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Narrative interview with homeless persons with mental illness: experience report

Abstract

Objective

report the experience of using the narrative interview with homeless persons who suffer from mental disorders.

Method

experience report held in a capital city in the South of Brazil. The data collection took place from July to October 2019.

Results

the application of the narrative interview was developed in two stages: approach to the field and selection of participants; and construction of the narrative. The first involved an insertion in a Street Office and made it possible to identify and develop a link with the users. The second occurred with the development of the narrative interview and involved the following steps: contact and negotiation, main story and questioning phase.

Conclusion

the narrative interview presents itself as a methodological tool with potential for the construction of therapeutic itineraries for homeless persons with mental disorders, contextualizing their options in the search for their care from the perspective of their life stories.

Implication for practice

narrative interviewing makes it possible to make oneself heard in often neglected stories. By having as a central focus the construction of senses by those who experience a certain reality, it allowed the reconstruction of these, allowing new looks and insights in relation to the very experience of those who reported.

Keywords:
Mental Health; Narration; Homeless Persons; Qualitative Research

Resumo

Objetivo

relatar a experiência do uso da entrevista narrativa com pessoas em situação de rua com transtornos mentais.

Método

relato de experiência realizada em uma capital do Sul do Brasil. A coleta de dados ocorreu de julho a outubro de 2019.

Resultados

a aplicação da entrevista narrativa desenvolveu-se em duas etapas: aproximação com o campo e seleção dos participantes; e construção da narrativa. A primeira envolveu uma inserção em um Consultório na Rua e possibilitou a identificação e o desenvolvimento de vínculo com os usuários. A segunda ocorreu com o desenvolvimento da entrevista narrativa e envolveu os seguintes passos: contato e negociação, história principal e fase de questionamentos.

Conclusão

a entrevista narrativa se apresenta como ferramenta metodológica com potencial para a construção de itinerários terapêuticos de pessoas em situação de rua com transtornos mentais, contextualizando suas opções na busca pelo seu cuidado na perspectiva de suas histórias de vida.

Implicação para a prática

a entrevista narrativa possibilita fazer-se ouvir em histórias frequentemente negligenciadas. Por ter como foco central a construção de sentidos por parte de quem vivencia determinada realidade, permitiu a reconstrução desses, possibilitando novos olhares e insights em relação à própria experiência de quem relatava.

Palavras-chaves:
Saúde Mental; Narração; Pessoas em Situação de Rua; Pesquisa Qualitativa

Resumen

Objetivo

relatar la experiencia de utilizar entrevistas narrativas con personas en situación callejera con trastornos mentales.

Método

informe de experiencia realizado en una capital del Sur de Brasil. La recolección de datos tuvo lugar de julio a octubre de 2019.

Resultados

La aplicación de la entrevista narrativa se desarrolló en dos etapas: aproximación al campo y selección de participantes; y construcción de la narrativa. La primera implicó una inserción en un Consultório na Rua y permitió identificar y desarrollar vínculos con los usuarios. La segunda ocurrió con el desarrollo de la entrevista narrativa y contó con los siguientes pasos: contacto y negociación, historia principal y fase de cuestionamientos.

Conclusión

la entrevista narrativa se presenta como una poderosa herramienta metodológica para la construcción de itinerarios terapéuticos para personas en situación callejera con trastornos mentales, contextualizando sus opciones en la búsqueda de su cuidado desde la perspectiva de sus historias de vida.

Implicación para la práctica

la entrevista narrativa permite hacerse oír en historias que a menudo se pasan por alto. Debido a que tiene como foco central la construcción de significados por parte de quienes experimentan una determinada realidad, permitió la reconstrucción de estos, posibilitando nuevas miradas y percepciones en relación a la propia experiencia de quien informa.

