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Saúde e Sociedade

versão impressa ISSN 0104-1290versão On-line ISSN 1984-0470

Saude soc. vol.24  supl.1 São Paulo abr./jun. 2015

https://doi.org/10.1590/s0104-12902015s01009 

Articles

Creative work and health care: a discussion based on the concepts of slavery and freedom

Túlio Batista Franco1 

1Universidade Federal Fluminense. Departamento de Planejamento em Saúde. Rio de Janeiro, RJ, Brasil. E-mail: tuliofranco@gmail.com


ABSTRACT

This article discusses the process of subjectivation in the labor and care process, and refers to the idea of subjectivity in Spinoza. The worker operates in freedom if he manages to control affectus, thus opening himself up to creative work. If one acts captured by capitalistic, moral or scientific lines, one acts according to these logics, and therefore in servitude. We conclude that it is difficult to have a work process that operates only by servitude or freedom. Of these two possibilities, a variation defined by the struggle between the forces at play was found most likely, one in which different degrees of freedom are imposed on the Work process. Creative Work is visible in the micro dimension of health work in spaces circumscribed by the work process, in different formats and intensities. Through it one can create diversions, innovations to the established pattern of care, thus conducting creative therapeutic projects, expression of freedom.

Key words: Work in Health; Care; Micropolitics; Subjectivity

RESUMO

Este artigo discute o processo de subjetivação no processo de trabalho e cuidado, e toma como referência a ideia de subjetividade em Spinoza. O trabalhador opera na liberdade se conseguir controlar as afecções e suas capturas, abrindo-se assim para um Trabalho Criativo. Se agir capturado pelas linhas capitalísticas, da moral ou da ciência, ele age conforme estas lógicas e, portanto, na servidão. Conclui-se que é difícil um processo de trabalho que opere apenas pela servidão ou pela liberdade. Entre estas duas possibilidades, verifica-se ser mais provável uma variação definida pela luta entre as forças em jogo, em que diferentes graus de liberdade se impõem no processo de trabalho. O Trabalho Criativo é visível na dimensão micropolítica do trabalho em saúde, em espaços circunscritos ao processo de trabalho, em diferentes formatos e intensidades. Através dele é possível criar desvios, inovações ao padrão instituído de cuidado, operando assim projetos terapêuticos criativos, expressão da liberdade.

Palavras-Chave: Trabalho em Saúde; Cuidado; Micropolítica; Subjetividade

Introduction

This text aims to discuss the processes of subjection, work and health care processes. It references the idea of subjectivity presented in the work of Baruch Spinoza (1632-1677), especially the concepts of liberty and servitude (Spinoza, 2008), two issues that are part of the human dilemma in producing their own life. Of interest to us in this debate is the association we seek to make between liberty and Creative Work, understood as the act of creation as something intrinsic to the work process in health care. We start from the assumption that creativity is only possible when the health care worker produces their work in liberty, but the concept of liberty undergoes a significant shift in Spinoza. He discusses it based on a very specific meaning, which we shall explore in this text in order to develop the idea that processes of subjection, through the agency of freedom, operate in forming Creative Work, affecting how care is produced. We intend, then, to tackle the issues: what is liberty and servitude? How can a health care worker free himself to produce health care? How can Creative Work be produced in health care practices?

The issue of Creative Work became a relevant issue in producing health care based on our observation of the workers in their day-to-day life. We take creation as the substantive - "evidencing the substance, the essence" (Houaiss, 2014) - of health care work, present as something concrete, immanent to health care practices. In day-to-day work in Health Care Units, whether primary or hospital care, on the "shop floor" of health care systems, public and private, it is possible to observe that, in the multiplicity actions and procedures conducted in the coming together of worker and user, there is mediation in the care plan, always exercised by the worker in their relationship with the user. It is in this encounter of worker and user in which the occurrences are not at the workers' or users' hub, but in the "field of consistency" that forms between them, that it becomes possible for unexpected or unplanned actions to happen. The care resulting from this encounter is formed based on the set of care acts, fruit of the actions of creation by the worker and the user themselves.

Observing the work of various health care professionals in the intense activity within Health Care Units, we verified some kinds of improvisation. When there are obstacles in the way of a certain treatment project, unusual actions are always conducted. We notice that they themselves flee from any prediction in the protocols instituted to guide and standardize behavior. It is invention, acts of creation that produce the chances of resolving the users' health care problems through deviation, "escape routes", in other words, it is something the re-signifies the problem, the need, the care in the context of the worker's relationship with the user.

