mixed Half-Way House. This was chosen because it shelters residents of both sexes, which is considered an advance in the process.
The criteria for including participants in the study were: a) Professionals: aged over 18, regardless of gender, working in any of the 06 homes, who have worked in the psychiatric hospital in which there was an intervention by the Ministry of Health in the town of Campina Grande b) Residents: living in the Mixed Half-Way House, due to the process of de-institutionalizing the hospital in which they were patients, and who display they have preserved the ability to communicate, and have a mental condition which allows them to understand questions and give answers. The criteria in common for both groups of collaborators are that they were able to participate by their free and spontaneous will and to sign the terms of free and fully-understood consent.
Professionals and residents in the body of the study are identified and shown, respectively, as: “Subject” (for professionals and residents interviewed) and "no." to identify the participant, following the criterion of the order of conducting the interview.
Instruments for Data Collection
Data collection covered a period of four months, from January to April 2007, and was conducted by means of systematic observation, of specific interview (semi-structured) for each group of participants and writing up a field diary.
The interviews were scheduled by telephone, the appointment being made for a place and a date for conducting the interview that, generally, was held in the Half-Way Houses themselves, sand they were guided by the following questions:
a) Residents: What do you think of the home? What do you do during the day? How do you look after yourself here in this home? Do you help with household chores?
b) Professionals: How do you see the aim of giving attention to mental health within the Therapeutic Residence? What self-care activities and household chores do the men and women residents take on? How have they been getting on together and what is their daily routine like? What activities are performed by the professionals for the residents in the residence?
All the interviews were undertaken and recorded, with the prior consent of the participants, and they were reproduced for each one of them, individually, soon after they had been interviewed, so they could confirm the fidelity and dignity of the recording, make any changes, include or exclude parts of what they said, in accordance with their wishes. After the end of this phase, the interviews were transcribed exclusively by the researcher.
Systematic observation was made during the entire period of field-work with a checklist guided by goals for capturing interpersonal relations that were established in the residences. To do so, the researcher visited the residences as follows: on each day of the week, the researcher would go to a residence where he remained for a period, morning or afternoon. In such moments, informal dialogues were entered into between the researchers, residents and professionals, through which it was possible to explore the context in which the residences were involved, to observe the relations which were established as an everyday routine, to get to know the residents’ way of life and the professionals’ work dynamics.
The field diary was written up during the daily routine of data collection, and recorded the contacts made with the interviewees, how they related to the men and women residents and the tasks which they carried out in the residence, as well as the researcher’s impressions, preliminary analyses and other information that became necessary such as the dynamics of the everyday routine of the residences and the care practices performed in them.
Treatment and analysis of the data
As to the treatment of content – the corpus – of the interviews, what was said was submitted to analysis of content, and of thematic type(8), the product of which gave rise to 03 categories, illustrated with extracts from what the participants had said, namely: 1) The accommodation is sufficient to supply a quality service; 2) The homes reflect a tendency to humanize; 3) The accommodation is an intermediate space from which citizenship can be reached.
Each category tackled specific issues, dealt with by the collaborators in the interviews: 1) This presents the conceptions about living in the residences, and indicates that this space is one of care and one that has been accepted; 2) It exposes the perception about the service rendered in the therapeutic homes and indicates there is a more humanized tendency which counterpoints the technical practice of a hospital; 3) It brings everyday life into the residences, and allows for relationships to be established between residents, professionals and the community in everyday living together.
Ethical Considerations
The development of the study followed the norms of the Declaration of Helsinki, 1965, in its revised 2000 version, and the guidelines issued by Resolution 196/96 of the National Health Council(9), which regulates research involving Human Beings, and in order to be made operational, the project was submitted for clearance by the Ethics Committee for Research of the State University of Paraiba, and was conducted only after approval by that body (Protocol 0304.0.133.000-07/CEP-UEPB), and after the collaborators had signed the Term of Freely Given and Fully Explained Consent
Analysis and discussion of the results
In this section, the analytical categories arising from what the interviewees said will be presented and simultaneously analyzed.
The half-way houses have managed to render a quality service
In the statements, the foremost understanding on the residences scores the facilities as good, due to the personal relationships that occur in them, because they provides care to the residents and because the residents may have contact with the outside world.
It is very important there really are some who have improved a great deal. (Subject 10)
It’s very good here. (...) they give us a bath, we go out. (Subject 2)
It was seen that one important way that the services to those suffering from psychological disorders through the Half-Way Houses were demonstrated was that it afforded the residents greater chances of recovery. It thus shaped up to being an appropriate proposal to that end, for it creates a new field of practice in health and new possibilities for producing care, because it is a place of residence, a home, which serves as a potential means to produce life and health(10).