Palabras clave:
Salud Mental; Narración; Personas sin Hogar; Investigación Cualitativa

INTRODUCTION

The street population is increasingly part of the big cities scenario, and the social imaginary conceives it as a homogeneous group of individuals immersed in poverty, who use public spaces to sleep, eat, make their physiological needs and use drugs, reducing the perception about what this individual does and how he or she uses the space on the street, about the lack of resources, of their own or regular home and hygiene.11 Pimenta MM. Pessoas em situação de rua em Porto Alegre: processos de estigmatização e invisibilidade social. Civitas. 2019;19(1):82-104. http://dx.doi.org/10.15448/1984-7289.2019.1.30905.
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These individuals are understood as part of a contingent that, historically, has become part of the scenario of cities, and because they are not recognized as citizens, but as “non subjects,” they are discriminated against and the target of prejudice and stigma. This population, victim of countless forms of violence, is invisible and placed in a permanent condition of vulnerability22 Nonato DM, Raiol RWG. Pessoas em situação de rua e violência: entrelaçados em nome da suposta garantia de segurança pública. Rev Direito Debate. 2018;27(49):90-116. http://dx.doi.org/10.21527/2176-6622.2018.49.90-116.
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, which results in negligence and withdrawal also as a consequence of the absence of public policies aimed at these people.

Because it is a heterogeneous group, there is one part of it whose invisibility is accentuated: people on the street with mental disorders, who have been naturally excluded from the street group itself.

The issues related to mental health care for the street population, in health services, public policies and literature, often have the emphasis on drug use, so that mental disorders - schizophrenia, bipolar affective disorder, depression - are on the sidelines and imply the challenge of generating psychosocial care for this specific group.

The Brazilian Psychiatric Reform (BPR), by proposing to transform the asilar mode of attention in mental health into a psychosocial network care, broadens the discussion about the space of madness. However, it is noticeable that the city still has its back to the different, to everything that breaks its illusion of homogeneity, thus segregating the crazy - even more when they are the “crazy in a street situation”.

In this direction, there are still epistemological and practical gaps in relation to the specifics of mental health care provided to the street population with mental disorders, which requires particular care that offers flexibility and is person-centered.33 Chrystal JG, Glover DL, Young AS, Whelan F, Austin EL, Johnson NK et al. Experience of primary care among homeless individuals with mental health conditions. PLoS One. 2015;10(2):e0117395. http://dx.doi.org/10.1371/journal.pone.0117395. PMid:25659142.
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Thus, it is understood that the advances in the paradigmatic change in mental health care, from the BPR, present obstacles related to the care of specific groups, among which people on the streets with mental disorders, who remain unassisted by health services in general and by the Psychosocial Care Network. Therefore, it is important to carry out researches, from the psychosocial perspective, that allow us to think about the forms that mental health care has been assuming and about how the mental health network responds to care directed to specific groups. In addition, it is urgent to understand how the relationships of care with these groups are built, which requires giving voice to neglected, oppressed or unknown subjectivities.44 Ayres JRCM. Cuidado: trabalho, interação e saber nas práticas de saúde. Rev baiana enferm. 2017;31(1):1-4. http://dx.doi.org/10.18471/rbe.v31i1.21847.
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Because of this, from the perspective of the Therapeutic Itineraries (TIs), we have a research strategy that makes it possible to apprehend the movements, dynamics and relationships that people build in their daily lives in the search for their care. TIs present themselves as a set of practical interactions that social groups weave to open fields of possibilities for health care. From this perspective, this research not only considers that the actors present different courses of action, vacillations, doubts, entrances and exits in several therapeutic modalities, but mainly understands that care is not restricted to the search for treatment. Rather, it is primarily aimed at developing arrangements and strategies and establishing social networks formed in the process of dealing with the “disease”.55 Alves PC. Itinerário terapêutico, cuidados à saúde e a experiência de adoecimento. In: Gerhardt TE, Pinheiro R, Ruiz ENF, Silva Junior AG, organizadores. Itinerários terapêuticos: integralidade no cuidado, avaliação e formação em saúde. Rio de Janeiro (RJ): CEPESC/IMS-UERJ/ABRASCO; 2016. p. 125-46.

Thus, the choices made, according to individual needs (and possibilities), are supported by the social networks of which people are part, and which can be analyzed from the TI perspective, showing how these networks are established and built, their meanings and meanings.

The TI approach allows research design to consist of different but complementary methodological techniques, which make it possible to understand the logic of the participants in their trajectory in the search for care. The option for the narrative interview is justified because it sought to capture perceptions related to mental disorder associated with life on the streets and, above all, the experience of seeking care in the context of relationships and connections established throughout life's trajectory, enabling the reconstruction of the TIs.