If it was verified that the worker can be creative in certain circumstances of their work, the user can also be. In certain contexts or situations in which they live and fall ill, he brings problems that are, in themselves, also unusual or unexpected, to a specific health care service. In contrast to what many think, the user is extremely active regarding their health problem and prescribed treatment. Even when they refuse to adhere to certain behavior, this can be understood not as a passive attitude but, on the contrary, as a reaction to a prescription by which they are not convinced, which does not make sense for them or clashes with their way of life. Regarding the worker-user relationship, everything is produced by the two of them. We notice than the world of health care is full of issues that appear as the users' singular needs and diverge completely from anything predicted in the structured technical knowledge or in the institutionally legitimized protocols.

We can see, therefore, two dimensions of the same problem, being: on the one hand, the frequency of unexpected health problems that swerve from a set pattern; and, on the other, the workers who are there to respond and whose response, in turn, calls for behavior that is, as a technical act, also outside the pre-conceived patterns. And all of this in the middle of intense activity by the user himself. The health care workers always see themselves as between the various choices for carrying out their work, between adopting solutions within what is expected and in the protocol or breaking the pattern and providing care based on what we call here "creative work". In other words, creating alternative care and thus inaugurating new behavior, accepting certain risks, working in a wider field of possibilities and often taking on responsibility. Or even a network is formed for decision making about their own creative work, such responsibility can also be taken collectively.

The worker exercises self-governance over their work process, with the power to decide what and how to do it. This elasticity in practice, with the possibility of working following the institution's logic of production was discussed by (Merhy 2002) as the effect of a work process, in the case of health, which is centered on living work in action. Their control of their own work process enables them to make decisions and choices. But such possibilities do not mean that the worker is free in the sense of freedom discussed in (Spinoza 2008), as servitude and liberty are ways in which subjectivities are realized, instituted in the individual as the process of subjectivation.

Subjectivation, the continuous, unlimited formation of subjectivities, occurs based on encounters throughout the individual's existence in determined space and time. The experiences pass through the individual, institute specific forms of signifying the reality in which they find themselves. We can imagine, therefore, that the multiple encounters the worker has in producing their own life modify them in a sensitive and continuous way.

Subjectivity, for example, can be organized by infinite agencies acting on the individual, but we highlight here several lines of subjective production of interest in discussing work in health care: i) capitalistic logic operating on the work process as lines of organizing professional corporate interests; ii) moral, working to regulate life according to hegemonic precepts of social behavior, establishing a value for life according to the individual's obedience to these precepts; iii) scientific knowledge which seeks to exert control over the bodies, a disciplinary regime, and the above forms of living, operating in the biopower logic. Each of these logics acts as a line of power of subjectivation, collective agencies making the health worker signify the specific way in which the users produce their lives. The health care worker's great dilemma, as for everyone else, is to live between servitude and liberty, a prisoner to these lines of force or free to act according to their own ideas of care. Being in servitude or at liberty is the effect these lines of agency have on the worker and, consequently, on the work process in the function of caring. Something that we notices was, even counting on the possibility of deciding and governing one's own work process, being free goes beyond free will, referring rather to a way of life in which production itself and the world are confused when a worker performs according to their own nature in the act of caring. He encounters a synthesis between internal and external, without and within, subjective and social. Thus, the greatest agency of this productive process is the encounter itself and the extent to which it is governed by affect. In order to understand this process, we will return to (Spinoza's 2008) theory of affectus, as subjectivation - the dynamic and intense process of subjective production -, is a central issue in defining Creative Work.

The subjective agencies operating in the work processes often go unnoticed by the worker himself, but it is based on them that he has options regarding his own practices, work technologies and the way he relates with the user. And as for understanding the processes in which he participates, this may be formed limited to the level of technical knowledge, or may go beyond, according to what (Spinoza 2008) calls "intuitive science", which we will discuss later Regardless, it is important to point out what perceptions in different dimensions signify both different ways of approaching health problems and caring for users.

The question driving us is mainly what makes certain workers have health care practices operating Creative Work, while others do not. We aim to understand the health care producing mechanism, including the act of creation within the work process and why others do not include this. This is because we understand that Creative Work has significant repercussions on the way treatment projects are carried out, affecting the care produced.

