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Revista da Escola de Enfermagem da USP

Print version ISSN 0080-6234

Rev. esc. enferm. USP vol.45 no.2 São Paulo Apr. 2011

http://dx.doi.org/10.1590/S0080-62342011000200030 

ORIGINAL ARTICLE

 

Social companies and solidary economy: perspectives for the work inclusion of individuals with mental disorders*

 

Empresa social y economía solidaria: perspectivas en el campo de la inserción laboral de portadores de transtorno mental

 

 

Isabela Aparecida de Oliveira LussiI; Maria Alice Ornellas PereiraII

IPhD in Sciences. Occupational Therapist. Professor, Federal University of São Carlos, Department of Occupational Therapy. São Carlos, SP, Brazil. bellussi@ufscar.br
IIRN. PhD in Nursing. Professor, Nursing Department, Medical School at Botucatu, Universidade Estadual Paulista “Júlio de Mesquita Filho”, Campus Rubião Junior. Botucatu, SP, Brazil. malice@fmb.unesp.br

Correspondence addressed to

 

 


ABSTRACT

The psychiatric reform process requires the implementation of public policies that guarantee the work inclusion of individuals with mental disorders. To do this, work must be understood as a promoter of autonomy, emancipation and citizenship. The objective of this study is to reflect on the theoretical concepts related to social insertion through work, with the purpose of exploring the inclusion of individuals with mental disorders in the work market. The concepts social company and solidary economy where selected as fundamental for the study. In the social company, the subject is considered to be a social being, focusing on the development process towards emancipation. In solidary economy, the objective is to develop an economy that is more just, equal and solidary. Further discussions on these concepts should be developed to support the implementation of projects for social inclusion through work.

Keywords: Mentally ill persons; Rehabilitation; Work; Mental health; Deinstitutionalization.


RESUMEN

El proceso de reforma psiquiátrica requiere de la implementación de políticas públicas que garanticen la inserción laboral de portadores de transtorno mental. Para ello, es necesario que el trabajo sea comprendido como promotor de autonomía, emancipación y ciudadanía. El objetivo de este estudio es reflexionar acerca de concepciones teóricas relacionadas con la inserción social mediante el trabajo, apuntando a explorar el campo de la inclusión de portadores de transtorno mental en el mundo laboral. Se eligieron los conceptos de empresa social y de economía solidaria como fundamentales para el estudio. En la empresa social, el sujeto es entendido como ser social, enfocándose su proceso de formación con sentido emancipatorio. En la economía solidaria, se objetiva el desarrollo de una economía más justa que tiene como característica la igualdad y solidaridad. Sugerimos que la discusión de tales conceptos aporte como base de implantación de proyectos de inclusión social mediante el trabajo.

Descriptores: Enfermos mentales; Rehabilitación; Trabajo; Salud mental; Desinstitucionalización.


 

 

INTRODUCTION

Historically, labor has been the focus of attention in the context of psychiatric and mental health. Even before psychiatric facilities emerged, the structure of confinement institutions destined to socially exclude the entire marginalized population was based on the proposal to subordinate the confined population to an ethics of work considered capable of fighting poverty and idleness(1).

With the moral treatment introduced by Pinel in France in 1773, not only was the asylum acknowledged as a therapeutic means but a therapeutic nature was also attributed to labor. However, the therapeutic objective of labor within the moral treatment concept was to correct the behavior of mental patients considered to be out of socially accepted standards, end disorganizing idleness, punish, control and reward those who complied with institutional rules, and finally to reduce costs(2).

Labor within asylums has always had this meaning. However, a discussion emerged within the Italian deinstitutionalization movement that began in the 1960s. The discussion concerned the right to work as a means of profit, as a tool to promote self-assertion, to make exchanges and construct social networks, to diminish the stigma linked to mental disease and especially the right to work out of the asylum’s walls(3).

Coupled with this discussion is the idea that a rehabilitating intervention in mental health should address issues such as lack of access or unemployment for people with mental disorders, unemployment as a risk factor for mental disease, and their current exclusion from the job market. Such an intervention should also encourage policies that include individuals in the market who, due to disability or social disadvantage, are excluded from the world of production and are entrusted to the world of care(4).

Focused on these issues, this study presents a theoretical reflection on concepts of social enterprise and solidarity economy, which have been adopted in Italy and Brazil respectively as a potential alternative to include patients with mental disorders in the job market. This reflection can support the practice of professionals in the health field who are committed to the issue of social inclusion for individuals with mental disorders in the current context of Psychiatric Reform.