In addition, TI studies, based on the understanding of the narrative, have provided people with new perspectives in their way of living and organizing themselves in society. They also shed light on the practices and strategies used to face daily problems, especially in relation to the demand for health care in contexts of social inequalities.66 Gerhardt TE, Riquinho DL. Sobre itinerários terapêuticos em contextos de iniquidade social: desafios e perspectivas contemporâneas. In: Jorge MSB, Pinheiro R, Mota CS, Rocha AARM, organizadores. Contextos, parcerias e itinerários na produção do cuidado integral: diversidade e interseções. Rio de Janeiro (RJ): CEPESC/ABRASCO; 2015. p. 364.

It can be added that, when considering that people build their stories in the midst of the heterogeneity of their subjective, socio-cultural contexts and accessibility to attention to illness, the construction of narratives of people who live surrounded by the plurality of these elements must consider the uniqueness of each one, both in relation to the objective and subjective aspects. Based on this, the use of narratives can be applied to the construction of TIs, however, this does not mean drawing a schematic and predetermined plan, but rather, composed of elements that emerge from personal experiences.77 Pereira LP, Wetzel C, Pavani FM, Moraes BM, Olschowsky A, Kirch I. A entrevista narrativa na construção de itinerários terapêuticos de pessoas em situação de rua com transtornos mentais graves. Resumos dos trabalhos apresentados no 8o Congresso Ibero-Americano em Investigação Qualitativa em Saúde; 2019 jul. 16-19; Lisboa, Portugal. Lisboa: CIAIQ; 2019. p. 185-90.

Based on these considerations, it is necessary to critically reflect on how people on the streets with mental disorders chart their paths in the search for care. In the same way, one must think about what the implications of this are in the elaboration of ways of caring for mental health.77 Pereira LP, Wetzel C, Pavani FM, Moraes BM, Olschowsky A, Kirch I. A entrevista narrativa na construção de itinerários terapêuticos de pessoas em situação de rua com transtornos mentais graves. Resumos dos trabalhos apresentados no 8o Congresso Ibero-Americano em Investigação Qualitativa em Saúde; 2019 jul. 16-19; Lisboa, Portugal. Lisboa: CIAIQ; 2019. p. 185-90.

Based on these assumptions, this article aims to report the experience of using narrative interview with homeless persons suffering from mental disorders.

METHOD

This is an experience report that addresses the application of the narrative interview with homeless persons suffering from mental disorders.

The context of the study, in which the narratives were obtained, was the central region of a capital city in southern Brazil, in a municipality that has the highest percentage of people living on the street. It was decided to use, as a mediator of contact with the participants, the Office on the Street, which has more than three thousand registered users on the street.

Eight individual interviews were conducted from July to October 2019 and the participants were given fictitious names so that they could not be identified.

It is important to emphasize that, for the accomplishment of this study, were guaranteed the ethical-legal precepts applied to researches carried through with human beings, in accordance with Resolution n. 466/2012, of the National Health Council of the Ministry of Health, obeying the dispositions present in Resolution n. 510/2016, that foresees specificities in the applicable norms to researches in Human and Social Sciences. The research to which this report is tied was approved by the Research Ethics Committee of the Federal University of Rio Grande do Sul, under the Ordinance 3.272.312.

Narrative interview: theoretical-conceptual aspects

The narrative interview constructs textual data that reproduce, in a complete way, the interweaving of events and the sedimentation of the experience of the interviewee's life history. Thus, it takes into account not only the external course of events, but also the internal reactions, the experiences of the informant with the events and their interpretative elaboration by means of analysis models that lead to a detailed presentation.88 Schütze F. Pesquisa biográfica e entrevista narrativa. In: Weller W, Pfaff N, organizadores. Metodologias da pesquisa qualitativa em educação: teoria e prática. Petrópolis (RJ): Vozes; 2010. p. 211-22.

One of the characteristics of the narrative interview is the adoption of unstructured tools in order to obtain greater depth on the subject to be researched, a moment in which the life stories of the person interviewed and the social context in which he or she lives emerge. The objective is to provide more stimulus to those who are reporting the events of their life, giving more space for them to speak.99 Jovchelovich S, Bauer MW. Entrevista narrativa. In: Bauer MW, Gaskell G. Pesquisa qualitativa com texto, imagem e som: um manual prático. 13ª ed. Petrópolis (RJ): Vozes; 2017. p. 90-113.

