Educating for anti-asylum stance on the street: screens, knowledge, cultures, and care

Abstracts

The process of psychiatric reform underway in Brazil has as one of its objectives to promote social transformations regarding the conception of madness. This narrative is report of the experience of a meeting of students, professionals from the healthcare network and from the university, made possible by the Education Program for Work in Health (PET-Saúde), in a Psychosocial Care Center for the care of people with troubling drug use, of the Brazilian National Health System (SUS). The proposal to think of the street, the culture, as a place of education also enables the enrollment of students in another social dimension, which causes displacements in traditional education. Culture is a powerful resource for inclusion. However, in order for cultural actions to be educational instruments in Mental Health and social inclusion strategies, the activities need to take place in the city’s spaces.

Keywords
Mental health; Culture; Deinstitutionalization; Care; Health education

O processo de Reforma Psiquiátrica brasileira tem como um de seus objetivos promover transformações sociais acerca da concepção da loucura. Essa narrativa consiste em um relato da experiência de encontro de alunos, profissionais da Rede de Atenção à Saúde e da universidade, viabilizado pelo Programa de Educação para o Trabalho em Saúde (PET-Saúde), em um Centro de Atenção Psicossocial para o cuidado de pessoas que fazem uso problemático de drogas, do Sistema Único de Saúde (SUS). A proposta em pensar a rua, a cultura, como lugar da formação, possibilita a inscrição dos alunos em outra dimensão social, a qual provoca deslocamentos na formação tradicional. No entanto, para ser possível que as ações culturais se constituam em instrumentos formativos na Saúde Mental, as atividades precisam acontecer nos espaços da cidade.

Palavras-chave
Saúde mental; Cultura; Desinstitucionalização; Cuidado; Formação em saúde

El proceso de reforma psiquiátrica brasileña tiene como uno de sus objetivos la promoción de transformaciones sociales sobre la concepción de la locura. Esta narrativa consiste en un relato de la experiencia de encuentro de alumnos, profesionales de la red de atención de la salud y de la universidad, realizado por el Programa de Educación para el Trabajo en Salud (PET-Salud), en un Centro de Atención Psicosocial para el cuidado de personas que hacen un uso problemático de drogas, del Sistema Brasileño de Salud (SUS). La propuesta de pensar la calle, la cultura, como lugar de la formación posibilita la inscripción de los alumnos en otra dimensión social, que causa desplazamientos en la formación tradicional. Sin embargo, para que sea posible que las acciones culturales se constituyan como instrumentos formativos en la Salud Mental, las actividades tienen que suceder en los espacios de la ciudad.

Palabras clave
Salud mental; Cultura; Desinstitucionalización; Cuidado; Formación en salud

Approaching the mental health field with education and culture

Beginning in the moment that health is conceived as a citizenship right, equity becomes a fundamental issue in terms of health policies, programs and actions. The discussion about health requires the understanding that it makes up a field composed of the exercise of citizenship, access to goods and services, education, housing, work, and culture, among others. Thus, culture integrates health in its expanded perspective, since it encompasses different spheres of life. The centrality of culture in human relations invokes the recognition of cultural rights as a possibility for the construction and exercise of citizenship.

The Psychiatric Reform (PR) processes and the anti-asylum movement work in favor of the defense of life, for the right to health, to citizenship and to the city for people in mental distress. The perspective of an anti-asylum care in freedom, therefore, implies in the understanding of arts and culture as devices for the reversal of the social representation of insanity, of the insane, and the affirmation of an ethics of care through coexistence based on difference.

We borrow the concept that considers PR as a complex social process¹ that encompasses different axes, not being restricted to structural reforms of mental health care services. PR intends to change the social imaginary about madness, in order to weave a solidarity network that is able to break through the resistance related to the insertion of madness in the city. In this way, PR aims to weave new possibilities of life, expression, and social inclusion for people in mental distress², in confronting segregation, violence, discrimination, and exclusion.