 

THE INCLUSION IN THE JOB MARKET OF INDIVIDUALS WITH MENTAL DISORDERS IN THE CONTEXT OF BRAZILIAN PSYCHIATRIC REFORM

In general, all the processes of the psychiatric reform initiated in the 1960s in Europe were intended to gradually overcome the asylum model through the creation of services in the community and focus on therapeutic interventions in the social context of people, prevention and rehabilitation(5).

However, what occurred in many of these processes was the specialization of territorial services according to the rational paradigm of psychiatrics, that is, intervention focused on a given problem (disease) to achieve a rational solution (cure), producing a new chronicity among individuals with mental disorders, characterized as a process of deinstitutionalization(5).

The Italian psychiatric reform movement was a historical process, deconstructing the hospital-centered model, which called into question the rationalist model of psychiatrics. The institutional solution is dismantled in the deinstitutionalization process – the ways people are treated are transformed – to dismantle the problem: the suffering of people. Hence, the objective of psychiatrics becomes the suffering existence of people and not the disease(5).

The criticism of the entire institution was not only a process of dismantling the asylum model, but above all, it was a process of reconstructing the institutionalized individual. Hospitalization institutionalizes the person in defined categories causing a loss of material and psychological power(6). Reconstruction maintains that the inverse path should be taken, that is, reacquire power, deinstitutionalize fictitious identities, reconstruct the individual’s history, reconstruct spaces so as to make the expression of meaning possible(6).

The deinstitutionalization process is characterized by three aspects that gradually take shape as the asylum is deconstructed: a) The construction of a new mental health policy based on the foundation and interior of institutional structures through mobilization, participation, and confrontation of all the stakeholders; b) The centralization of the therapeutic work to enrich the complex and concrete global existence of patients in such a way that they, more or less sick, are active subjects not objects in their relationship with the institution. The order of progress is: from the asylum, the ground zero of social exchange, to the extreme multiplicity of social relations; c) The construction of external structures that are a total alternative to hospitalization in the asylum, just because they come from within its decomposition and the use and processing of material and human resources deposited there(5).

The psychiatric reform movement in the Brazilian context, ongoing since the end of the 1970s, brought overcoming the asylum into debate, questioning the role of technicians as agents of social order and exclusion, especially the production of new ways to deal with individuals with mental disorders(7). The process of Brazilian psychiatric reform, as in Italy, was guided by deinstitutionalization.

Deinstitutionalization is presented as a work focused on reconstructing people as social actors, transforming their ways of living and experiencing suffering and presenting ways to transform their daily concrete lives(5). But how do we transform the concrete life of individuals with mental disorders? Another study(8) exploring this subject suggests conceiving rehabilitation as a process of gaining citizen’s rights.

Rehabilitating means to construct or reconstruct true access to citizens’ rights, the progressive exercise of such rights, the possibility of having them acknowledged, and the ability to put them in practice. These are political, legal and social rights(9).

Rehabilitation with this meaning is presented as a set of strategies aimed at multiplying and enlarging opportunities to exchange resources and affections, opening spaces to negotiate with individuals who use the mental health services, their families, the community of which they are part, and the services that provide care to these individuals(8).

Psychosocial rehabilitation “is a strategic attitude, a political will, a complex and delicate comprehensive modality of care to people vulnerable to the habitual modes of sociability” and who require complex and delicate care(10).

The strategies to broaden opportunities for material and affective exchanges can be defined as the web of a network of negotiation as they increase the participation and power of real contractuality of the more fragile individuals of a society. The model of multiple networks of negotiation put into focus the participation, in such a way that the objective is not to cause fragile people to leave this condition so they can play with the stronger ones but rather to change the rules of the game so that both fragile and strong individuals participate in it in permanent exchanges of skills and interests(8). It is argued that it is in the web of negotiations, through the exercise of contractualities that the social network of people is constructed whether at the family level or at an enlarged level.

The literature addressing psychosocial rehabilitation appoints that the increased contractual capacity of the users of mental health services should occur within their habitat, social network, and work with social value(8,10-11).

The effectuation of bonds and release of resources in these three contexts and the acknowledgment of these individuals’ access is only one level of the rehabilitation process. The other two levels correspond to legal strategies and to the production of access to value, promoted through education and information, the construction of opportunities and collective health practices in favor of users in their totality. These three levels of intervention are ratified when considered jointly with the rehabilitation process, but are corrupted if they are promoted in a dissociated way(9).