Thus, narratives “open the doors” to subjectivity and new meanings about situations and experiences: the person who narrates and talks about his/her experience assumes a central role in the process of caring, emerging and becoming an active part of the process.1010 Artioli G, Cosentino C, Taffurelli C, Ferri P, Foà C. The narrative interview for the assessment of the assisted person: Structure, method and data analysis. Acta Biomed. 2019;90(2):7-16. https://doi.org/10.23750/abm.v90i6-S.8640.
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When considering the street population as an informant, one can also consider the advantage of “making oneself heard”, because, because they are not heard, these people, often stigmatized and consequently excluded from research, have their stories ignored.

Narrative interviews can help to learn - in a rich and differentiated way - more about the social phenomena that are in the essence of individual stories. Considering the context and relationships that influence storytelling is important when analyzing data from narrative interviews and, in addition, the direction of the narrative is channeled and determined by the participant, who chooses the stories that are most significant to him/her.1111 Mueller RA. Episodic narrative interview: capturing stories of experience with a methods fusion. Int J Qual Methods. 2019;18:1-11. http://dx.doi.org/10.1177/1609406919866044.
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Thus, through the use of narratives, the aim is to establish the structure of an episode, organize the sequence of events, establish explanations through their interpretation, identifying the dramas and/or social conflicts and the meanings that give meaning to the experience.1212 Silva DGV, Trentini M. Narrativas como a técnica de pesquisa em enfermagem. Rev latinoam enferm. 2002;10(3):423-32. http://dx.doi.org/10.1590/S0104-11692002000300017.
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However, it is less important to order it in an anamnesis-like chronology and more to link it in a proper way, guided by the relief given by the people themselves to their experiences, always referring to “their time and place”.1313 Bellato R, Araújo LFS, Maruyama SAT, Ribeiro AL. História de vida como abordagem privilegiada para compor itinerários terapêuticos. In: Gerhardt TE, Pinheiro R, Ruiz ENF, Silva Junior AG, organizadores. Itinerários terapêuticos: integralidade no cuidado, avaliação e formação em saúde. Rio de Janeiro: CEPESC/ABRASCO; 2016. p. 203-21.

In this sense, the different languages and expressions are valued: sonority of the voice, tones, emotions, rhythm, intensities, silences, reticence among others. Moreover, the story is produced and constituted in the field of action, that is, the stories are also told through the body, and the gestuality must be understood as “proper way of saying”.1313 Bellato R, Araújo LFS, Maruyama SAT, Ribeiro AL. História de vida como abordagem privilegiada para compor itinerários terapêuticos. In: Gerhardt TE, Pinheiro R, Ruiz ENF, Silva Junior AG, organizadores. Itinerários terapêuticos: integralidade no cuidado, avaliação e formação em saúde. Rio de Janeiro: CEPESC/ABRASCO; 2016. p. 203-21.

In the narrative interview, the interviewer should use the form of language of the informant, because this method allows the point of view of the interviewee to be better understood when using their language of spontaneous medium.99 Jovchelovich S, Bauer MW. Entrevista narrativa. In: Bauer MW, Gaskell G. Pesquisa qualitativa com texto, imagem e som: um manual prático. 13ª ed. Petrópolis (RJ): Vozes; 2017. p. 90-113. Thus, in this perspective, such aspects should be considered as a specific way of life, and not only as a reflection of the perception of the event.

In this sense, the narratives must be understood by the interpretation of those who tell them, privileging the reality of what is experienced by the informants, referring to what is real for them. Particular representations/interpretations of the world are proposed, not being open to verification and not being able to be simply judged as true or false. Furthermore, it is assumed that the narratives express the truth from a point of view, from a specific situation in time and space, always inserted in the socio-historical context.99 Jovchelovich S, Bauer MW. Entrevista narrativa. In: Bauer MW, Gaskell G. Pesquisa qualitativa com texto, imagem e som: um manual prático. 13ª ed. Petrópolis (RJ): Vozes; 2017. p. 90-113.

What is stored in the memory is selective, and some events can be forgotten, both intentionally and unconsciously. Thus, what matters is what the person has kept track of their history and what is true for them, and not how the events in fact were. In the narrative, what matters is the expression of a point of view in a certain social and historical context.99 Jovchelovich S, Bauer MW. Entrevista narrativa. In: Bauer MW, Gaskell G. Pesquisa qualitativa com texto, imagem e som: um manual prático. 13ª ed. Petrópolis (RJ): Vozes; 2017. p. 90-113.

