Collective building of a leisure understanding in territorial mental health, by occupational therapists: a qualitative study

Abstract

Introduction

Leisure is considered an occupation present in studies, evaluations and interventions of occupational therapy. In Latin America, there are few works dedicated to building the understanding of professionals or their perceptions about leisure. There are even fewer studies that correlate the understanding of these professionals with occupational science on this occupation within the field of mental health.

Objective

To know the understanding of leisure by occupational therapists working in the mental health of public services that substitute the asylum psychiatric model.

Methodology

: This research was qualitative, descriptive and exploratory, with a cross-sectional design. A focus group and thematic analysis of information arising from the process of collective construction of occupational therapists, working in public services with a territorial base of urgency in mental health, in the city of Belo Horizonte, Minas Gerais, Brazil, on their understandings regarding leisure were used.

Results

Three categories emerged: (a) Leisure - pleasure; (b) Leisure - free choice; and (c) Leisure - transcendence of hardness.

Conclusion

Leisure is an important occupation for occupational therapists working in mental health in the territory; may find resonance in practices that encourage contractuality and autonomy, especially when combined with the principles of occupational science of valuing human doing in its variable ways of experiencing it. It is believed that this research can help occupational therapists and occupation scientists in understanding contemporary leisure, in dialogue with care in the territory and anti-asylum positioning.

Keywords:
Occupational Therapy; Mental Health; Leisure Activities; Mental Health Services

Resumo

Introdução

O lazer é considerado uma ocupação presente nos estudos, avaliações e intervenções da terapia ocupacional. Na América Latina, há poucos trabalhos que se dedicam à construção do entendimento dos profissionais ou suas percepções acerca do lazer. São ainda mais escassos os estudos que correlacionam com a ciência ocupacional o entendimento destes profissionais sobre tal ocupação dentro do campo da saúde mental.

Objetivo

Conhecer o entendimento de lazer por terapeutas ocupacionais atuantes na saúde mental de serviços públicos substitutivos ao modelo psiquiátrico asilar.

Metodologia

Esta pesquisa foi qualitativa, descritiva e exploratória, com desenho transversal. Foi utilizado grupo focal e análise temática da informação advinda do processo de construção coletiva de terapeutas ocupacionais, atuantes em serviços públicos de base territorial de urgência em saúde mental, da cidade de Belo Horizonte, Minas Gerais, Brasil, sobre seus entendimentos quanto ao lazer.

Resultados

Três categorias emergiram: (a) Lazer - prazer; (b) Lazer - livre escolha; e (c) Lazer - transcendência da dureza.

Conclusão

O lazer é uma ocupação importante para terapeutas ocupacionais atuantes em saúde mental no território; pode encontrar ressonância em práticas que fomentam a contratualidade e autonomia, especialmente ao se aliar aos princípios da ciência ocupacional de valorização do fazer humano em suas variáveis formas de vivenciá-lo. Acredita-se que esta pesquisa possa auxiliar terapeutas ocupacionais e cientistas da ocupação no entendimento do lazer contemporâneo, em diálogo com o cuidado no território e posicionamento antimanicomial.

Palavras-chave:
Terapia Ocupacional; Saúde Mental; Atividades de Lazer; Centros de Atendimento Psicossocial

Introduction

Occupational Science is a field of research that is expanding little by little in Latin America (Jara et al., 2016; Morrison et al., 2021; Queiroz et al., 2021a). Consequently, studies that consider conceptualizations about leisure, from the perspective of occupational therapy, are scarce. In this context, this text presents the understanding of leisure, by occupational therapists in a Brazilian city, working in the mental health of public services substituting the asylum psychiatric model, and correlates it to Occupational Science. Therefore, it contextualizes the recurrent understandings of leisure in the literature of occupational science and in Brazilian occupational therapy. It presents Brazilian mental health with a focus on emergency care, and traces the relationship between occupational science, occupational therapy, leisure and mental health.

In an exploratory search for articles, without determining the year, carried out during the month of June 2022, using only the word leisure, in the Journal of Occupational Science — the main scientific medium focusing on occupational science —, 1058 articles were found with the descriptor leisure present in the title, abstract and/or keywords. It was observed that leisure was recurrently addressed, with work as a reference applied as a counterpoint, complementarity, and resource for balancing work/leisure (Passmore, 1998; Håkansson & Ahlborg Junior, 2010).

The anthropological and cultural focus was also identified during the research (Darnell, 2009), often with an emphasis on the dichotomy between work/leisure or obligatory activities/leisure (Downs, 2008). There were also articles that reported practices such as leisure occupation, associating them with quality of life and well-being (Costa & Cox, 2018), relating them to identity and personality (Daily et al., 2021), to socialization (Jacob et al., 2009) or even to identity, contexts of marginalization and social participation (Almeida, 2022; Gonçalves & Malfitano, 2022; Suto, 2013).