In the end, what makes the worker take on the act of creation as a tool in their day-to-day practice, transforming their work process into a form of "creative work"?

Freedom and work in health care

The first important issue is to define what freedom is. For (Spinoza 2008), freedom is not simply the possibility of choice, but is what happens when the individual manages to control the effects of the affects to which he is exposed, the affectus acting according to their own will. Understanding will as the strength coming from within the individual and acting as a driving force moving them in producing their own life and the world.

According to Alquié (apud Fragoso, 2007), in a discussion of Spinoza's Ethics:

He who most affects us is the one we understand to be free, as liberty is the power of sufficiency and not free will or the power to choose, that is, a being is said to be free when he is the cause of his own actions. A free being is, then, a being who is himself sufficient to explain, as total cause, the resulting effects. (Fragoso, 2007, p. 57).

What Spinoza is saying is that individuals are not free, they are always subject to the force of that which affects them - affectus, the effects of affect, defining subjectivity. Understood as:

Affect can be understood as the body's affectus, through which its power to act is increased or decreased, stimulated or held back and, at the same time, the ideas of these affectus. (2008, p. 163).

Spinoza tells us that bodies have the capacity to affect others in encounters between them, and the effect of the affects is what he calls affectus. In his work, he describes countless of them, but production of happiness and sadness based on the encounter plays an important part in this discussion. When looking at the functioning of a Health Care Unit, it is easy to see the intensity of the encounters taking place at each moment, of workers who form a network between themselves and with the users. In the dynamics of the functioning of the Health Care Unit there are both good and bad encounters, producing both happiness and sadness and thus corresponding affectus in workers and users present at the scene of producing care. We see that subjectivities are variables, fluid and are intensely modified over the course of a day. In the logic of Spinoza, if the individual is taken by sad affectus, these reduce his power to act in the world, whereas the happy increase this power. In other words, the basis of vital energy and its oscillation between stronger or weaker is in the encounter itself and its effects. There is a permanent process of subjectivation, not stagnating subjectivity, as it may appear. At each moment we modify ourselves based on multiple encounters and on the effect of the affectus.

Freedom assumes a practice which is the expression of will and which comes from the individual's inner strength, thus making them the protagonist in their own life. The individual act driven by ideas with which they understand things. This understanding is not merely rational but also passes through the sensitive body, what the author calls "intuitive science", as mentioned previously. "Who is born free and remains free has but adequate ideas. Thus, they have no concept of evil nor, consequently (as good and evil are correlates) of good". (Spinoza, 2008, p. 343). An adequate idea is one which the individual forms about complete understanding of an event, that is, what happens in his relationship with the world. It is formed based on the second and third kinds of knowledge, which we will be discuss further on.

According to the concept described here, liberty is the possibility of Creative Work, counting on will as a driving force and such work is carried out based on the idea that each has something for which to care, based on third kind of knowledge. In order to achieve liberty, the health care worker must break away from market, moral and scientific signals as agencies of his subjectivity and, therefore, as lines of capture that act to shape his practice. Thus, to be free, it is necessary to open "escape routes", creating deviations, which means re-signifying their world of work and care or dealing with, as in combat, the forces that impose servitude.

In the free man, then, the firmness of escaping in time is as great as that needed to fight; i.e. the free man chooses flight with the same firmness or with the same courage with which he would choose single combat. (Spinoza, 2008, p. 345).

As we can see, for Spinoza flight is not an act of leaving the struggle for freedom, but rather of facing up to it with new weapons; concepts and ideas. Flight, in this case, means re-signifying health practices and care. We can use as an example the idea of a worker, whose subjectivity is inscribed in market or moral values, or prisoner of scientific knowledge, organizing the work process in relation with other professionals and with the user, taken by these logics. However, even in an atmosphere of great discomfort and oppression, he may open "escape routes", in other words, deviate practices, re-signifying the work process, operating care strength of the encounter itself, based on "intuitive science", that is, on knowledge that recognizes the affective body as a source of knowledge and, therefore, with operative power over reality.

We will now move on to discuss what servitude is, as an assumption for thinking about work conducted based on liberty. It is by understanding the multiple possibilities of imprisonment in the work process, the signs imposed by affects, that we may find the paths of subjective production, opening itself to Creative Work. The act of creation, then, will be the effect of a rupture, a dislocation at the level of subjectivities present in producing care, an expression of the workers and of the users. Micropolitic is the action plan moving the forces in the struggle through which the action of each worker will pass, its singularity, and the effects of the encounter with the user in the care situation.