In this direction, narrative interviews can help professionals to better understand people's experiences and behaviors compared to other quantitative means of research. This is because narrative interviews are not concerned with the absolute truth of the facts, but with the meaning of the experiences lived.1010 Artioli G, Cosentino C, Taffurelli C, Ferri P, Foà C. The narrative interview for the assessment of the assisted person: Structure, method and data analysis. Acta Biomed. 2019;90(2):7-16. https://doi.org/10.23750/abm.v90i6-S.8640.
https://doi.org/10.23750/abm.v90i6-S.864...

Since narrative is a method of capturing experience, and since experience is something fundamental to achieving in qualitative research, in this interview system both the researcher and the interviewee will come out of the meeting modified.1414 Creswell JW. Investigação qualitativa e projeto de pesquisa: escolhendo entre cinco abordagens. 3ª ed. Porto Alegre (RS): Penso; 2014. p. 342. Thus, using this methodological perspective is justified by the power it has to generate stories, because it is a method that allows one to go beyond isolated responses.1515 Moreira DJ, Bosi MLM, Soares CA. Uso de narrativas na compreensão dos itinerários terapêuticos de usuários em sofrimento psíquico. In: Gerhardt TE, Pinheiro R, Ruiz ENF, Silva Junior AG, organizadores. Itinerários terapêuticos: integralidade no cuidado, avaliação e formação em saúde. Rio de Janeiro (RJ): CEPESC; 2016. p. 223-36.

Narrative interview: practical aspects

The use of narrative interviewing as a data collection technique needs to be contextualized as it demands approaches with a specific group. To do so, a description of how this approach happened and the selection of participants is presented at first, and then the actual interview is carried out.

Approximation with the field and selection of participants

Research with homeless persons requires strategies of approach and sensitivity to context. In this direction, qualitative research provides a deep understanding of the participants' point of view, making it possible to elaborate adequate explanations for social behaviors. From a closer observation, of long duration, in a given social context, it becomes possible to construct a narrative account of the causal processes and put in a diachronic continuum the coherence between events and actions.1616 Cardano M. Manual de pesquisa qualitativa: a contribuição da teoria da argumentação. Petrópolis (RJ): Editora Vozes; 2017. p. 376.

The approach to the research field occurred through an extension project in the reference service; the objective was to broaden the look toward homeless persons with mental disorders, seeking to know the specificities of the health needs of this group. The project activities were developed over ten months, with four to five shifts per week.

During the period mentioned, people with mental disorders were identified during the monitoring of the activities developed by the service team, approaching people in a street situation in the territory; it was sought to know the needs of health care and the resources available, developing proposals for intervention and care that covered the people accompanied and the support network. With this, it was possible to get to know the potential participants of the research and start the fundamental approach to develop the following steps. Thus, when identifying users with mental disorders, it was proposed to them an informal conversation, aiming to know a little more about their life and their follow-up in the service, not to mention the research.

Each meeting was an opportunity to reaffirm the values that sustain the participant-researcher relationship, and the process of rapprochement with the field and with the participants allowed for the creation of a bond and the establishment of a relationship of trust between them and the researcher.

Initially, the selection of the possible participants was made based on the inclusion criteria (being over 18 years old, being on the street for at least six months, being diagnosed with some mental disorder and being able to understand the research). However, after two interviews it was realized that these criteria were not enough, and a more in-depth evaluation of the conditions of the individual constructing a narrative at that moment was necessary. The conditions to participate, in this case, refer to certain specificities of the methodology used, because the elaboration of a narrative requires the development of an identity construction and the organization and ordering of the events of his/her life.

Thus, to the inclusion criteria, initially established, a previous interview with the possible participants was added, which included questions about personal data and the history of the street and health situation, from which it would be possible to evaluate the possibility (or not) of building a narrative interview. The inclusion of this moment was important, considering that the invitation to research restricted to the initial inclusion criteria, before the possibility of not having adequate selection accuracy, could generate certain expectation and frustration in the participants and in the researcher.

After that, the individual was invited to participate in the research. In case the participant could not or chose not to conduct the interview at the moment following the invitation, it was possible to schedule it for another day. However, it was realized that, being a group of interest with its own and very specific characteristics, the scheduling strategy did not work, because the participants did not return on the agreed day. Thus, when the interview was not held on the same day of the invitation, the next spontaneous meeting at the service was awaited.

After the people who met the inclusion criteria were identified, they were relatively often left without access to the service again, even though they agreed to participate in the survey. When they returned, they told what had happened in their lives since their last contact, and the most diverse justifications were given for their removal: having gone temporarily to another municipality; having been hospitalized; or even having been arrested.

