Deinstitutionalization and network of mental health services: a new scene in health care

Objective: to analyze the process of deinstitutionalization resulting from a psychiatric hospital shut down, and know the fate of users after dehospitalization. Method: a descriptive, qualitative study based on the critical-analytical perspective, which had as its setting the Hospital Colônia de Rio Bonito . Institutional documents and narratives of five managers who participated in the deinstitutionalization process were analyzed. Results: Hospital Colônia deinstitutionalization lasted longer than expected. For this to happen, a tripartite intervention was necessary, and especially the mobilization of networks and implementation of Psychosocial Care Networks by the cities. Regarding destination of users, most were referred to therapeutic or transinstitutionalized residences. Final considerations: Hospital Colônia deinstitutionalization led to the establishment of connections between services and people. This was a powerful device for the implementation of Psychosocial Care Networks at municipal level. Deinstitutionalization; Health Care; Health Public


INTRODUCTION
In the late 1970s, under the influence of social movements criticizing psychiatry around the world, the process of psychiatric reform began in Brazil. This reform aims to build an ethic of mental health care and ensure the rights and citizenship of people with mental disorders. Assuming it as a social and cultural process, one goes beyond the idea of operating changes only in the services that serve this population, breaking with the exclusivist biomedical logic of the pathological concept that involves madness (1) .
The Brazilian Psychiatric Reform gained strength mainly from the late 1980s, along with the Sistema Único de Saúde (SUS -Brazilian Health System) and mobilizations for country redemocratization. From then on, mental health conferences and congresses gain visibility. The first Psychosocial Care Center (CAPS -Centro de Atenção Psicossocial) is created, nursing homes are shut down, and Therapeutic Residential Services (SRT -Serviços Residenciais Terapêuticos) are established. The feasibility of its implementation occurred with the sanction of several laws and ordinances, especially Law No. 10,216 of 2001, known as the Psychiatric Reform Law. This law aimed at protecting the citizenship rights of users and proposed redirection of the care model. Understanding that breaking with the segregating logic implies more than shutting down asylums and opening therapeutic residences (2)(3) , it is important to cite Ordinance No. 336 of 2002. This Ordinance established CAPS as priority care devices. Law No. 10.708 of July 31, 2003 created the Homecoming Program (Programa de Volta para Casa), enhancing deinstitutionalization through financial aid for long-term graduates, making life outside the walls of psychiatric hospitals more viable.
Another important milestone in shaping the Brazilian National Mental Health Policy (Política Nacional de Saúde Mental) was the implementation of the Psychosocial Care Network (RAPS -Rede de Atenção Psicossocial), established by Ordinance No. 3088 of 2011 (4) . This Ordinance articulates the fundamental devices for the advancement of Psychiatric Reform such as Street Outreach Offices and SRT that should offer differentiated care to people with mental disorders. Within its scope, the Deinstitutionalization Program (5) was created, which aims to remove psychiatric hospitals from the scene, significantly reducing their hospital beds (6) .
In Brazil, even in the face of difficulties in consolidating SUS, its basic principles permeate the perspective of mental health care, seeking a subject-centered practice that goes beyond the health sector. However, it is necessary to overcome the fragmentation of services, based on Health Care Networks (RAS -Redes de Atenção à Saúde), understood as a tripartite construction process, of horizontal and dynamic organization of services. Notwithstanding the many challenges for their real articulation and alignment, RAS are an innovative arrangement that is coherent with the principles and guidelines of the SUS through which the integrality is achieved (7)(8) .
While many advances can be seen, such as increasing CAPS coverage and its place as a network and care organizer, there are still many challenges in consolidating mental health care practices consistent with Psychiatric Reform principles (9) . Psychiatric hospitals, for example, still play an important role in many situations in which, for CAPS, the possibilities of crisis contour are exhausted, or in which the user is or exposes third parties to risk situations, thus justifying an internment for social reasons.
In this connotation, walls often gain a protective character and are seen as a unique resource in a given context, by professionals, family members and even users who are in vulnerability (10) .
Despite the recognition of psychiatric hospitals bankruptcy as care institutions, Ordinance No. 3588 of 2017 was implemented. The daily psychiatric hospitalization value increased and proposed the increase of psychiatric beds, potential incentives for hospitalization. This denotes a marked loss for the advance of the deinstitutionalization proposal in the country. In addition, it therefore points to a setback in the Psychiatric Reform movement as it establishes a new direction of mental health policy.
In this setting, deinstitutionalization guideline adoption requires the implementation of new ways of dealing with madness, developing services and user-centered actions that work with the logic of the expanded clinic and that have the territory as a locus of action (3,9,11) .
However, after some years of RAPS implementation in the country, and facing setbacks in the direction of public policies on mental health, there are some gaps and dissonances about the possibility of adding essential attributes of Psychiatric Reform, as well as its innovative power in care. Despite many advances in mental health care such as the expansion of community-based territorial services and the significant shut down of beds and psychiatric hospitals, it is necessary to know how networks have been organized to care for users outside segregation spaces, if they are and how they are working to get users into life and the city.