When the search was limited to the descriptors mental health and leisure, without restriction of publication date, 5 articles were found with the inclusion of these two descriptors, in this case, contained in the abstract. Of those, 2 are from 1998 and dealt with leisure and work of adolescents (Passmore, 1998), and the use of time, stress, quality of life and mental health (Zuzanek, 1998); the third concerned an exploratory study on older people and engagement in dance (Owen-Booth & Lewis, 2020); and the two remaining studies addressed the occupational effects of the COVID-19 pandemic (Jokić & Jokić-Begić, 2022; Richardson et al., 2022).

In terms of theoretical support, focusing on the construction of a practice or reasoning based on the chosen concept of leisure, most studies elect the concepts of researcher Robert Stebbins (Lobo, 1999; Rampley et al., 2019; Taylor & Kay, 2015). Stebbins is a sociologist and researcher in the field of leisure studies who, since the 1970s, has been developing the theoretical framework called “Serious Leisure Perspective”, whose study treats this occupation as serious leisure, casual leisure and/or project-based leisure.

In short, in the Serious Leisure Perspective, Stebbins (2008) assumes that leisure is associated with activities in which people voluntarily engage, feel satisfied and even complete with activities, and develop them in their free time. This time is understood as dedicated to pleasant and non-mandatory activities, which implies the duality between occupations — mandatory and non-mandatory — and characterizes their time as free time. In this framework, it is emphasized that people's skills and abilities are used to achieve a certain satisfaction with the activity (Stebbins, 2008).

In the Brazilian literature of occupational therapy, four understandings about leisure were recurrent in an exploratory search within the context of the profession, carried out by the authors of this article, in publications of the last two decades, in national magazines, dissertations and theses on the subject.

The first and most widespread understanding comes from the Practice Domain and Process Framework of the American Occupational Therapy Association (Gomes et al., 2021), which considers leisure as a “non-compulsory activity that is intrinsically motivated and performed during free time, that is, the time not committed to mandatory occupations, such as work, self-care or sleep” (Gomes et al., 2021, p. 250).

The second was developed in the 1970s by the sociologist Jofre Dumazedier and is very similar to the one used by AOTA, in which mandatory activities are centralized as routine organizers. Dumazedier defended leisure as a set of occupations understood as activities and practices, with which human beings occupy their time, and leisure activities were developed in a time free of obligations. Leisure occupations were intended for rest, entertainment or the development of the person experiencing it (Dumazedier, 1979).

The third understanding is from the Brazilian researcher Marcellino (2006), who, like his predecessors, presents leisure separately from other occupations, although he lists elements that value the person in the leisure experience, such as: time; attitude; values; and leisure content for an activity to be considered as such (Marcellino, 2006). The author reinforces the “disinterested” character in practice and its occurrence in a liberated time.

Marcellino also adds the values of rest, fun, personal and social development to his understanding of leisure and the belief that people should be “encouraged to participate and receive a minimum of guidance that allows them to choose” (Marcellino, 2006, p. 17). The author classifies leisure in six areas: artistic, intellectual, physical, manual, touristic, and social. He states that, although the transit of people in more than one area is ideal, this does not occur due to lack of knowledge of the contents.

Although Marcellino (2006) points out important points for reflecting on leisure in dialogue with the person who experiences it, his perspective is reductionist and subtly suggests a hierarchy of knowledge by minimizing people's knowledge about their leisure activities. In addition, it reinforces the idea of leisure time as something far from people's daily lives.

Finally, the fourth understanding is from Gomes (2014), who discusses leisure as a dynamic context, characterized by a broad dialogue with the socio, historical, political, economic, and cultural time of society. In this way, it presents leisure as a dimension of the culture in which it is experienced, in addition to a basic human need, such as other needs (Gomes, 2014). In this perspective, leisure takes place in a unique time-space of those who experience it, and not necessarily in an institutionalized one, such as vacations and holidays.

It is observed that the first understanding (Gomes et al., 2021) is aligned with the precepts that emphasize the dichotomy between human occupations, which had its peak in the industrial revolution, which reinforced a society focused on work (Gomes, 2015). The last three understandings (Dumazedier, 1979; Gomes, 2014; Marcellino, 2006) were forged within leisure studies, requiring researchers to align themselves with occupational therapy proposals (Acácio et al., 2021; Martinelli, 2011; Queiroz et al., 2020a, 2021b; Saito, 2010) and occupational science (Oliveira & Carretta, 2020; Queiroz et al., 2021a; Queiroz, 2020).

Understandings about a phenomenon, here specifically leisure, are important, as they present the reflections and commitments of the profession with the time in question. In those cited above (Dumazedier, 1979; Gomes, 2014; Gomes et al., 2021; Marcellino, 2006), there is an intrinsic relationship with mandatory activities, guided by the logic of the industrial revolution, capitalism, and the continuous production of capital. In these understandings, leisure occupation would be experienced based on a capitalist production, which defines and redefines itself without clear limits, serving itself and being able to “absorb and metabolize anything it comes into contact with”¹ (Fisher, 2009, p. 6). While the understandings that approach the dynamism of society do not seek to serve it, but to dialogue with it, they validate not only its production of capital, but, mainly, its cultural production and interlocution with the dynamism of life.