Servitude in health care

An affect is like an outside force touching the individual, altering subjectivity. It therefore produces an effect on the body; affectus. For (Spinoza 2008), an individual who acts exclusively as an effect of affectus, in other words of outside forces, is subject to servitude as he does not produce his life counting on his own will. Looking again at the situation of practice, it is easy to see that workers view themselves faced with the various happenings in their day-to-day work that has the effect of causing them sadness or happiness, reducing or increasing their power to act. For example, when there is a team meeting and certain workers operate based on the idea of hierarchy between professionals, this is a bad encounter for those who see their possibilities reduced. If a user is happy because of the result of a treatment project by a worker, and the worker reacts as if it were a gift or a favor, in his relationship with the user he will form the idea of "paying back favors, according to affect", rather than based on the values that characterize health care. If the worker takes the effects of these encounters for himself, without forming an understanding of them, he will suffer a capture, that is, he will come to define his acts according to the idea produced by the effects of affects. The work process, then, no longer expresses his own ideas, his will, as something portraying himself and his relationship with the world of health care. He always acts due to the force of affectus, subject to external forces, to passions. Why passions? Because his body suffers from affectus, he is subject to them. He lives in servitude.

In the three larger lines of subjective agency discussed here as fields of capture and subjectivity - of the market, of morals and of scientific knowledge -, we can say that the worker who acts centered on these ideas is in servitude, as he organizes his work and care process based on these precepts and not according to an idea originating in himself

It is worth emphasizing that, for Spinoza, the "mind and body are one and the same thing". (2008, p. 167). This signifies that, when speaking of the affects that cause effects on bodies, we mean to say that, based on these effects, ideas are formed about what that body encounters. These are deemed "inadequate ideas" when produced from the effect of affectus, in other words, when the worker perceives the effects of the medium, but has no explanation for them. For example, we can cite situations in which the health care worker "punishes" the user, prolonging the wait to be seen, providing poor care, because he is taken by subjectivity making him unable to bear those who do not organize their lives according to what he deems to be the appropriate precepts, in other words, he is intolerant of difference, thus intending to regulate lives and bodies. This is why certain groups of users suffer greatly from discrimination and are objects of poor care. This worker begins to "antagonize" certain user groups with no clear conception of his motives for doing this. He acts through the force of the affectus of the logic of the market, moral and scientific lines, but not by the lines of liberty, expressing himself, produced in the encounter itself. According to Spinoza, "all those ideas that are inadequate or confused belong to the first kind of knowledge" (2008, p. 135). What we see is the fact that a worker forms his thinking and practice based on ideas conceived through multiple experiences, without forming an understanding of them. The first kind of knowledge also includes the paranoid behavior of some workers on health care teams who perceive the effects of the medium on themselves and imagine certain persecutory objects in their relationship with the world of work. This defines a behavior in permanent tension with other workers.

It is in this context that Spinoza states that individuals are condemned to live in a regime of servitude, under the effect of the affects, because he is always operating in the world subject to "external forces".

Servitude is human impotence to regulate and restrain affects. Those submitted to affects are not under their own command but that of chance, the power of which is subjected to such a point he, often forced, although perceiving what is best for him, does what is worst. (Spinoza, 2008, p. 263).

An example of the effect of demonstration, the statement of a Health Care Center manager:

The team were looking after a woman in her eighties, mother of a man aged some fifty-five years old, also being cared for by the team. She had morbidities common to those her age, and he had a slight mental disability, without greater consequences for his autonomous life. The relationships with the care were very good until, one day, the team learned that they were living as a couple, having a sexual relationship. From that time onwards the team could no longer care for them, as they began to condemn their incestuous behavior. Faced with the team's own paralysis and suffering, which had begun to discuss the problem as if it was transgressing a social norm, the topic began to be analyzed in a continuous educations activity (Narrative of the Primary Health Care Unit Permanent Education Manager, 2012).