OBJECTIVE
To analyze the process of deinstitutionalization resulting from a psychiatric hospital shut down, and know the fate of users after dehospitalization.

Ethical aspects
This is a research involving human beings, being submitted to the Research Ethics Committee of Hospital Universitário Antônio Pedro of Universidade Federal Fluminense, with approval in July 2017. All recommendations of the Brazilian National Health Board (Conselho Nacional de Saúde) Resolution No. 466/12 were followed. Signing of the two-way Free and Informed Consent Form was included, as well as clarification of the risks and participation in the research through recorded interviews.

Type of study
It is a descriptive, qualitative research, based on the criticalanalytical perspective, understood as a possibility to understand the social phenomenon investigated. This study endowed hermeneutics as a methodological way to ground qualitative research, allowing to value the relationships and practices of the studied phenomenon. For this method, there is no impartial observervalues subjectivity, allowing a critical understanding and allows closer approximation with the real. It is a method that allows greater understanding of the phenomenon of madness and shutting down processes of psychiatric hospitals, as it enables the identification of differences and similarities, seeking to understand the reports and relate them to the historical social context.

Study setting
The research had as setting the Hospital Colônia de Rio Bonito (HCRB). This is a large private psychiatric institution located in Rio Bonito, Metropolitan Region II of the state of Rio de Janeiro.

Data source and study participants
Institutional documents pertinent to deinstitutionalization were constituted as data source, especially records related to discharge and destination of HCRB patients, and narratives (12)(13)(14) produced by participants.
Seven health managers were invited to join the study. It was considered as inclusion criteria to have effectively acted in shutting down the HCRB, at the municipal and/or state level. Of these, five became available, thus conforming the sample of this research.

Collection and organization of data
Data were collected through documentary research and five open interviews conducted at the participants' place of operation, in August and September 2017.
The documents analyzed in the scope of this study were previously made available by the interviewed managers. In possession of this material, a primary evaluation was carried out to select and organize the relevant documents to the research proposal, followed by reading and highlighting the information of interest.
Narratives produced by interviewees were recorded and then fully transcribed and identified by the letter N (narrator), followed by a number corresponding to the chronological order of the meetings.

Data analysis
Document appreciation happened through exhaustive reading, guided by a script prepared from the objectives of the study. It was composed of topics of interest, such as hospital history, shutting down and deinstitutionalization process and data related to discharge and destination of hospitalized patients.
Narratives, in turn, were analyzed according to the method of hermeneutics (15) . This method was chosen because it is useful to understand the social dynamics, choices and perceptions of individuals in dynamic and non-neutral fields, such as mental health services. Therefore, after interview transcription, a first general reading of the set of statements was carried out, identifying the main themes on which they addressed. Then, exhaustive reading of each narrative was conducted to apprehend the individual experience of the deinstitutionalization process, based on information and experiences impregnated by the encounter that each one could establish with that action.
From this process of critical analysis, two categories were elaborated: "Deinstitutionalization Process: The Beginning of a New Scene" and "What Destination Did HCRB Patients Have?" The first category addresses hospital shut down and RAPS broadening based on the narratives of the subjects involved in the process under analysis. They were grouped into scenes that synthesize HCRB's deinstitutionalization path. The second category, in turn, deals with the fate of users after their hospitalization.

RESULTS
Inaugurated in 1967 and affiliated to SUS, the HCRB treated about 15,000 patients by 2016. As a result, it closed its doors, following a public intervention by the three federated entities, mainly motivated by complaints about poor care conditions, structural precariousness and significant numbers. of patient deaths, later confirmed by the State Prosecutor.
The four-year HCRB deinstitutionalization process (2012-2016) was conducted by the Mental Health Management of the state of Rio de Janeiro. The management supported and advised the interning cities to know and receive patients in their place of origin. It is about this process that the categories of analysis address.