Notwithstanding the implementation of the PR process underway in the country, it is still necessary to go further in the deconstruction of the forms of social exclusion of differences and, consequently, of insanity. To this end, it is necessary to expand the debates about the citizenship of people in mental distress and the inclusion of the different and of differences in the daily life of cities. On the other hand, in what concerns professional education, there are two provocations that fit here: is it possible to teach to provide care?³. How to teach for a care in anti-asylum freedom?

A concrete possibility occurs when the understanding of PR overflows the limits of the services, of assistance, and advances in the interventions in the territory, in the culture, in the spaces where life happens - when anti-asylum care meets the street, and its different ways of knowing, doing, and educating.

The forms of teaching-learning practiced in the streets of the city, by “[...] ordinary subjects practicing the everyday risks [...] is as diverse and broad as the social experiences produced over time”⁴ (p. 74). They are other modes marked by subaltern identities that reveal other grammars and other forms of mastery of knowledges, that take responsibility for life in response to everyday dread, by always being embarked in struggles against cognitive and social injustices.

The pedagogies of the streets do not mark absolute opposition to the modes/aesthetics produced in university spaces, considered more “scientific” in the Western perspective. And it is in this sense that we agree with the proposal of a Pedagogy of the Crossroads⁴, whose political mark is precisely the affirmation of the power of the ‘I cross’, of the movement, of the possible transgression in the encounter of multiple forms, which deny a single creditable possibility of being, knowing, and teaching.

From the point of view of encounter, “ [...] conviviality is the social expression of spatially located encounter. And, as a result of this encounter, conviviality connotes the spatial practice of cohabitation”⁵ (p. 186).

In this sense, the encounter assumes different forms. Among them, “convivial encounters” stand out, marked by the possibility of shared construction of ethically referenced collective identities. It is these sensitive and creative encounters that should be potentiated in convivial spaces, properly encouraged. Following this line of thought should guide us to reflect on spatial practices in the city that are inscribed in the challenges of a different kind of coexistence, mobilized by the ethical values of care and responsibility, which inscribe a convivial metropolis⁶.

Historically, this perspective has been common to the so-called new urban activisms⁶ which are characterized by associations and groups of people, mostly self-organized, that configure self-managing spaces for the reformulation of the ways of being, living, and existing in the cities in a collective and non-mercantile way. Guided by the ‘Southern Cross’ of the commons principle⁷, they have as their outlook the maximization of the city as a use value. The diversity of social movements and collectivities guided by this vision emphasize the potentiality of permanence and cohabitation in the city - an enabler of encounter, of the unforeseen, of exchange. More than the claim for access to the built spaces, they seek creative ways to exercise the right of creative and progressive construction of a more democratic public space, where the definition of what is legitimate and illegitimate is not given a priori, but is built contingently, and from the deliberation and collective participation⁸. Therefore, they are not limited by those who call themselves activists, but involve all those engaged in articulating new ways of relating in and with the city. Among the social movements and collectivities that invent creative practices, negating the city as productivity/production (the principle of urban development), the self-managing practices of artistic and cultural occupations of squares and public spaces, and their policies of “urban engagement”⁹ stand out.

By taking here the power of art and culture to promote social transformations about madness and the vulnerable¹⁰, it is necessary to dispense with the idea of art as therapeutic¹¹, circumscribed to the space of Psychosocial Care services¹².

Culture is therefore a driver, a device for social inclusion that enables people to experience life in other ways. The subjects of diversity¹³ have the right to the city and to social participation, which have been historically subtracted by institutionalization, by the impediment of the exercise of citizenship and of transit in the city.

By enabling social inclusion in urban interventions, culture would be a tool for other perceptions about people in psychic suffering, about insanity, and about other vulnerable people. In view of this, to achieve one of the main goals of PR, that of demystifying society’s perception of madness, it is necessary to work on the sociocultural dimension¹⁴ of PR, that glimpses another place for madness and for the subject in psychic suffering in society and in the city.

The deinstitutionalization paradigm¹ points out to setting up networks that establish articulations and ties with other public policy sectors¹⁵. Therefore, it cannot remain restricted to the health system. Since Psychosocial Care advocates intersectorial networking for mental health care and foresees the articulation of different social and political segments, services, actors, and perspectives.