What we see here is the fact that a group of workers, affected by moral signals with which they find themselves in the agency of their subjectivity, they formed an idea of the couple they were caring for, and that idea associated their behavior to the equivalent of a "perversion". In the next act, they went on to condemn and punish them with abandonment. Thinking, then, was produced from external signals and not by the agency of their own encounter and from their inner strength and will. Their understanding of the couple is defined by the moral affectus they cause the workers, based on "inadequate" ideas of both, as they do not express the production of the encounter, the professionals being moved by "external forces", expressions of affectus. They do not understand why they have left off caring, the "inadequate idea" is a confused idea. They begin to punish the elderly couple with a judging attitude, without being aware of it. They produce an "incorporeal transformation". Deleuze has the following to say on the concept:

These acts appear to be defined by the set of incorporeal transformations in progress in a given society, and that they are attributed to the bodies of this society. We can give the word "body" a more general meaning (there are moral bodies, souls are bodies etc); we should, however, distinguish between the actions and passions affecting these bodies and the acts that are mere non-corporeal attributes or that are "the expression" of an enunciation. (Deleuze; Guattari, 1997, p. 13).

In this short text, Deleuze offers us some concepts that assist in better understanding the above mentioned care scene. Firstly, we see that the team produces and enunciation about the elderly couple they cared for. This enunciation became that of a couple whose behavior "transgressed the moral", in other words, the team produced a change in the concept based on their behavior. They ceased to be users needing care and became, in the workers' representation, "sinners". This is where the "incorporeal transformation" is produced which, in modifying the concept, has immediate effects on the work process, as the couple is no longer an object of care and becomes an object of penitence, punished for its acts. This is the origin of the "not caring", abandonment, dispensed to them. The same will occur with other groups of users who, similarly, organize the production of their life in a way that differs from that which certain workers judge to be morally adequate.

In the example, we can see the effect of affect on the worker forming an idea of what the user is, based on a subjectivity inscribed under a moral precept, "there are moral bodies, souls are bodies" (Deleuze; Guattari, 1997). The worker begins to act by the agency of the encounter with this moral, thus producing and "inadequate idea" of the couple in question. Sometimes, when the worker acts because of external forces, he acts under the effect of a "passion", because his body is suffering, in other words, he is subjected, as mentioned above (Spinoza, 2008). Here, he is in servitude. In contrast, when he acts because of the force of the encounter, based on ideas originating within himself, there ceases to be a passion to have an "action". This is characterized as resulting from interior forces, linked to the worker's own will in relation to the world of producing care.

The third kind of knowledge and its relation to creative work

In this paragraph we return to the idea of affects and their effects in order to introduce the discussion of the third kind of knowledge, the central issue in formulating the concept of Creative Work. Spinoza says that all affect stems from infinite causes. "The mind comprehends that all things are necessary, and are determined to exist and to operate by virtue of an infinite concatenation of causes" (Spinoza, 2008, p. 375). When these causes are not explained, they generate an "inadequate idea", the individual acts by the agency of affectus caused in the encounter with other bodies, by "external forces": passion. Then these causes are explained, generating an "adequate idea", the individual acts through the agency of their own forces, born within themselves, from their strength: action. Here, the individual becomes free, exercising liberty in order to act with the "forces that come from within", thus defining their actions in the world in which they live. For (Ulpiano 2014):

A free being is the man who can produce his life from the forces that come from within. Forces that come from within are what Nietzsche calls "strength of will". Spinoza is saying that liberty only gains in strength when it is the forces from within that constitute one's life. One only has liberty when one produces one's own life, that which one's own nature produces. (Ulpiano, 2014).

This is what is achieved if the worker understands the affects from which he suffers, that is, the affectus that is the agency of the way he acts. Understanding the forces affecting him, or the process of subjectivation, is a condition for him to act according to the "third kind of knowledge". In the thinking of Spinoza, "understanding" is not a merely rational act, but means producing knowledge through "intuitive science" Learning by the body and with the body, in an idea in which the body and mind are not separate, which also assumes knowledge through affects.

For Cláudio (Ulpiano 2014), the third kind of knowledge is what links the individual to the idea and action of liberty and creation, as the author says:

The third kind of knowledge is the power of invention and of the rigor of the human subject. It is when the human subject, instead of merely knowing what is outside of him, through the third kind of knowledge, through this "intuitive science", invents and creates. [...] He aims to produce new ways of life. He is an inventor, he is creative, his function is like that of art, produce something new, and it is like mathematics, highly rigorous. This third kind of knowledge is what links him to the issue of liberty. (Ulpiano, 2014).