Deinstitutionalization Process: The Beginning of a New Scene
To present the results, deinstitutionalization that took place at HCRB was taken as a movie, a kind of drama. For this reason, it was decided to describe his shut down in shots, in real life scenes of who led this process: managers, understood here as narrators of this story.
Scene 1: The Beginning From the narratives and documentary analysis, it was found that HCRB deinstitutionalization lasted longer than expected. The main reasons given were: slow bureaucratic and bidding processes; absence or precariousness of the network established in the interning cities, making it impossible to receive patients outside the asylum; untrained professionals in the field of mental health; resistance to deinstitutionalization; lack of patient documentation; fragile or absent family support; no financial income; and high turnover of professionals throughout the process.
If, on the one hand, the delay was longer than expected, on the other hand, it was possible to take a closer look at this process. Patients with more delicate clinical and social issues remained in the HCRB, so the deinstitutionalization team needed to take care of the hospital's physical space and food and hygiene issues to ensure a process of deinstitutionalization from the inside out. This situation did not happen without conflict. At first it was difficult to consider the organization of the asylum and then shut it down. Many regarded this act as a strategy for maintaining the institution, which proved false after the hospital's shut down in February 2016: forwarding an end to a new beginning.

What happened to Hospital Colônia de Rio Bonito users?
Following the Public Civil Action prosecution for HCRB deinstitutionalization by the Federal Prosecutor and State Prosecutor, the 7 of Deinstitutionalization and network of mental health services: a new scene in health care Lima AM, Souza AC, Silva ALA. main objective was to remove patients admitted to the hospital for a RAPS territorial assistance device, as directed by Law No. 10.216 of 6 April, 2001 (16) . Each federated entity had its role determined in this action, and it took a shared movement to finalize the process. After agreement between the three spheres, managers made a commitment to receive users. In this sense, there was intense conversation in the various spaces of inter-federative articulation such as the Regional Management Commission (Comissão Intergestores Regional), Bipartite Management Commission (Comissão Intergestores Bipartite) and State Health Council. Some cities found many impasses to receive these patients, because they do not count as a substitute network, with the necessary devices to absorb the demand. As a result of the Public Civil Action, hospital's doors were closed and, consequently, deinstitutionalization. Table 1 shows that 255 discharges were computed in the period 2012-2016, of which 68 were given in 2012, the year in which the deinstitutionalization of hospitalized patients began.
Most patients were referred to therapeutic residences in their respective cities of origin (51%). It is noted that municipal networks were organized to receive these users and implying the strengthening of the deinstitutionalization policy. On the other hand, among those who were transferred to other institutions (19%), most were sent to other psychiatric hospitals, suggesting that the asylum-replacement device network is still deficient. Moreover, the fact that only 24% of patients are able to return to their families shows that there is still fragility or lack of affective ties with family members after a long period of hospital asylum.  psychiatric institutions shut down per se does not guarantee the adoption of non-asylum practices. Deinstitutionalization alludes to full exercise of citizenship (1, [16][17][18][19][20] . The institutionalization of psychiatric patients, not only in the HCRB, has had an effect of exile in their lives, resulting in loss of citizenship, values, obligations and social rights. In this sense, the deinstitutionalization process was configured as a rescue to life, inserting users into the life of cities. And this was possible, among other strategies, by the adoption of Singular Therapeutic Projects (PTS -Projetos Terapêuticos Singulares) (21) , which need to consider the subject's lifestyle and must be built from the real needs of users.
Agreement between the three federative entities provided for the financial transfer for the expansion of outpatient care devices that would enable the cities to receive patients from the HCRB. However, there was a slowness in the organization of this action. There was a delay in the shutting down, lack of structural resources in the cities to receive patients, absence of establishing care networks, in addition to issues related to social stigma and fragile bonds between family and patients, making it difficult to return to their respective homes.
Since the beginning of HCRB shut down, the number of discharges has been progressive, culminating in shutting down hospital activities in 2016. Many patients had already lost ties with their families, mobilizing managers and professionals so that more patients were referred for SRTs.
Although many patients did not return home due to their families' structural needs, they were referred to the SRT. HCRB deinstitutionalization constituted an ethical need and concretely meant the possibility of rescuing patients' lives, restoring their citizenship and their right to live in freedom. In this understanding, SRTs cannot replace the asylum space, occupying the segregation function assigned to the hospital. They must enable the transit of people in the city, work on the autonomy of the residents and constitute themselves in houses inserted in the community (22)(23) .
Reflecting on the substitute network and the adoption of innovative care practices to counter the insane asylum ideas is necessary for the advancement of psychosocial care (11) . Therefore, it must be considered that the asylum goes beyond the physical space of the institutions, it represents the repression and violence used as sources of segregation and social isolation of the mentally ill subject (24) . Network replacement needs to be configured beyond physical space. To build a network that actually replaces the asylum, it is necessary to deal with anguish, contradictions and difficulties that surround the occupation of services and, above all, of the territory (10) .
It is essential to take territory as a possible social place for mental health users, reducing the stigma attached to the mad subject and transforming the social relationships established with madness (25) . Shutting down a psychiatric hospital and the consequent deinstitutionalization demand new and different ways of thinking about mental health care, based on the personcentered care in its territory (26)(27) .
This reinforces the importance of expanding the number of CAPS III in a stronger and more articulated network to receive and not collect, and in a process of individual deinstitutionalization that moves away from asylum practices (10) . Moreover, health professionals prepared to intervene with strategies that ensure continuity of care outside the hospital.