Making alternative transit modes in the cities possible for people in psychological distress implies diversifying and expanding networks¹⁶ for the social space. And, for that, it is necessary that the workers be more and more in the city, in the streets, in the territories. To work in a network is to weave possibilities of being in the lived spaces of the subjects. However, it is necessary to build networks of power¹⁷, of life creation, that seek autonomy and the production of subjectivation.

In this way, culture presents itself as a possibility to build other ways of being with people in psychic suffering in the streets, in the community, in city life. Furthermore, this change implies coexistence with madness, with difference, and this causes interference in the harmful effects of segregation and exclusion, practices related to the traditional model of care.

The Fourth National Mental Health Conference¹⁸ remarked the need for intersectoral work, and gave legitimacy to a work that was already underway, supported by actors, services, training institutions, whose focus was to develop cultural activities in the spaces of the cities, no longer within the limits of mental health services; and thus, bring together different people whose point of intersection is art. In the field of culture, three programs stood out, Cultura Viva (living culture) and Pontos de Cultura (Culture points), from the Ministry of Culture, and the project Loucos pela Diversidade(crazy for diversity), developed by Fiocruz in partnership with the Ministry of Culture¹⁹.

We will take as an analyzer the experience of the activities of Cine na Praça and Praça Cultural (Movies in the Square and Cultural Square), which make up the Project Culture in the Open (PCaCA), created in 2019. Imbued with the proposal of an alternate health care, which took the streets, the city as a space of production of life, this project has in culture a generating point of connections between people living on the streets (PSR) and other vulnerable people, services and university. In this sense, one of the objectives of PCaCA consists in the exercise of the right to the city and, for such, cinema, leisure, music, artistic expressions, and culture.

These projects helped us reflect on the role of culture and care on the street, but, mainly, had as a main goal to discuss the importance of these experiences in the formative process of future professionals who, through the Education through Work in Health Program (Pet-Saúde/ UFF/ Niterói), from the street, in the experiences of “Cine na Praça” and “Praça Cultural”.

Cultural actions as a strategy in the production of new subjects

In order to reflect on the relationship between mental health, educational processes and the anti-asylum logic, we start from the assumption of culture as a privileged instrument to facilitate the social inclusion of people in mental distress in the community and their lived territories, enabling other forms of living with and from the differences, while enhancing the expansion of solidarity networks. It is important to reaffirm the need for intervention in society, since it is here that the mechanisms of stigmatization and exclusion of differences originate²⁰.

The development of policies inscribed in the production of new subjects, committed to a life with more autonomy, also happens through culture; and, as we understand culture as a health device, we can operate with other logics and ways of making health. The language of art is considered a binding element in social relations. It is in the movement of producing new ways of doing health through culture, of producing life, that we find the exercise of creating possibilities of transit for people in psychological distress and other vulnerable people, besides fostering other formative processes.

Under this perspective, cultural activities are strategies for creating forms of social and family inclusion¹¹. However, the spaces for leisure, coexistence, work, and collective mobilization need to go beyond the strict domains of mental health services and equipment.

The dimension of culture in psychosocial care seeks to provide opportunities for deviations and the production of life in the coexistence of difference, and thus break with behaviors, habits and manicomial attitudes²¹, including the perspective of health education. Therefore, culture must circulate the affective force that operationalizes care, considering that the subjects that interact, break with the traditional modeling of the clinic²².

By positing culture as the central axis for the adoption of other modes of social insertion of people in psychological distress and other vulnerable people, we approach a clinic that creates possibilities and sociabilities²³. A clinic in movement, which allows the setting to be deterritorialized²⁰, to inhabit the limits and the tension of everyday life on the streets, in the city. And thus provoke the destabilization of the subjects involved, helping in the reduction of the stigma related to madness.