One’s personal autonomy, education, professional education, social ability, the need for power and the ability to express oneself in an understandable way are essential goals to be achieved, however, what remains, always exclusively rehabilitative, is the process through which these rights are pursued, rather than their complete realization(9).

The actions of the social network will be the interests it promotes, the real access to communication networks, and especially, the social value of the relationship network. Hence, the axes of home, work and socialization become slightly reductive. Even more reductive is to identify rehabilitation and reacquisition of capacity in an individual way. Hence, the ability to work, for instance, may be distant from acquiring citizen’s rights if the work is inserted in a context of passivity and the execution of orders performed without freedom(9).

In summary, one needs to take into account in the rehabilitation process that the decisive power of interpersonal relationships is valid within the concrete modification of the subject’s reality, who cannot live only from personal relationships but also needs concrete modifications of work, activity, material and culture(9).

The same author(9) attributes a prominent position to labor in the rehabilitation process as he questions how is it possible to talk about healing without labor, defending the view that it structures human and social existence.

The emancipation of users of mental health services is related to the educational process triggered by inclusion in the job market. When inclusion in the job market becomes a policy intended to educate individuals in the cultural, social and political spheres, a field of interests, desires, and exchange with the world is opened, which is significantly restricted for most of the users of mental health services(3).

Psychiatric reform in Brazil put on the agenda asylums and interventions methods that follow the model of exclusion and segregation, among them labor-therapy and other occupational forms, emphasizing the need to implement services that replace the asylum model(1). Such services gave origin to new forms of relationship among mental patients, their families and mental health professionals and the practices focused on social (re)insertion.

This conception of treatment changed the references of care in the mental health field in which a growing concern with some issues related to habitat, to the family and work of individuals with mental disorders has been seen in recent years. These elements function as indicators in the development of more effective programs in psychosocial rehabilitation(8,10,12)(8,10,12).

This view focuses on the notion of

singular projects based on a profound transformation of the perspective built around the disease, disability and incapacity: which have as the starting point the validation of the other individual, knowledge and dialogue with the histories of people in their context and network of relationships. Based on people-centered care, this way of thinking requires the development of practices in the real contexts of lives, bringing onto the scene activities and networks of relationships that weave everyday life, dwellings, territory, work, communication, the playful, fantasy(1).

From this perspective, thinking in terms of projects to include users of mental health services in labor activities means to abandon the therapeutic perspective of labor and conceive it as a resource to produce life.

Based on these assumptions, professionals from the mental health field became concerned with the inclusion of users of mental health services in labor activities that really promoted their social inclusion.

For labor to be a tool of social inclusion, it needs to be understood as the production and exchange of goods and values. It is necessary to reflect on the meaning of labor in the rehabilitative process based on the notion of labor as promoter of the articulation of interests, needs and desires(8). Hence, for labor to be a resource of production of exchange it is essential it loses the therapeutic emphasis and that the problem of the relationship between labor and mental disorder be faced based on an alternative reference that allows restructuring the field of labor(8).

A study conducted in the Project Copiadora at the CAPS Luís Cerqueira in the city of São Paulo, Brazil and that aims to include users of mental health services in labor activities, reported that the users participating in this project move labor from the condition of treatment to the condition of the means or ways of accessing something, such as respect and identify it as a means and access to a different social place, of inclusion, that turns a human being into a citizen(13).

Therefore, we highlight that the experience of users in labor activities that in fact enable them to experience issues related to the job market promotes social, affective and material exchanges and confer on them social value, transform the conception of therapeutic labor jointly with the production of meaning and life.

The Brazilian psychiatric reform process promoted a strong transformation in the mental health care model emphasized by the affirmation of the citizen rights of patients with mental disorders, among them the right to work.

 

SOCIAL ENTERPRISE AND SOLIDARITY ECONOMY

A potential alternative in the mental health field to transform institutionalized therapeutic labor into labor as production of meaning can be through the creation of integrated cooperatives. These cooperatives are experiences in mental health practiced since the 1970s in many Italian cities in which the process of psychiatric reform had an important impact(8).