Recently, Queiroz (2020) developed an understanding of leisure based on the perception of leisure by occupational therapists working in mental health emergencies, triangulating precepts from occupational science, Brazilian mental health/psychosocial rehabilitation, and leisure as a dimension of culture and human need. The researcher explains that leisure is a necessary human occupation, which manifests the culture of those who experience it, being subjective the choice of what is, in fact, leisure or not. Based on this perspective, he states that this occupation encompasses four important elements for occupational therapy: occupational awareness; autonomy; pleasure; and social belonging. The relationship of these elements, based on the understanding of leisure by Gomes (2014), is significant for the profession, as well as for the person in care, as it helps the professional in his understanding of the concept and context of occupation for that person, as well as their leisure.

In the scientific literature on occupational therapy, leisure is constantly addressed as a therapeutic resource (Parker et al., 2001; Queiroz, 2015; Silva, 2015; Wensley & Slade, 2012). When, focused on mental health, occupational therapy dialogues with this field, associating leisure as a therapeutic resource with the concept of contractuality (Moura et al., 2014). According to Saraceno (1996, p. 16), contractuality is defined “by the individual's ability to make exchanges”. These exchanges can happen in different ways: economic; cultural; policies, but always demand social interaction.

Considering the stigma that hangs over the public assisted in mental health, the work of professionals should favor “the process of restitution of the user's contractual power, with a view to expanding their autonomy” (Kinoshita, 1996, p. 56), without tutelary, overestimating or underestimating. Contractual power can be expressed in various everyday scenarios, which is interesting for leisure, as it can also be experienced in different environments.

In the context of Brazilian mental health, which had its psychiatric reform in the late 1970s and early 1980s, leisure can dialogue with the care approach disseminated by Benedeto Saraceno in the 1990s, when he was in the country as a representative of the World Association for Psychosocial Rehabilitation (Pitta, 2001).

Mental health care in Brazil is encouraged, in its national mental health policy, to be a substitute for the asylum care paradigm (Brasil, 2001). This implies not only a paradigm shift, but also care actions, which start to happen in a network, that is, in a capillary way with other services, and at a territorial level — where people live, where they develop their relationships in the community. In this sense, “The psychosocial paradigm opposes the still hegemonic psychiatric paradigm, privileges the individual in their social conditions, uses forms of intervention guided by the needs of the user and aims at social inclusion” (Leão & Barros, 2012, p. 574).

For Saraceno, psychosocial rehabilitation is “a process of reconstruction, a full exercise in citizenship and also full contractuality in the three main scenarios” (Saraceno, 1996, p. 16): dwelling; social network; and work with social value. Psychosocial rehabilitation is not a specific technique, it is an ethical position of care, which includes “a set of intersectoral practices in health, social security, housing, work, school, leisure, culture and others” (Pitta, 2001, p. 6). Therefore, it is open to dialogue with other models, such as recovery (Anastácio & Furtado, 2012).

One of these scenarios refers to the housing axis. In this case, within the Brazilian mental health policy, leisure is mentioned in the literature, in the context of therapeutic residential services, as a facilitator of a new daily life (Queiroz, 2015; Queiroz et al., 2020a, 2020b), an opportunity for the former psychiatric hospital graduate to construct his role as a resident and citizen of a locality.

The scenario of social networks is also characterized as fertile for leisure and, when dialoguing with occupational therapy, it often refers to elements of participation, socialization, social interaction and guarantee of rights (Moura et al., 2014). However, these elements are often exemplified by leisure as a practice (Alcântara & Brito, 2012) and, due to this, even though they emphasize the ludic character and the potential for favoring contractuality, they lead to a distancing from the understanding of this occupation in a broad way. Therefore, attention is drawn to reflections and actions that prevent leisure from being reduced to a list of practices, such as an arsenal of resources, which bring fun and relaxation, during a phase of life and/or context (Chen & Chippendale, 2018).

The health care network in the city of Belo Horizonte, where this study was conducted, acts as a substitute network for the psychiatric hospital, even with recent attacks on the Brazilian mental health policy with reduced funding and/or autonomy for care on a territorial basis or the resumption of the psychiatric hospital as a care facility (Brasil, 2016, 2020). The mental health reference centers (CERSAM) and the mental health reference centers for alcohol and/or other drugs (CERSAM ads) are part of this network and are dedicated to welcoming users in crisis in their psychic suffering and/or in abusive use of alcohol and/or other drugs. They work 24 hours a day, seven days a week, have beds for users who need immediate care, and multidisciplinary teams.

This network is built daily within the three axes/scenarios of the psychosocial rehabilitation model and within the principles of the Brazilian psychiatric reform (Brasil, 2001), which has in its principles network care in the territory, user autonomy, and plurality of interprofessional knowledge.

Given the above, this study asks what the understanding of leisure for occupational therapists is working in the mental health of public services substituting the psychiatric hospital. Is there an influence of the basic care model (psychosocial rehabilitation) on the understanding of leisure? And, if so, how does it influence this understanding? It is believed that the search for answers to these questions can help occupational therapists and occupation scientists in understanding contemporary leisure, in contexts of urgency in mental health and others.