Through cultural actions, different resources of the territory are mobilized - which allows the expansion of the circulation spaces of people in psychic suffering and other vulnerable people - besides qualifying the formation in health, increasing possibilities of living sensitively and creatively in the city, in a way different from the manicomiality. However, it is necessary to ensure that these subjects (including workers, students and supporters) occupy another place in actions guided by respect for difference²⁴, in the care and responsibility. This is the only way that other circuits can be traced to operate in the perspective of deinstitutionalization, thus configuring the cultural actions in Mental Health as devices of social transformation. Through culture, the social transformation may be able to deconstruct the modus operandi, the way of being and acting produced in dealing with the difference through negation.

Sitting on the sidewalk…

The article is based on the narrative experience of one of the authors, during the activities of the Education through Health Work Program, developed in a Psychosocial Care Center for the care of users in problematic and abusive use of alcohol and other drugs (CAPS AD).

PET-Health, a strategy of the Ministry of Health to foster changes in training, was implemented from proposals to reformulate the Professional Training Policy, associated with the reorientation of the care model focused on health promotion and disease prevention actions, as opposed to biologicist care. PET-Health has incorporated the structuring axes of the national guidelines for health training, with tutorial learning groups in strategic areas for the Brazilian National Health System (SUS), characterized as a device for in-service qualification of undergraduates, teachers, tutors and other professionals in the health care network. Moreover, it has as a guiding thread, the integration of teaching-service-community; being this, also, an educational space to support other training policies in health.

The educational logic of PET-Health produces agency developments related with the streets, with people, and with the world of work. The traditional space of the university seems insufficient for the production of care for life in the city. On the other hand, the PET-Health experience promotes ruptures in the formation cloister and incites another formative logic. In addition, remarkable characteristics such as interprofessionalism, collective and collaborative work favor the production of care in the territory.

The PCaCA experience, which involves the “Movie Square” and the “Cultural Square”, takes place in one of the public squares of the city of Niterói, state of Rio de Janeiro, since 2019, and is developed by CAPS professionals responsible for psychosocial actions in the territory, and constitutes one of the activities of the PET-Saúde/ UFF/ Niterói project.

The reported experience seeks to express the dimension of what is lived as an event²⁵ that produces unique ways of being in the world, in public spaces, and goes beyond the perspective of a mere “testing of learning in practice” - which has no existential meaning as a formative process -, since learning in the experience with the other becomes transformative when (re) lived in a shared, contingent way, making it one’s own and embodied²⁶.

In this sense, we chose to collect this learning experience and narrate it in a field diary²⁷, from the perspective of Institutional Analysis, which allows us to incorporate the analysis of experience. The diary, under this rationale, is recognized as a research tool in the field of health and education²⁸.

The reflections of the experience recorded in the journal are brought here, in the form of results, allowing the discussion about the experience that associates art, culture, health, and education.

The PCaCA emerged from the perception of the CAPS AD Alameda team on the need for the service to approach the homeless people and occupy the streets, squares and collective spaces of the city as a new proposal of health care. There was in the team the discomfort by the limitation of occasional meetings with the PSR, which led to the rupture of the bond established with some people.

It was, therefore, urgent to explore the right to the city by establishing a dialogue with cultural occupations that included the commonly marginalized bodies of the PSR and other invisibilized populations.

The proposal intended to create a project that would encompass both leisure, through presentations and exhibitions in the artistic field, and the offer of services necessary to maintain the citizenship of the subjects. The PCaCA activities - “Cine Praça” and “Praça Cultural” - were initially scheduled to happen twice a month, with a proposal to expand them. Although the cultural axis was central, the project sought to grasp the demands of a care that contemplated singularities and people’s experiences, valuing the creation of bonds in the promotion of autonomy and in the exchange of knowledge.

This project was formulated by a group composed of an anthropologist, a nurse, a harm-reduction agent, a physician, and a medical intern from the PET-Health Interprofessional Program. The PCaCA aimed to go beyond the walls of the services, in a continuous exercise of citizenship with the intention of occupying the streets and territories of the city.