This detail was a great learning experience, because in previous experiences of conducting interviews with other groups, scheduling the day and time for the event proved to be a very effective strategy. However, the people who would integrate this research, for living in a street situation, demanded more flexible ways of approaching the event. And the long insertion in the field was fundamental for this learning. This is because the individual's search for the service is determined by his/her own needs, according to other logics of organization, and not by predetermined schedules, and many factors must be considered: roaming, lack of resources for the use of transportation, mistrust of services, among others. In the case of the inclusion of this population in the research, the flexibility and customization of strategies initially foreseen were fundamental.

In this sense, it is understood that simple changes in procedures, as reported, can be fundamental to remove certain obstacles, contributing to the effective inclusion of participants considered relevant to the research.1717 Malterud K, Siersma VD, Guassora AD. Sample size in qualitative interview studies: guided by information power. Qual Health Res. 2016;26(13):1753-60. http://dx.doi.org/10.1177/1049732315617444. PMid:26613970.
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Another challenging issue was to ensure the adequacy of a sampling strategy, articulating the sample size with the feasibility of its execution, considering the specificities of the participating group. Thus, a sample was sought that would allow quality to be achieved in the information collected in relation to its uses, the specific research method and the intended research product.

For this purpose the power of information criterion was used. The size of a sample with sufficient information power depends on the objective of the study, the specificity of the sample, the use of the established theory, the quality of the dialogue and the analysis strategy. The power of the information indicates that the more information the sample possesses and is relevant to the actual study, the smaller the number of participants will be.1717 Malterud K, Siersma VD, Guassora AD. Sample size in qualitative interview studies: guided by information power. Qual Health Res. 2016;26(13):1753-60. http://dx.doi.org/10.1177/1049732315617444. PMid:26613970.
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As the interviews were conducted and transcribed, they were analyzed in a preliminary way, observing their content in relation to some thematic axes: the conception of care, the interpretation of the disease, and the TIs. This allowed the set of eight interviews to be considered sufficient, as the methodological perspective aimed to deepen the way in which people with mental disorders interpreted and gave meaning to this condition, considering their life history, and how they sought their care.

It is worth mentioning that conducting this number of narrative interviews was a challenge, demanding a long insertion in the field. Even though it is a service aimed at homeless persons, there is not one look, one focus, for the questions related to their mental health care needs.

Conducting the narrative interview

The obtaining of the narratives began six months after entering the field, from July to October 2019. Of the eight interviews conducted, five met the methodological criteria of a narrative interview and were submitted to analysis. The three that were not analyzed were excluded due to limits related to the understanding of their content, due to the confused and disorganized language of the participant or due to his/her difficulty in reporting his/her story and in establishing a chain of facts.

The following steps were followed to conduct the interview88 Schütze F. Pesquisa biográfica e entrevista narrativa. In: Weller W, Pfaff N, organizadores. Metodologias da pesquisa qualitativa em educação: teoria e prática. Petrópolis (RJ): Vozes; 2010. p. 211-22.: contact and negotiation, explaining the modus operandi to the informant; main story or central narrative; phase of questioning and recommendations1818 Rosenthal G. Pesquisa social interpretativa: uma introdução. 5ª ed. Porto Alegre (RS): Edipucrs; 2014. p. 576. about the rules of conducting narrative interviews.

The contact and negotiation phase took place from the invitation to participants. At that moment the objectives of the research were made explicit, emphasizing the importance of the possible participant's life experiences for the project. In most cases, the possible participants reacted positively to the researcher's proposal. To those who accepted to participate, the modus operandi of the interview was explained, based on the reading of the Free and Informed Consent Term.

In addition to the proposed narrative, the following instructions on the narrative interview were provided: “I am interested in the life story of people who live or have experience on the street and also have mental disorders. I would like you to tell about your life story, not only about your illness, but also your story and what else you find important to talk about. You can report all the experiences that come to mind, and use as much time as necessary. At the beginning, I won't make any interruptions, I'll just take notes, to later resume some themes. If we can't finish today, we can schedule a second interview”.

From this, the central narration phase began. And as the object of the narrative was the life story of the informant, and it went through understandably, the narrative was not interrupted by the researcher, aiming at greater detail and respecting the system of relevance of the interviewee.88 Schütze F. Pesquisa biográfica e entrevista narrativa. In: Weller W, Pfaff N, organizadores. Metodologias da pesquisa qualitativa em educação: teoria e prática. Petrópolis (RJ): Vozes; 2010. p. 211-22.