Methodological Considerations

It is noteworthy that this research makes use of data collected during the doctoral study of the first author (Queiroz, 2020). From October to November 2018, emails were sent to the management of occupational therapists of public territorial emergency services in mental health, providing assistance to adults in the city of Belo Horizonte (Reference Centers in Mental Health - CERSAM), inviting them to answer an individual interview about their perception of leisure in the context of their practices. Of the 23 professionals interviewed, 6 accepted the invitation to discuss their perceptions about leisure, mental health, and occupational therapy in a focus group. Scheduling conflicts were the main reason for the absence of the other occupational therapists interviewed, and the date chosen was the most congruent. Qualitative research resulted in this article, which is dedicated to the constructions arising from discussions about leisure in the aforementioned focus group.

This information production technique features more in-depth interviews of specific topics in a group discussion format (Gundumogula, 2020), providing understanding of participants' perceptions and beliefs on the subject (Trad, 2009). The literature does not point to a consensus on the frequency of the focus group, and it is common not to mention the number of meetings (Seïler, 2016). However, there is consensus on the importance of facilitated discussion and an inviting ambience (Dias, 2000; Gundumogula, 2020; Rodriguez et al., 2011).

In this sense, the focus group reaches its objective when it responds deeply to the question raised, presenting “the meanings from the perspective of the subjects, the relationships that are present and the interconnections between the actors and the facts” (Minayo, 2017, p. 9). In this logic, saturation is not a search, not least because an experienced researcher can always present new questions and interpretations to the group, and the purpose of a qualitative researcher is not to reach saturation, but “to flesh out his research and make it defensible” (Mason, 2010 as quoted in Minayo, 2017, p. 9), based on the contribution of the participants.

Based on Costa (2021), it is possible to infer that the development of this research group was facilitated not only by the ambience, but also due to the fact that most of the participants and the researcher already knew each other from other work meetings or mental health events. and/or public health. Therefore, based on the availability of participants, a focus group was held in this research, lasting 3 hours, which is consistent with the design and scope of this exploratory, cross-sectional, and descriptive study.

The focus group, recorded and transcribed by the first author, was held on a Saturday morning, in November 2018, at the School of Physical Education, Physiotherapy and Occupational Therapy of UFMG, in Belo Horizonte, where the 6 occupational therapists graduated. Participants were invited to write their understandings about leisure on cards, with no limit on cards per participant. From then on, the group collectively constructed the understanding of the term cited. Under the mediation of the researchers, there was a discussion and presentation of the group's understanding of leisure.

The participants were occupational therapists, female, aged between 26 and 55 years, working in the public services of territorial base of urgency in mental health of Belo Horizonte (CERSAM), where they assist adult users with psychiatric disorders, with psychosis and severe neuroses, or users of alcohol and or other drugs concomitantly with psychiatric disorders or not, in CERSAMs ads.

All 6 participants underwent continuing education in mental health, 2 of which have a master's degree in related areas, and 1 graduated before the Brazilian Psychiatric Reform Law (Brasil, 2001), having done an internship in psychiatric hospitals. There are 3 participants working in CERSAMs, and 1 also works in primary care; and the others in CERSAMs ad. The average working time as an occupational therapist in mental health for 4 participants is 5 years, with the oldest working for 20 years and the youngest for less than 4 years.

Ethical issues

The research was approved through the embodied opinion n. 2.692.844, by the research ethics committees of UFMG and Belo Horizonte City Hall. All participants signed an informed consent form, including authorization for audio and image recording. Coding (E0-E6) was used to ensure the participants' anonymity and the names and locations of the services were not mentioned. The collected information will be stored by the first author for 5 years, in an electronic device with a password that only she has access to. The authors report that there are no competing interests to declare.

Rigor and credibility

To maintain rigor and credibility, in addition to the facilitator, the focus group had three participant observers, namely: an occupational therapist with a PhD in semiotics; an occupational therapist with a master's degree in Sociology; and an observer with a degree in philosophy and a doctoral candidate in Interdisciplinary Leisure Studies. The observers' notes and the recordings of the discussion were especially important for the organization of the consensus speeches.

Analysis

The chosen methodological analysis was thematic (Vaismoradi et al., 2013). The authors maintained the names and categories generated by the group during the discussion, however, the result of the transcripts and analysis was not presented to the group. The categories were created after analyzing the participant observers' notes, the images and the group's statements, considering the care model developed from the Brazilian psychiatric reform and based on the psychosocial rehabilitation disseminated by Benedeto Saraceno, in the 1990s. constancy of the information answering the questions of this study, it was understood that the category was contemplated, without, however, assuming data saturation, as knowledge is not saturated (Minayo, 2017).