A cooperative is

a more innovative organizational form: it not only is the opposite of the exploitation of dependent work but is also a concrete form of solidarity. A cooperative is in fact a collective form of enterprise. From a legal standpoint, an Integrated Cooperative is characterized by the presence of ‘regular’ and ‘disqualified’ partners (at least 40% of the latter) and the support of local entities (especially regional ones), which is concretized in promotion interventions (facilities to acquire equipment and locations); facilities to include disqualified individuals (supervision of social burden); interventions to encourage production (credit lines and training programs)(8).

Among the advancements that resulted from the process of psychiatric reform in Brazil, a partnership was established in 2004 between the Technical Department of Mental Health at the Ministry of Health and the National Secretary of Solidarity Economy at the Ministry of Labor and Employment to foster the generation of income in the mental health field(14).

The ideas of the group of the national secretary in relation to cooperatives are close to the concept of integrating cooperatives since they assert that a cooperative cannot be composed only of people who present some kind of disability or disorder, but it has to have a considerable number of people who do not have any kind of disability(15). Hence, the importance of family members, friends and other people with no psychological or physical disability whatsoever is evident, who desire to make a living and take part in cooperatives jointly with people with such disabilities.

A study carried out in one of the already extinct CECCOs (Social Centers and Cooperatives) from the City Health Department of the city of São Paulo, SP, Brazil supported the view that projects using labor to promote social inclusion are doomed to failure if they are strongly connected to mental health facilities but do not have the support of other social actors besides users of such facilities. The projects of cooperatives become insufficient when they are not linked to other institutions and other social actors(16).

Through integrated cooperatives, new and more autonomous forms of work are being created, other types of organizations and different routes are being developed focusing on the disadvantaged population. Hence, a new practice is emerging from there, that is, the social enterprise that has not only a economic but also social nature. It promotes new networks and new relationships among social subjects(8).

The practice of social enterprises is largely discussed in Italy in the scope of mental health care, evidencing changes in the roles of those participating in the process of health care, that is, from passive recipients of care they become producers of resources(17).

A social enterprise can be a more credible attempt to explore the meaning of labor as a rehabilitative tool. It encompasses activities of education and labor, which on the one side, has an enterprising character and on the other side educates people. It is a project with two pillars: entrepreneurship and the ability to encourage education(3).

Social enterprise is an alternative to break with the separation between job market and care. It occurs through an alliance with entrepreneurs but especially with a change in care culture and practices. The traditional psychiatrics

provided scientific justification and legitimated the most violent systems of the selection of work forces, frequently defining in medical terms one’s inability to produce. But in the passage from extreme exclusion from the asylum to the welfare world [...] it is particularly miserable because it is still imbued by the perspective of invalidity [...] it is certainly not enough that people whom we care for move from the status of reclusive to that of excluded(9).

Institutional rules deny and harm the subjects’ resources. When we talk about rehabilitation, we should primarily acknowledge such resources, find ways to free people from constraints and suffocation(9).

Actively constructing real access to rights means to create conditions for people to heal but also to produce, to have a home, an activity, relationships, economic means, values, etc. This is possible through integrated social cooperatives because these are instruments of

real production of activity and the possibility to produce goods for the market, within the context of quality, qualification of the ways of production and product. A possibility of cultural education that is also education for the written and spoken word, theater, body, video, image, school within the social enterprise inside the places of production, on an individual, singular scale(9).

From this perspective, one recovers the educational dimension. The residual ability of autonomy and of working with one’s own body is permanent and active. It is worth noting that a social enterprise is not possible without cultural transformation(9).

The Brazilian literature lacks discussions concerning the concept and practice of social enterprises but there seems to be a growing interest in recent years concerning the concept and practice of solidarity economy in the country’s context.

Solidarity economy is another form of production, the basic principles of which are collective or associated property of the capital and right to individual freedom. The implementation of these principles unites all those who produce in a single class of workers who posses equal capital in each cooperative or economic society. The natural result is solidarity and equity, the reproduction of which, however, requires government mechanisms to promote solidarity redistribution of income(18).

The solidarity economy emerged as an alternative to competitive capitalism and is characterized by a hetero-management system. One of the characteristics of solidarity economy entrepreneurship, which can be a cooperative or other form of association, is self-management. In this form of organization all the decisions are made in assemblies, in the case of small enterprises, or by a group of representatives elected by the partners and who shall act on behalf of all, in the case of larger enterprises, in which it would not be viable to make decisions in general assemblies(18).