Referring to the idea that in the third kind of knowledge the individual is fully exercising their liberty, the possibilities appear of working based on ideas originating from within oneself, in encounters based on themselves. In the case of health care, it is as if the worker, based on "intuitive science", fully understood what was at stake in the work and care scenario, thus able to act according to his own forces, what (Deleuze and Guattari 1972) define as desire - a driving force producing the world in which he finds himself. Based on this concept, one can discuss the possibility of health care work when seen as an act of creation, Creative Work.

It is important to note that Spinoza refers to the second type of knowledge as that in which the individual has "common notions and adequate ideas of the properties of things" (2008, p. 135); in which "the mind is capable both of perceiving more things adequately the more properties the body has in common with other bodies" (2008, p. 131). We are talking here of scientific knowledge, through which the individual perceives the effects of the medium on himself, a form of understanding in relation to them. And it is where the universals of knowledge are formed, based on the idea that the properties of things are repeated and form common fields of representation in relation to themselves.

The second type of knowledge is reason. It has the capacity to recognize the 'forces that come from without'. It does not, however, permit man to produce or create, because it is a kind of knowledge in which man has the capacity to understand that which already exists, that is, it does not exceed conscience and knowing reality. (Ulpiano, 2014,).

For (Spinoza 2008), the second and third kinds of knowledge come together in forming the understanding of things in relation to the medium. It is an important issue as, even formulating the concept of "intuitive science" operating in the third kind of knowledge, Spinoza recognizes the importance of the second kind, rational knowledge, while also describing its limitations. It is, then, worthwhile pointing out that the force of creation lies in the third kind of knowledge, it is where the individual fully exercises liberty and force.

"Intuitive science" as the source of creative work

Whoever knows things through this kind [the third kind] of knowledge achieves supreme human (definition of affects), and feels supreme happiness, accompanied by the idea of himself and his own virtue. Then (by the definition of affects), the greatest satisfaction that can exist comes from this third kind of knowledge (Spinoza, 2008, p. 395).

In order to discuss the concept, we will look a scenario of crack use, strongly present in the current imagery of SUS works, especially those who from the teams of "street clinics". We will start by discussing the issue of care aimed at controlling abuse of alcohol and other drugs. One important tool in such care is the harm reduction (HR) program. Working to reduce harm assumes the recognition that drug use is something in the human make up. (it comes from the old idea of the first reports of harmonious existence between the human and drugs, throughout history and up to the present day it has an intensive presence in religious cults and considered in other uses). This recognition, then, enables a police of reducing harm which sometimes begins with negotiating a substitute for the drug in use, and evolves into establishing a link and future negotiation of a shared treatment project between the worker and the user. Abstinence, absolute interruption of drug use, is not proposed. Rather, it is the authorization of using a drug within the program, which mainly functions as a tool for encounters and for care, which may be followed by a greater feeling of autonomy. Autonomy means that he produces his existence in the world based on multiple links; work, family, social groups, including drug use, differing from the situation in which he produces his life totally captured, breaking other ties and focusing on the drug as the only source of pleasure. The multiplicity of relationships to which he is exposed constitutes a variety of both pleasure and happiness. Thus, the drug is merely one of many and he can therefore control it, deciding when and where to use. this constitutes liberty, not as free will, but as controlling affectus and enabling him to operate on the plane of existence with his own forces.

In the ambit of drug control policies, the worker comes up against moral rules and scientific knowledge, aiming to regulate the issue based on the idea of prohibition and banning use. If the health care worker is affected by the moral or scientific rule, forming a territory on the plane of his subjectivity, he starts to conform to these precepts. This same worker, when he goes to work, for example, with harm reducing policies, will encounter great difficulty in "not judging" or "not punishing" users, as he is following the norms of prohibiting drug use, he is subject to these forces and his care acts are defined by them. He is operating, in this care, in servitude, as he is acting subject to moral and scientific affectus.

This has been a problem in conducting health policies in general, and those involving the homeless, mental health and other equally vulnerable groups, in particular. Affecctus are constituted in their subjectivity, imprisoning them in that directive. It is as if they were lines of force making up and organizing the work process. Is it possible to modify the subjectivity inscribed in these lines of capture? This is perhaps the greatest challenge of institutional support and permanent education proposals when they propose to change of qualify health care. Exposing the scenarios of practice, as with exposing their own work processes, operating simultaneous analysis and self-analysis, would perhaps indicate possibilities for producing and self-producing new practices, moving from servitude to liberty.