Results and Analysis

The collective construction of the group's understanding of leisure took place in three categories. The first category (a), Leisure - pleasure, explores this interaction, questioning and expanding the understanding of pleasure in this occupation. The second category (b), Leisure - free choice, discusses the relationship between leisure and free choice, as well as what free choice is within the context of users assisted by the mental health emergency. The third category (c), leisure - transcendence of everyday hardship, reflects on the elements that impact the engagement of leisure in everyday life. In search of a consensual nomenclature, the group referred to practices, activities, and leisure experiences. The speeches, written in italics throughout the paragraphs, are those that were constant and were agreed by the participants as group speech, being presented as E0.

(a) Leisure - pleasure

This category was marked by the frequent presence of the term pleasure. From the group's perspective, pleasure is “fun; it's horny as a solution” (E0). The latter in the sense of satisfaction: “of desire and personal” (E0).

For the group, pleasure “is a prerequisite” (E0) for leisure, emphasizing that the two have “a very intimate relationship” (E0). And, although pleasure is “directly related” (E0) with leisure, based on the logic that “if an activity is not pleasant, there is no way to have leisure” (E0), it still recognizes that not everything that is pleasant is leisure: “Working is pleasurable, but it is not a leisure activity” (E0).

The authors interpreted that the group's speeches are in line with the researched occupational therapy literature regarding leisure, since it also reinforces the presence of pleasure as a substantial element in leisure (Alcântara & Brito, 2012; Alegría et al., 2013; Almeida et al., 2018; Costa, 2008; Queiroz, 2020). The same can be said in the stronghold of occupational science, since feelings involving pleasure — such as joy, happiness and satisfaction — are present in the literature that addresses leisure (Atler et al., 2016; Bentz et al., 2022).

The group also highlighted that the same experience can be found in more than one occupation: “Every day you go to the gym, that day was boring, but you went. It's not leisure. It's almost an obligation” (E0). In this group example, what caused an occupation to change from leisure to something like simple health management was the absence of the pleasure element. This understanding refers to what Cutchin & Dickie (2012) explain about occupation as something in motion, an action. In this case, an action influenced by the feeling of pleasure awakened in the experience of the occupation.

This transit between occupations presents the possibility of reducing the distances between them. Thus, the dichotomy defended by Dumazedier (1979), Marcellino (2006) and Gomes et al. (2021), within the understanding of the dynamics of experiencing leisure and occupations, becomes questioned or even does not exist.

Still on the context of the gym, exemplified by the group, it was pointed out that the experience of something boring or tense does not eliminate the pleasure that exists in leisure. For that, it delineates between the feeling experienced in leisure, as well as the experience itself, with the motto being to reach the pleasurable moment.

It's one thing to talk about the feeling I experienced when I was there. Another thing is to experience it with a feeling of anguish. There are two steps, I think it's not the same thing. How many times do I get to say: oh, I want to get home, I want to do nothing. I want to see a movie to cry. And that for me is the moment to have the pleasure. Not necessarily the experience in there is of joy (E1).

When E1 mentions the encounter of feelings, commonly understood as antagonistic — anguish and pleasure — she expresses pleasure as something not romanticized, which can be exposed as contentment and/or satisfaction.

The authors point out that the group's recognition that it is possible to have “pleasure in things that are not good” (E0) brings their understanding closer to the understanding of leisure(s) as subversive(s) to the order of normative health, curative and rehabilitative. It also approaches the understanding of literature that points out that leisure reflects ways of life in a culture (Darnell, 2009; Gomes, 2014). This reinforces leisure as something far beyond a therapeutic tool: an occupation that expresses the dynamism of life.

The duplicity of leisure-pleasure in everyday life appears not only in the health segment, but also in the understanding of leisure as an occupation, when they understand it as “subjective, the subject will decide” (E0). At this point, the group made a certain move that looked at leisure beyond previous conceptualizations and judgments. Even so, there is duplicity of thoughts and actions, as they often depart from their own leisure experiences to understand the users' leisure.

Thus, they underscore the importance of attention to pleasure as a relevant element in the experience of occupations, exemplifying the argument with an activity experienced in different ways in everyday life: “When I dance for two it is very different from spending 8 hours rehearsing. Despite having pleasure in both things. There is the pleasure of professional activity and leisure activity”. (E2)

In their understanding of the pleasure experienced in the leisure activity, which is ensured by the perception of freedom, the group highlights: “I think it's a freer thing, you go out whenever you want, you get tired of [referring to dancing]” (E5).

Based on their own experiences, the group brings the correlation between the feeling of freedom and the feeling of well-being, pointing out that the first qualifies the second. In this sense, based on the perception of the relationship between their leisure and pleasure, expanding to personal satisfaction in dialogue with feeling free, they agree with the understanding of leisure as “experience(s) of pleasure, in which this is understood as satisfaction of desire and personal satisfaction, being leisure itself something that brings physical and psychological well-being” (E0).

This conclusion of understanding based on pleasure is consistent with the understandings of leisure found in occupational therapy and occupational science, even though in the former, leisure is considered therapeutic and a means to achieve something. It is added that the participants' understanding was aligned with the emphasis given to the feeling of pleasure and personal satisfaction arising from the experience provided by leisure occupation. This is seen both in the studied literature of occupational therapy and in that of occupational science.