In the case of “Movie Square”, which proposes the exhibition of national films, with the objective of promoting greater identification with people’s daily lives, every first Thursday of the month at São João Square, located in downtown Niterói, the non-governmental organization (NGO) BemTv provided tripods, projector, screen, computer, speaker, microphone, and other technological apparatus to show the films. Partnerships were also established with the Municipal Park Library of Niterói, which provided the external space of its institution for the presentations, with the Secretariat of Culture, which, through a public notice, offered a fee for the artists who performed, as well as a soundboard for the events. The SESC Community Center of Niterói, through a public notice, offered approximately 100 snack kits to each “Movie Square”. The Reference Center for Social Assistance (CRAS) of Niterói, volunteered to be in some editions of cinema with the completion of the Unified Registry (CadÚnico) of those present, in addition to providing information about people’s citizenship rights. The “S.O.S. Mulher” ambulatory of the Hospital Universitário Antônio Pedro of the Universidade Federal Fluminense was present with a tent in order to make the population aware of the problem of violence against women, to welcome possible victims, as well as to forward the demands and complaints received. The LGBTQIA+ Citizenship Center of Niterói was present in one of the events with the action “Travando a Praça”, in which there were music activities, Drag Queens shows, fashion show and conversation about citizenship, especially of transvestites and transsexuals. The NGO Pela Vida and the Street Clinic were also present providing Sexually Transmitted Infections testing. The Children and Youth Reference Team for actions of attention to the use of Alcohol and other Drugs and the Bispo do Rosário Shelter also participated in the actions and provided materials for decorating the space and snacks.

The “Ocupa Praça” had the partnership of the Collective Health Institute of the Universidade Federal Fluminense, which developed, with the participation of students and health professionals, activities for children. Popular activities were prioritized, such as a samba round dances, jongo, clowning, storytelling, funk dance workshop, and a street orchestra, among others.

The leisure activities were mixed with moments of conversation about daily life topics, in addition to the partnerships that helped in the realization of the project.

The strategy of calling the population to the events was based on printed posters and smaller invitations, which were distributed through the extended network of care to the PSR - shelters, street clinics, polyclinics, and Family Health units -, as well as meetings at the places where the activities would take place. On the two Thursdays that there were no PCaCA activities, the CAPS AD team continued with its work of listening and receiving demands on the street, promoting the event. With the development of the project, the activities increasingly relied on the support of the PSR themselves, which became the main promoters and protagonists of the actions. A homeless girl joined the project team, whose participation was central to making it happen, and was awarded a work scholarship by CAPS AD.

The trust established between the PSRs and the organizing collective of PCaCA became so important in the work in the city spaces that, from this relationship, it was possible the access to housing occupations of these people, previously forbidden. We realized that with the project and the occurrence of cultural actions, the street team of CAPS AD was being considered by the PSR as their partners, establishing more horizontal and complicit relationships.

During the editions of PCaCA that took place in 2019, the average number of people during Cine Praça was around 50 per session. And the “Cultural Squares” had the participation of 25 people per event.

The importance of occupying public spaces was very much observed by the team, and the performance of the proposed activities was a way to reorganize the look of the institution itself and of the workers regarding those to whom it aims and wants to offer care.

The participation of other public services and equipment, guided by intersectoriality and integrality, made it possible to go beyond the barriers between different instances and secretariats, which maintain distances between people who need care and the institutions that should care. The PCaCA is a way to boost the promotion of and access to social rights, as it aims to make both society and institutions aware of the marginalization processes. Despite the web of supporters and articulations, from the point of view of cultural occupations, possibilities such as the PCaCA are not difficult to execute, even though they are little considered in the institutional context as central strategies to achieve the sociocultural dimension of the psychiatric reform.

Taking culture as a means of transforming subjectivities, of expanded production of health - and why not say of life -, as a possibility for the rescue of people’s rights and potentialization of lives, enables inflexions in the ways of caring for subjects in psychic suffering and other vulnerable people, as well as incites us to think about health education in a different way from the one adopted until then.

The viability of the PCaCA was made possible through interprofessional, collaborative, and collective work with institutions, partners, and the PSR’s.