It is of salutary importance that the residences offer therapy and re-socialization to those who have come from asylums because the residences fulfill an educational and model function for their residents, whose fantasies and fears are reduced when they start to have contact with the social context(5).
This is because in other places we do not feel so at ease, you know! This place [therapeutic residence] is good, because in others they very often do not treat us right, but I came from João Pessoa (the capital of the state of Paraíba) just now. I went to the beach. (Subject 6)
It is encouraging to read the statements because they demonstrate the ability that substitute services, in this case, the half-way houses, have to reinsert those coming from psychiatric hospitals into social spaces, which they should never have been deprived of.
The houses reflect a trend of humanizing
Another concept on the residences is that expressed by some residents on food and medication.
I think it’s good, all round. I think it’s good to have food and to take medicine. (Subject 4)
On analyzing these statements, it is noted that the users identify what they like, and this cheers them up, something which, as Goffman(11) says rarely happens in hospitals – total institutions, where the patients were subjected to extreme conditions of survival, which many do not even manage to resist, being overcome by cold, hunger, loneliness and ill-treatment, and this reaches the point of leading some to death(12).
I say to you today: it is a blessing because there! there was sweet Fanny Adams, the floor was bare, we lay naked, in a bed without a mattress, there were security staff who beat people up and I saw them do it and I could do nothing, there was a hell of a lot of torture going on (...). (Subject 8)
With regard to medication, the "patients" of psychiatric institutions are, almost always, over-dosed in order to keep them sedated, so they do not have the ability to fight for how they are cared for nor even to vent their madness. This sets up well, a scene typical of asylums, which is that people drag themselves round the edges of the walls, in an effort to remain awake during the day, screaming for help at half-open doors and windows (13).
I take medicine but I don’t place much trust in it! Because I was there in a hospital (the psychiatric hospital) and they slipped me doctored medicine, and the thing is that if you want to move about, you’re in such a state you can hardly do it! (Subject 6)
It may be said that the substitute services have been struggling to reverse that reality, through some strategies, namely: an increase in the variety of medicines offered, which respects the individuality of the subjects(14), and through battling to make professional psychiatrists aware that they should avoid dosages that make those suffering from psychiatric illnesses dependent on them, and as far as possible, they should go about suspending such drugs. For some participants, this is a more humanized way to provide assistance.
The issue which I find in this work proposal is the human question, then, on the other side what is seen more is the technical(…).(Subject 1)
The substitute services and, particularly, the Half-Way Houses are "open services", which transcend traditional practice and promote giving value to the subject and reconstructing their identity and social space, increasing their autonomy, their ties and their perception of life(15).
Everyone on the street already knows everybody’s names. In the afternoon, I open the door and we slip outside, the guys walk about, they speak to everyone. (Subject 8)
The statements express that the residents move about within the area of the district in which they live, this being a factor of great importance, because when the Residences were inaugurated, some associations for the districts tried to prevent these homes being located in their territory, from being rented to house a clientele with mental disorders.
The housing is an intermediate space so that citizenship can be reached
With an ideology contrary to that of psychiatric hospitals, the Half-Way Houses are inserted into the community and are part of the dynamics of the neighborhood, which allows its residents to become inhabitants of the city, and thus to experience its dynamics(7).
Therefore, anyone who obtains the chance to live in a home such as the Half-Way House, experiences two-fold integration(16): he/she is a user of a non-hospital network of psycho-social care(2), in which his/her therapy program is followed; and they are “the masters”, residents of the home, where it is possible for them to regain the basic functions of living, in accordance with their life-histories and with the new relationships they establish, which create independence so that they may care for themselves.
There is a resident who has really well. He is studying, he is looking after himself, he’s truly taking part in society. (Subject 9)
I take baths and all that, I brush my teeth, I comb my hair, I also put on perfume, and get dressed. (Subject 4)
Self-care is the "practice of activities that the individual initiates and performs for their own benefit to maintain their lives and their welfare." However, when someone suffering from a psychiatric illness leaves hospital and goes to the Residence, it is necessary to encourage the (re-)learning of self-care as if he/she were a child (7). This finding is reaffirmed in the statement below:
This account of brushing teeth, taking baths, they, mostly, do so by themselves, which is a very great advance, because, (when) they left hospital, they did not in the least manage to do this. (Subject 3)
This is because under the asylum way, therapy has little or no regard for the existence of the subject. This means no investment in mobilizing the user as a participant in the treatment(13), for it sustains the hypothesis that what basically works is the medicine, because it is not the subject, but rather the organism (illness), which is the focus of attention.