(b) Leisure - free choice

You are forced to do it, even when it doesn't give you pleasure, it doesn't. So, it's not leisure.

Does all leisure have free choice? - facilitator.

I think there is a point of free choice. I think there is a decision (E6).

In the group's view, free choice is related to decision-making power, which, within the psychosocial rehabilitation model, dialogues with one of the principles of contractuality: autonomy. This, according to Kinoshita (1996), must be complex, diverse, subjective when constructed from links with various points in life, that is, it speaks of the potential for the person to connect to various processes of participation in the community and social interaction. This participation requires positioning, choice, decision, connection. The group's speech corroborates the potential of leisure as an occupation that favors contractuality, especially due to the elements of autonomy and pleasure:

Even if you try it and then end up giving up because you've attached yourself to something else. Because you thought it would be a pleasant thing. And even if it is disconnected from pleasure... Although I think this is not disconnected from pleasure (E1).

The practice of contractuality brings into play co-responsibility, a characteristic of the territory-based care paradigm, which respects the user's autonomy in decision-making regarding their own care (Streb, 2015).

Every time I go to forró²it is wonderful? No, it is not. But it continues to be my activity, which I continue even though I’m not very good; you have a choice (E2).

The point of decision, the point that makes you choose that experience is really free. Even if that doesn’t guarantee you the pleasure of something that you can’t get back (E4).

The element of responsibility for choice enables the group to understand an experience as leisure by looking at the whole occupation rather than its parts.

If you think more longitudinally, maybe you can classify the whole experience (going to the gym) 'As a leisure thing'. There are specific moments there that were good (E3).

When thinking about the people they serve — people in psychological distress, generally psychotics and severe neurotics and/or using alcohol and other drugs —, the group discusses whether there is free choice for them in terms of leisure, or if they participate because they are already in the environment of CERSAM/CERSAM ad.

At first there is some offer. If the person is going to get involved there is no way to know (E6).

Our guide is activity as therapy. But some more pathological pictures sometimes won't be able to choose. And there are things that we will be talking about. We are going to consider the subject that exists, but I had a patient who, to everything we asked, he answered “I don't know”. It is another sense of offer (E1).

Although justified by the therapeutic work, the group itself realizes that, sometimes, “you make an agreement with the user, but in fact you are not making an agreement, you have a ready-made proposal. The user answers yes” (E3).

This group's reflection refers to the purpose of care on a territorial basis, in which “stimulating to think about what is actually being proposed” (E0) would be facilitated not only by professionals in the services, but also in various points of the community where the user was exercising its autonomy and contractuality. The group identifies two moments for stimulating these elements that influence the person's choice.

There are two moments: when the subject, user, citizen arrives in crisis, he is unable to choose. He starts the treatment, resumes a little of what he understands of what it is to live with society, with the culture, with the family. Then we start building agreements with users in crisis (E3).

From listening to the suffering and the signs of what the user presents as possible contractuality within their moment of need for care, agreements seem to be the measurement points of choice. And therefore, the possibility of choice can be barred from the pre-judgment of the professional, arising from their own leisure experience.

When we think about what leisure is, we consider our experiences. Now, when we consider a pathological condition... Ah, so I think this issue of free choice stops exactly at that (E6).

The symptomatology becomes not only the justification for barring the possibility of choice, but something that discourages the investment in it. Allied to this, there is the precariousness experienced in the services, which makes the possibilities “limited” (E0), either due to lack of resources in the services and community, or because the professional cannot leave the unit to seek alternatives in the territory. One of the results is the difficulty in building a therapeutic project that includes leisure and that helps the user to engage with life outside the service.

What anguishes me is while he's there and I don't have the conditions to offer. I can't go out and look for deals. If I leave, I stop answering. If I leave the shift, I'm absent and I'm called attention (E4).

Faced with the impasses of the work process that cross the inclusion of leisure in care, the group reflects on the way of life of capitalist society and how it influences the leisure experience. At this moment, it is observed that the group expands its understanding of leisure beyond a person-centered occupation, but which is crossed by life contexts and macro situations, such as economics and politics. This understanding dialogues with the vision of occupational science, which understands that the processes immersed in the socio-historical contexts of a society are dynamic and interconnected (Humphry, 2005; Morrison, 2022), influencing and impacting occupations. Therefore, the understanding of leisure must reflect this movement.

In general, we have a capitalist way of life. Leisure is of zero interest. Provide pleasure experience, for what? Because I can get a lot of pleasure out of my work, but I focus on subsistence production in my life. Leisure is in the background (E3).

We are undermining the investment in all pleasure experiences because this has no place in this world (E5).

All we say is that we don't just want to take care of the symptom, but we arrive at the service and we are dealing with the symptom. This bothers me deeply (E6).