Spinoza, in On the Improving of Understanding (2004), and later in Ethics (2008), refers to displacing a "vague or inadequate idea", meaning the first kind of knowledge, in favor of an "adequate idea", in which the second and third kinds of knowledge operate. This is only possible if one manages to understand the affectus in the sense of their construction in the affective body. Understanding that the body and the mind operate inseparably, as Spinoza says:

Just as ideas are ordered and connected in the kind according to the order and concatenation of affectus of the body, so, inversely, the order and connection of affectus of the body is, likewise, done in the same way as thoughts and ideas of things are ordered and concatenated in the mind". (Spinoza, 2008, p. 371)

This idea of understanding formed through parallel lines of connection and actions suggests that, for Spinoza, "the human mind perceives not only the body's affectus, but also the ideas of these affectus" (2008, p. 115), The issue that now challenges us is: in dealing with the case of health care, particularly in the organization of work processes, how can logic be produced by third kind of knowledge lines?

We refer to the idea according to which the process of subjectivation exists in daily life, and there is an intense production of new subjectivities based on multiple encounters, producing modifications in the bodies that go through them, for example, from any work activity. Sometimes the center of the issue is experience, in other words, individuals are taken by their day-to-day experiences, and exposure to others and to the world of life is what produces changes. It is based on the force of encounters, on analysis and self-analysis of experiences, that it becomes possible to produce the displacements needed to control affectus.

The idea of permanent education presents itself as an important tool, as we are talking of learning through the affective body, through "intuitive science". This is learning that contains (Morin's 2001) idea of "unlearning", as it provokes displacement, rupture, dispossession of the actual cognitive structures and flows, with others in which intuition is also a tool for understanding the world, and experience is the source of knowledge. Following this path, the health care worker may be capable of realizing what he is made of, be enlightened as to the affects that take his body and, thus, control the affectus that are the mark of subjectivity. There is here the possibility of doing Creative Work, in other words, work as an act of creating health care.

The "act of creation" in the work process is viable as long as it is free of constraints and prohibitions caused by the force of affects. In the example we gave, these are produced by capitalist, moral and scientific logics. Although rules and norms attempt to regulate professional activity and establish lines of force to imprison his work, he may find new possibilities through "escape routes", in other words, giving new meaning to his own work. Re-signifying reality, this is the issue that place the forces capturing work processes in danger, as it gives new meaning to things, is linked to action, to acting at liberty, establishing new parameters of producing health care work, based on convictions and will originating from within the worker himself, based on the encounter and its production in the act.

Lines of macro-policy and the space of micro-policy

Micro-policy is understood here as the day-to-day actions of each, based on their work spaces. This activity is not in opposition of macro-policy, they are together and in relation. Macro-policy is understood here as the institutions, rules, norms and logics that regulate life. When we state in this text that the processes of subjectivation are produced based on capitalist, moral and scientific logic, we are saying that their norms and rules are expressions of macro-policy, in other words, that which regulates life, work and the activities of production. The lines of macro-policy cross through groups on a molecular level, that is, day-to-day activity which is intense, nomadic, always in movement. In this scenario, the level of micro-policy, is where new possibilities can come into play. We conclude that the day-to-day relationship between macro- and micro-policy constitutes a permanent tension within organizations.

How does a health care worker exercise his work process in relation to macro-policy? This constitutes a strength which is not a fixed unchangeable force, but rather a possibility that is always there in producing the world of which the worker forms a part. The strength is always in the encounter and thus counts on positive affectus, producing "happiness", according to Spinoza. There are always the agents of desire. As happens with flows, there are variations in the work process, in other words, in the idea of strength, nothing is fixed and unchanging, reality is understood as a constantly changing becoming. This means that the worker may modify his work process, the way of receiving and taking responsibility for patients, for example, as this is subject to variations in affects based on the multiple encounters in their daily work and also on the affectus in the medium. We therefore want to state that the act of caring is always singular, it is unique in a given space and time, it is an encounter that will never be repeated. Thus, the singularity of each encounter for care in which the worker and user are unique. The same worker who is welcoming at a given moment may not be welcoming at another, and this variation depends on the affects by which he is taken, and of the affectus that are the agents of his action.