Solidarity economy, through self-management, can be

a better alternative to capitalism. Better not in strict economic terms, [...] better because it enables people to adopt a better life as producers, savers, consumers, etc. Better life not only in the sense that individuals can consume more with less productive effort, but also better in terms of relationships with their families, friends, neighbors, co-workers, classmates, etc.; each has the freedom to choose the work s/he derives more satisfaction from; each has the right to be autonomous in productive activity and not to submit to the command of others, and can fully participate in decisions that affect his/her life; and has certainty that the community will never abandon him/her(18).

By comparing the two concepts we argue that the discussion concerning social enterprise focuses on the subject as a social being and his/her training process towards the promotion of emancipation. On the other side, the discussion of solidarity economy focuses on collective groups seeking the development of a fairer form of economy whose characteristics are equity and solidarity with a view to socially emancipate these groups.

Solidarity economy in Western European countries plays an important role in fighting unemployment and in promoting social inclusion through social cooperatives. Cooperatives’ members perform functions previously performed by government employees such as

services focused on supporting children at risk, elderly individuals without material means to satisfy their vital needs, alcohol and drug addicts, individuals with mental or physical disabilities, etc(19).

These cooperatives are included in the third sector and take the form of non-government organizations supported by the government through contracts.

It is argued that these social cooperatives are classic examples of what in Italy is called type A social cooperatives, that is, service agencies that are organized to fight unemployment of young individuals with high educational level without the prospect of employment.

There are also type B social cooperatives, which in this paper were previously called integrated social cooperatives. These cooperatives are designed to work with marginalized individuals who are at a social disadvantage and out of the job market. The first are not social enterprises and the latter will only be social enterprises to the extent they appropriate social spaces and use them to enable vulnerable people to work(20).

An initiative was taken in this direction in Brazil. On November 10th 1999 law nº 9.867 was enacted providing on the creation and functioning of social cooperatives(21). The goal was to encourage the inclusion of disadvantaged people in the job market through social cooperatives. However, the law has undergone several vetoes and became unsuitable for the cooperatives’ effective implementation.

Analyzing the common elements between social cooperatives and solidarity economy and the reflections presented here concerning social cooperatives and social enterprises, one can say that the concept of solidarity economy differs from that of the social enterprise. However, a second condition for a social cooperative to become a social enterprise is the existence of real cooperation among its partners and it to be in fact concerned with the social aspect(20).

From this perspective, it is argued that an enterprise of solidarity economy can be considered a social enterprise since solidarity and social inclusion are among the principles of cooperation.

Additionally, there are in the Brazilian literature diverse names or concepts to identify an alternative economy to the capitalist one, that is, the other economy, such as solidarity socio-economy, popular solidarity economy, labor economics, self-managed enterprises, new cooperatives, ethical investment, and social enterprise, among others(22).

 

CONCLUSION

In the Brazilian context people with mental disorders have been included or re-included in labor activities through the implementation of solidarity economy, although some initiatives to structure cooperatives in the mental health field were not viable. One of the reasons may be the difficulty caused by inappropriate laws that regulate social cooperatives.

Nonetheless, some projects to generate income, usually linked to associations of users of mental health services, their family members and mental health workers or to Psychosocial Care Centers (CAPS), have become important resources of labor inclusion and achievement of citizenship for individuals with mental disorders. However, these experiences are fragile, isolated and have few conditions to effectively generate income for those who participate in them.

Given the considerations presented, we argue that the discussions of concepts of social enterprise and solidarity economy can contribute and enrich the process of including individuals with mental disorders into the job market. We consider it important to reflect upon this subject in the current context of mental health. It is believed that innovative projects involving the generation of income and that strengthen mental health users’ power of contractuality can emerge and even lead to an initiative focused on the implementation of integrate cooperatives.

According to the theoretical concepts presented here we conclude that a cooperative, whether it is socially integrated or based on the principles of solidarity economy will become or fail to become a social enterprise depending on its objective and on the characteristics of the work it develops.

 

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Correspondence addressed to:
Isabela Aparecida de Oliveira Lussi
Rodovia Washington Luís, Km 235
CEP 13565-905 - São Carlos, SP, Brazil

Received: 04/24/2009
Approved: 08/17/2010

 

 

* Extracted from the doctoral dissertation “Trabalho, reabilitação psicossocial e rede social: concepções e relações elaboradas por usuários de serviços de saúde mental envolvidos em projetos de inserção laboral”, University of São Paulo at Ribeirão Preto, College of Nursing, 2009.

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