The narrated experience allowed the emergence of an understanding of health, which attempts to “teach” in the academic space, and that -we dare to say- is only possible in the daily life on the streets, in the encounter and coexistence with the other, in the city - and with the adversities of the plan of acting practice. One of the many reverberations of the experience lived in PET-Health by the people in training was the opening of the question: how would it be possible to “teach” co-responsibility, bonds of affection and friendship, notions of welcoming, and other “softer” attributes of care in a traditional classroom space? By building pedagogical devices in which being together, in contact with the user, was always mediated by the construction of a two-way street between learning and teaching. The learning obtained in the experience lived by the PET-Health students was only possible by the encounter, in the beat of the streets and in the accelerated pulse of the city, which crosses the daily routine of the services.

Education as it is practiced today, confined to university benches, self-centered, centered on technical-scientific knowledge, has much to learn from the ways of knowing and teaching that operate at the crossroads. And PET-Health, as an educational policy, is a privileged place for this encounter.

Through the insertion in PET-Health it was possible to become aware of the urgency of producing new ways of doing Psychosocial Care - which also seems impossible to me for a traditional training based on aseptic knowledge, alien and distant from people, disincarnated. This kind of training is insufficient to guide in relation to the various constraints and tensions that imply the situations in front of the suffering of the other, once historically and structurally formulated in and for the perspective of the biological efficiency of existence. If this process is detached from reality, and without the activation of other formative resources that allow other learning possibilities, the mental health education becomes incapable of sensitizing future workers in relation to the affections, which are propellants of the production of other knowledge and modes of mental health care.

Closing remarks

Culture is a powerful strategy for the production of differentiated modes of social inclusion for people in distress and other vulnerable people.

The creation of ethically oriented living spaces from the perspective of difference, care, and co-responsibility is essential to promote social inclusion. This requires a broad articulation, aiming at the promotion of community life and the autonomy of the subjects.

Using as stepping stones the cultural actions, which allowed subjective repositioning of the subjects, the training considered traditional, centered on academic-professional knowledge, can be crossed with the knowledge of the street people and thus, another way of perceiving the training can be experienced. In the conviviality, in the dimension of the encounter, the construction of bonds and situations of complicity can be given, not only in relation to the care of people, but also as a rich and embodied experience of another view of the teaching-learning process in mental health.

The activities developed in the street, in the weft of people’s territories, where life happens, operate in the sociocultural dimension of the psychiatric reform and coadunate for the construction of another social place of insanity - that we have insisted so much throughout the text. However, the whole process of dismantling health and education policies in recent years has implied difficulties for experiences such as the one reported here. Difficulties from the political point of view, but also from the de-funding that has been going on for several years, and that has worsened in recent times, postponing the continuity of the existence of the RAPS services, and the in-service educational programs in SUS, from the perspective of deinstitutionalization and the Psychiatric Reform.

The present experience, provoked interference in the circuits of exclusion of differences in the city, reinforcing the need for funding, for the continuity of the service. We can believe that these actions change the way society deals with insanity, with the insane and with the difference, making possible other transits to people in mental suffering and other vulnerable people, and the right to the city.

On the other hand, considering the possibility of the experience in the formative process of future mental health workers, and the centrality of PET-Health for the viability of this process, the current landscapes of dismantlement of the public funding of universities and the current direction of the Public Policy of Mental Health are to be feared. As a follow-up with the initial proposed provocations, and put in another terms, it is inescapable to the anti-asylum perspective the pedagogies of the crossroads with their beings, knowledges, doings and ways of educating. Once the premise of an anti-manicomial care in freedom is the horizon of Psychosocial Care, how could one “learn to care” without the street? Culture puts a double defy for Mental Health: of other forms of care, and for another type of education.

• Honorato GLT, Souza ÂC, Santos AI, Campos GA, Abrahão AL. Educating for anti-asylum stance on the street: screens, knowledge, cultures, and care. Interface (Botucatu). 2022; 26: e220349 https://doi.org/10.1590/interface.220349

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Edited by

Editor

Simone Paulon

Associated editor

Moises Romanini

Publication Dates

• Publication in this collection
  10 Oct 2022
• Date of issue
  2022

History

• Received
  08 Nov 2021
• Accepted
  30 May 2022