Based on the group's speech and the studied literature, it is considered that the requirement of acceleration of daily survival, on the part of capitalism, presents itself in the occupational therapeutic practice as an obstacle in care, beyond the symptomatology. This ends up undermining the possibilities of care in dialogue with psychosocial rehabilitation, which demand financial and time investment in the suffering person and their transactional relationships. Even so, the group points out possibilities at an institutional level based on the dialogue with occupational science, which understands that human beings are not isolated in the world, nor in themselves, but are connected to different interactions with people, communities, and histories (Persson & Erlandsson, 2002).

Within what is part of the institutional schedule, there is not much flexibility, it is such a trip, such a schedule and it will do that. What the therapist can construct is: does it fit for you or does it not fit for you? Is there anything we can try to do differently? But, the institution has a schedule that is even necessary to organize (E1).

In this category, the group discussed the influences of leisure, such as free choice, problematizing the adjective “free” when realizing that, for themselves, total freedom no longer exists, given the societal responsibilities to which they are submitted. For the user, the choice itself is already barred, even if he is committed to care that respects autonomy and contractuality.

The aforementioned barrier (“barred choice”) is understood by the group as necessary when the user is in crisis, which raises reflections on symptom-centered care. The group resists this way of thinking and the influences of capital production, seeking loopholes to encourage autonomy and contractuality.

The authors of this article interpret that, for this group, when free choice is the guiding variable for understanding leisure, it appears at the time of planning as a decision, a way of exercising autonomy. Leisure is for the capitalist logic as a subversive occupation by stimulating pleasure, autonomy and contractuality, even if not in all its moments, being necessary to see the whole experience to identify it as leisure.

This reasoning is corroborated when one reads Persson & Erlandsson's (2002) reflections on the action of Western societies that live in a continuous competition that brings prestige as it tries to control the world and, more aggressively, people's time. The most common form of time control is in mandatory activities, more specifically in work or educational demands. In this sense, when people experience leisure, they face resistance to the control of their time and, even if leisure does not guarantee the survival of human beings, it becomes an important occupation that can favor the critical thinking of professionals and users.

(c) Leisure - Transcendence of the hardness of life

The first point that appears in this block is the importance of leisure as an occupation that “transcends the hardness of the daily routine and helps in encounters with the small joys” (E0). The routine would be “standardized actions, which repeat; you can't get out” (E0). To get out, lightness is needed.

For me, the hard part of the routine is this: waking up! [loud laughs]

The hard part of life is being alive.

Waking up already has a bit of a train at home, then at work a bit of a train.

It's really tough obligations (E5).

The harshness of the routine refers to daily oppression, like what society expects from women; precariousness in the work environment; daily experiences as stigma to mental health; racism; depreciation of what is public, etc. Oppressions influence not only the work process of emergency service professionals in mental health, but also the therapeutic project of users and the daily lives of participants (Merçom & Constantinidis, 2020; Queiroz, 2015, 2020).

In the group's perspective, leisure would help to transcend hardships by favoring encounters with small joys, which would be experienced in “simple or complex activities that say deeply about ourselves” (E0), permeated by lightness and spontaneity.

Desire is something relaxed, rested, with another tone, not necessarily pleasure. A rest, a lightness sometimes to get out of the routine (E4).

One person I attended managed to transcend pain and anguish. One beautiful day she was able to see the sunset and feel extremely happy. Which requires absolutely no resources! (E3)

For the group, watching the sunset would be a simple activity, “because it doesn't require any instrument, it doesn't require financial resources, it doesn't require skill, it's just being a person in the world” (E0); “the activity can be simple due to material resources, but the cognitive level can be high” (E0).

Complex activities would be the ones that demand more skills: “For some people to build a formula, discovering the plots of these formulas is absolutely so good. In my view, it's complex because I don't have the instruments and I won't be able to do it, I find it difficult” (E0).

The presence or absence of simple and/or complex activities in the user's life dialogues with the group's perception of what would be a poor routine or not:

Poor is staying at home just sleeping and watching television, with no demand for other activities.

If you can't stand being in relationship with others, in society, you can still have a very rich everyday life, be productive. The person can read, take care of things, even write. It is rich because they are producing life (E3).

Understanding the complexity of the person's daily life helps the group to perceive their role in everyday life, and how the therapeutic relationship can facilitate and maintain oppression. In this sense, they conclude that the absence/presence in everyday life is related to the person's participation in their own life and how this participation is unique, including as a recognition that being quiet can mean that the person “is super present. The amount of internal movement that being there watching other people generates!” (E0).

In this movement, the group understands that the leisure of users, rich or poor, requires a range of elements and contexts that are interrelated:

It could be the supply, resources to engage, access, in general it's from our perception in the sense that there are few activities, maybe happening, little engagement. Now, to conceptualize (leisure) we would go in his (user) relationship with the activity and participation (E4).

And throughout life, because when they get sick, and you're going to build their life story... They didn't have any offers, or possibilities throughout their life and they arrived there at that point, many times uninterested (E6).

Finally, the group reflects on the terms poor/rich and simple/complex and how the first pair carries economic judgment. As well as the logic of presence/absence, the group's reflections dialogue with Ramugondo's (2015) understanding of occupational awareness, being a possible gap for critical thoughts about leisure experiences and how they influence and are influenced by the hardships of life.