The variations in the potency of the worker's actions, on the other hand, signify that he himself is realizing micro-movements of dispossessing and repossessing, as an expression of alternating between servitude and liberty, that is, between greater and lesser control of the affectus of capture by the lines normalizing life and work.

In the environment of micro-policy, there are always possibilities for change, for re-signifying. It is here that the third kind of knowledge and the capacity to understand the instrumental and affective issues implied in producing health care is perceived. Analyzing movements on the micro-political level, it is possible to observe Creative Work as an action appearing in minimal acts, within the work process, in silent gestures that change to course of the treatment projects, re-signifying care, operating to protect and defend life.

Education is an important tool in Creative Work if it is seen as permanent, as it operates exposing the worker to his own work process, forming an experience of the his own work. It therefore opens up the possibilities of understanding the affects in the body, in the lines of capture and producing liberty.

We think, then, of education as inseparable from work processes as the activity itself contains learning as something intrinsic. Thus, cognitive and affective processes go hand in hand based on exposing the individual to their own work, providing learning through reason and through the body and the same time and in one single process. Thus, we recognize all forms of producing knowledge that consider that learning is simultaneously through cognitive and affective processes in which cognition and subjectivation involved constructing a human becoming, the individual in permanent change.

Final considerations

Referring to the philosopher Baruch Spinoza (1632-1677), the practices of an individual in the world are a combination of "action" and "passion", with "action" concerning the "forces from within", that is, those originating from the individual himself; and "passion" existing when the individual acts according to "forces from without", because the body suffers the effects of affects, of the capitalist, moral and scientific lines normalizing life, placing constraints on the work process.

This text discusses the process of subjectivation, uncovering the concepts of liberty and servitude present in (Spinoza's 2008) work, which help us to understand how subjectivities are formed and, consequently, how they interfere in the processes of work and producing care.

Here, the concept of liberty if a state in which the individual breaks away from all capitalistic, moral and scientific signs regulating life and its production. Such signs, in the work process, represent servitude. By breaking away from them, dispossessing them, the worker begins to operate based on that which originates within himself, opening himself to the agency of the encounter in act, enabling Creative Work.

The process of subjectivation, understood as the individual's continuous and unlimited production in their relationship with the world, as we can verify, undergoes changes throughout the time and space in which the individual lives and works, and these micro-modifications of subjectivity in day-to-day life operate under different signs, between servitude and liberty.

We can conclude with different possibilities within the variations in the subjectivation processes: a worker who organizes himself and works in servitude, totally captured by the lines regulating his life and work process - capitalist, moral and scientific -, is no longer the protagonist of his world, he permanently acts under the effects of affects, making use of external forces, without controlling the affectus that take his subjectivity. He acts according to the first kind of knowledge, prisoner to the norms of behavior, subject to moral values, to a rigid interpretation of the protocols, to the lines of force of the markets. He guides his work process according to these issues and his production is over-implicated by the thematic fields and by subjectivation.

In a second, equally unlikely, scenario the worker operates his work process in total freedom. Contracting work in current society, and in health care networks in particular, subjects the worker to countless lines of regulation in his work, capturing desire and prohibiting creation in producing life and in health care practices. To effect the concept of liberty, as an expression of the forces originating in the individual himself, appears to require entering into a struggle against the forces that seek to regulate it. It is in this tension that we find a third possible scenario.

Between servitude and liberty, there are countless possibilities and different degrees of realizing work processes. The process of subjectivation places forming subjectivity as a continuous and variable act throughout the same day, with the health care worker able to act in a varied way in encounters with the users, permitting diverse degrees of liberty.

Creative Work is the result of the greater liberty present in the work process, it is a level of realization in which the lines of servitude do not have the power to prohibit. The worker produces this power when operating according to the second and third kinds of knowledge, those capable of producing understanding through "intuitive science", in other words, in which wisdom appears as a precept, assimilated by both the mind and the body, reason and affect, filling with world with meaning. We found, then, that the work process always acts by variations between servitude and liberty, with greater and lesser degrees of capture, which leads us to believe that Creative Work is a reality in day-to-day life, in the micro-policy. Moreover, its existence is capable of significantly altering the way of producing care, producing diversions capable of modifying the treatment processes and giving new courses to care and defending life.

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Received: July 14, 2014; Accepted: January 22, 2015

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