DISCUSSION
Deinstitutionalization represents a complex process that guides the actions of services and professionals, implies a work to rescue the subjectivity of people in psychological distress and proposes possibilities for life trajectories outside the hospital. However, it cannot in any way be reduced to the mere idea of dehospitalization. Care must be taken in freedom, but it is clear that hospital It is necessary to adopt a care ethic (28) based on users and the territory and, for this, it is necessary to invest in professional qualification, seeking to develop care strategies that ensure integrated and networked psychosocial care.
In addition, managers need to be involved in deinstitutionalization in order to enhance the adoption of new possibilities for dealing with madness in society. Amid the scarcity of resources, it is imperative that policies and planning of actions and services have the network as their working direction (29)(30) .

Study limitations
This study has limitations regarding the inclusion of only one actor in the deinstitutionalization process. This is because the manager, as spokesperson for his institution, may have focused more on the positive points of shutting down the HCRB. Another limitation lies in the fact that the research has as its setting only one large psychiatric hospital, which does not mean that the reality found is the same in other Brazilian cities.

Contributions to nursing, health or public policy
The results of this study contribute to the development of deinstitutionalization strategies, understanding that asylum in a psychiatric hospital affects people's health and citizenship in various ways. Policymakers, managers and health staff should act to mitigate the harmful effects of this practice.
Deinstitutionalization is pointed out here as a potent and indispensable strategy for the consolidation of the Brazilian Psychiatric Reform and for the importance of strengthening RAPS in this process.

FINAL CONSIDERATIONS
Narrative analysis indicated that the process of deinstitutionalization of the HCRB lasted longer than initially estimated. For the action to take place, a tripartite intervention was necessary, and especially the mobilization of the networks and RAPS implementation by the cities of origin of institutionalized patients. From the documentary appreciation, it was found that most patients were referred to therapeutic or transinstitutionalized residences. A smaller portion returned to live with their families, given the socioeconomic conditions of the family context of most users.
The qualitative approach adopted by this study made it possible to unveil issues inherent to the deinstitutionalization process whose implementation is paramount and which corroborates the progress of Psychiatric Reform underway in the country. Managers' , professionals' and users' perception involved in the process suggests that actions with this dimension enable the demystification of madness and enable the inclusion, in the city life, of people previously deprived of citizenship.
Considering that HCRB deinstitutionalization led to the establishment of connections between services and people, this was a powerful device for RAPS implementation at municipal level. However, it must be borne in mind that, in public health, something always escapes during the course of change. They are hampered by numerous financial, structural and political factors, demanding a daily struggle to maintain and improve the redirection of health practices.
In this case, after RAPS implementation, it must be made effective in the daily practice of services. Therefore, it is not enough to list and add the points of attention. It is necessary that a network of people, health services and territorial devices be formed, aiming at care from the perspective of psychosocial care.