In the hospital they were abandoned to their own devices. Besides being lonely, they had poor housing conditions, hygiene. Here the care has improved a lot. (Subject 8)
Due to this low quality of support from psychiatric hospitals, the Psychiatric Reform has been trying to revert biomedical / hospital-centered care to the psycho-social model - inserted into the community. As Basaglia states(17), the evidence must be on the subject rather than the disease. Therefore, the self-image and self-evaluation, which those suffering from psychic illnesses have, start to have therapeutic value.
I take a bath with a bar of soap, (...). I tint my hair, my hair has to be kept well cut. (Subject 6)
The statements show their concern with good appearance, giving value to themselves. To look clean, smart, in sum showing interest in hygiene and social presentation(18), are acts which indicate that the residents have been recovering the social ties that give them the status of "person", that is to say, new forms of sociability which elude the mass production approach of asylums.
I’m being sincere when I say they have got much better at things like sitting down, eating, drinking water, taking a bath. They used only to drink water from the tap, now they get a glass and go to the fridge. (Subject 11)
However, we must stress how uprooted the ex-patients from psychiatric hospitals have become from the town, because this is hardly the same, whether from the geographical or architectural point of view or from where people meet socially, and it can very often come across as being seen in a "hostile way, full of varied, unpredictable and even enigmatic rhythms”(15), as reported by one resident who went to a cultural exhibition:
They took me to a place there (a cultural show), I wept buckets, daddy. I felt like rushing off to hospital (the psychiatric hospital), because I was crying so much (...). So I say: I’ve suffered a lot and I am like this just as I am now. Then, I asked for help because I felt frightened. (Subject 7)
This reported fear can be explained as the loss of trust in the ties of belonging to a group or community, and to a form of sociability held in common. This feeling occurs in individuals who have been removed from their social environment and committed to asylums(15).
This delicate process of (re-) appropriation of the urban space implies a series of measures which (re-) signify the social environment, starting with the involvement of those measures to do with the residence, with the neighborhood, and with the town (15).
Final Considerations
Regarding the previously mentioned actions by professionals, it is observed that the work process in the residential accommodation has provided the team with a way to conduct care in a less technical way than occurs in hospital, and more subject-centered, that is closer to and more involved with every aspect of the resident’s individual, family and social context. However, it is necessary to set up a permanent process of training so that they can be guided by the new model for care in this field.
With regard to those suffering from psychiatric illnesses, they have been beginning to take ownership of an area that had been taken away from them long ago, that is to say their home, how to live in a town. And despite the long years of isolation in psychiatric institutions, such subjects have been surprising everyone by their ability to (re-) adapt and (re-) appropriate urban space, although some, still, feel threatened by the social movement, which was to be expected, given the time that have been held apart from it.
However, as a matter of basic ethics, the future of the Psychiatric Reform lies not only in the success of new therapeutic care services, but in the choice of Brazilian society, as to how it will deal with its "different" people, with its minorities, and with subjects living in social disadvantage.
Faced with the challenge of overcoming long-stay practices, there is a palpable need for a highly professional team that is committed to the proposal for deinstitutionalization and is able to act on this model for care. To do this, prominence should be given to the Nurse as the active agent in the process of deconstruction/ construction of care in mental health so as to offer unique and subjective care to people suffering from mental disorders and their families since the former need support on their route back to citizenship, with the focus being on society, the place from which they should not have been marginalized. Therefore, the practice of nursing, as a service which provides care, should adopt a stance of critical and self-critical activities in order to assist “the person and the family who are suffering" holistically, both in the contexts of the mental health services and the social network.
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Contribuição dos autores: todos os autores contribuíram para este estudo, tendo Hudson Pires de Oliveira Santos Júnior participado como orientado (concepção e desenho, colheita de dados, análise e interpretação e escrita do artigo); Maria de Fátima de Araújo Silveira como orientadora (concepção e desenho, análise e interpretação, revisão crítica do artigo); e Dulce Maria Rosa Gualda como Co-orientadora (análise e interpretação dos dados, revisão crítica e aprovação final do artigo).
Endereço para correspondência: Maria de Fátima de Araújo Silveira. Rua Marechal Deodoro, 137. Prata. Campina Grande, Paraíba. CEP: 58400-492. E-mail: fatimasilveir@uol.com.br.
Financiado por: CNPq - Conselho Nacional de Desenvolvimento Científico e Tecnológico. Concessão de bolsa de Iniciação Científica - PIBIC/CNPq/UEPB.