In this category, the understanding of leisure was developed as: “Leisure is when we can transcend the hardness of daily life and engage in simple or complex activities that bring us relaxation, lightness, encounter with small joys” (E0).

It is emphasized that the understandings created by the group demonstrate “an effort to conceptualize leisure for its own sake and not as a counterpoint to work. Leisure is one more point: there is self-care, there is work, there is rest, there is sleep, etc.” (E0). In this sense, the group's perceptions are close to understandings in which leisure should be an occupation in dialogue with others, and not in counterpoint (Gomes, 2014; Queiroz et al., 2020a; Queiroz, 2015, 2020; Queiroz et al., 2021b).

This dialogue would take place in everyday life. Element understood by the group as a specificity of occupational therapy, with occupations interspersed in it, and it being impossible to look only at daily life or only at occupations. It is in this sense that the authors of this work corroborate the group's conclusion about the role of the occupational therapist regarding leisure, which includes “evaluating everyday life. Evaluate how the subject is, based on the assumption of what activities are part of the repertoire” (E0). From the person's repertoire and the options that the occupational therapist has with the care network, the resumption of this occupation and the development of others are established.

Final Considerations

This study presented the collective construction on the understanding of leisure by occupational therapists, who work in the mental health of public emergency services replacing the psychiatric hospital, based on the knowledge of Occupational Science. Therefore, in addition to questioning these professionals about their understanding of leisure, we also sought to find out if there is an influence of the base model of care on the understanding of leisure. Furthermore, if so, how does it influence this understanding?

The research pointed out that professionals understand pleasure as an essential element for the characterization of an occupation as leisure, but emphasize that this is accompanied by co-responsibility and that not every pleasurable occupation is leisure, and it is the understanding of the whole experience that names it. as leisure, and not just some pleasurable points.

The choice of leisure is associated with the feeling of pleasure, which is similar to the satisfaction and expression of desires. Autonomy, as propagated by psychosocial rehabilitation, according to the analysis carried out on the group's statements, is intensely permeated by people's relationships and their leisure experiences. In this way, the impact of these experiences on people with psychological distress becomes more evident, given the stigma and the assessment of these individuals' ability to choose, when in crisis.

Finally, leisure is understood as a way of transcending the harshness of life, constantly crossed by socioeconomic and political changes, which generate hardships not only in a massive routine, but also in less complex daily lives, of which people are increasingly expelled.

From this research, it was stated that leisure can find resonance in practices that encourage contractuality and autonomy, elements present in the care process aimed at Brazilian mental health. However, the precariousness of the work associated with the lack of investment by the public power in the territory and in the substitutive services of the Psychosocial Care Network, as well as the “preconception” of professionals regarding leisure and the ability of users to choose, show that if impediments to a respectful work, aligned with network care and that goes beyond the symptoms in the three scenarios of psychosocial rehabilitation: dwelling, social network and work with social value.

Finally, the professionals' effort to seek to understand leisure itself corroborates research that presents critical thoughts from occupational therapists and occupation scientists, in general correlated to their practice, concepts and understandings. This, in this clipping, points to understandings of leisure within the cultural, political, and economic singularities of the Brazilian context.

In this way, we believe that this article also contributes to the integration between occupational science and occupational therapy by establishing how the concepts of both disciplines can dialogue to strengthen the theoretical development and understanding of different constructs that allow further debates on this matter.

Limitations and Implications of the Study

Although the results cannot be generalized to the five regions of the Brazilian Nation, they raise discussions that pervade and enrich the occupational therapeutic practice, as well as the clinical reasoning of occupational therapists from all over the country, since the research brings relevant reflections to the work of these professionals within the public mental health policy, as well as the policy itself and its theoretical basis. A national survey would be relevant for the development of an understanding of leisure consistent with the history and culture of Brazilian society, to whom the occupation of the occupational therapist within public policies serves. Reflections on leisure as a human occupation also favor occupation scientists from different areas, as they reflect the culture in which these understandings were forged, the way of living, of developing relationships of belonging, and how and what each culture understands as pleasure and autonomy.

• 1
  Free translation by the authors.
• 2
  Forró is a Brazilian dance, practiced in pairs.
• How to cite: Queiroz, A. G., & Morrison, R. (2023). Collective building of a leisure understanding in territorial mental health, by occupational therapists: a qualitative study. Cadernos Brasileiros de Terapia Ocupacional, 31, e3546. https://doi.org/10.1590/2526-8910.ctoAO265035462

• Funding Source

  Internalization Program for the Magíster en Ocupación y Terapia Ocupacional, Facultad de Medicina, Universidad de Chile and Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES) - Financing Code 001.

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Edited by

Section editor

Profa. Dra. Marta Carvalho de Almeida

Publication Dates

• Publication in this collection
  27 Oct 2023
• Date of issue
  2023

History

• Received
  16 Nov 2022
• Reviewed
  20 Nov 2022
• Reviewed
  05 Apr 2023
• Accepted
  21 June 2023