It is important to note that researchers who use narrative interview techniques do not set a fixed agenda, but tend to let the interviewee control the direction, content and pace of the interview.1919 Anderson C, Kirkpatrick S. Narrative interviewing. Int J Clin Pharm. 2016;38(3):631-4. http://dx.doi.org/10.1007/s11096-015-0222-0. PMid:26613739.
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During the interviews, some participants developed longer and more continuous narratives, while others quickly ceased the narration. In these cases, seeking to stimulate the narrative without going into the questioning phases, stimuli were used such as: “and what happened next?”. During this phase, notes were taken in order to develop the issues and deepen them in the later stage, in order to clarify inconsistencies and fill gaps. In general, keywords were noted, always taking as reference the interviewee's words and their sequence of relevance. The end of the central narration phase occurred after the indication of a narrative coda (a clear indication of end), as shown in the following examples.

And until today I'm here. All my story. (Luis)

It was a pleasure to tell my story. (Geni)

That's all I have to say. If you want to ask anything else. (Sarita)

After the “closings”, the questioning phase began, in which the narrative potential for additional sub-histories was explored, mainly from the notes taken. The sequence of the notes was respected, taking again as a reference the thematic structure and relevance developed by the participant. In this way, an attempt was made to unveil what was cut or summarized in the previous stage, aiming at the verification and deepening of the events addressed.

It is important that these questions present narrative characteristics, avoiding questions that may have as justifying or argumentative answers, because what is sought is the obtaining of more narratives.1818 Rosenthal G. Pesquisa social interpretativa: uma introdução. 5ª ed. Porto Alegre (RS): Edipucrs; 2014. p. 576. Furthermore, in case of discrepancies or imprecise information, when formulating the questions the status quo must be restored before the narrative process, that is, return from the passage of imprecise or discrepant text in the main line of the story to the last textual point of clarity.88 Schütze F. Pesquisa biográfica e entrevista narrativa. In: Weller W, Pfaff N, organizadores. Metodologias da pesquisa qualitativa em educação: teoria e prática. Petrópolis (RJ): Vozes; 2010. p. 211-22.

This stage, as expected, was quite heterogeneous among the participants. Some, even with questions with narrative potential, still developed stories with few details and, in these cases, it was necessary to ask more questions, seeking to explore the narration. There were questions on points of imprecision and discrepancies, but keeping in mind that these were moments that pointed to biographical experiences difficult to fade, rationalize or legitimize, and that not manifesting them was part of the system of personal defense of the informant.

Tell me a little more about your childhood, until you're 17. Before you leave your mother's house. What was your life like?

And then after childhood, what happened?

Can you talk a little more about these difficulties?

Descriptive and argumentative questions arose during this phase, resulting in the encouragement of abstract description of situations, paths and systematic contexts. In this narrative process, the major contexts of the course of life were highlighted, marked and noted in positions of special relevance. Also emerged the junctions of experiences resulting from events and developments that were not fully aware for the narrator himself.88 Schütze F. Pesquisa biográfica e entrevista narrativa. In: Weller W, Pfaff N, organizadores. Metodologias da pesquisa qualitativa em educação: teoria e prática. Petrópolis (RJ): Vozes; 2010. p. 211-22.

After these considerations, it is added that, when the questions based on the notes were closed, questions related to the thematic field of the research were asked, if they had not been mentioned until that moment. The initial question was: “How do you seek help for your health problems?”; from this, others could arise:

What helps to improve your problems?

And what or who would help you with that?

Given the conclusion of the narrative interview, care was taken to never finish it after the narration of a traumatic time or a difficult phase of life. In some cases, when the spontaneous ending occurred with the narrative of negative facts or experiences, the following question was included: “What was your happiest experience?”. Also, at the end, it was opportune for everyone to express themselves with the following question: “Is there anything else you would like to tell me today? Thus, the interviews were finalized.

In order to keep an open mind to the subjectivities of each new narrative, in the sense that it did not suffer interference from the assumptions and judgments of the researcher, an exercise of distance from each previous interview was necessary. In order to do this, we sought the suspension of personal and theoretical experiences, so that the content of the interviews was originally from the participant.

Empirical material analysis

The method proposed by Fritz Schütze was used to analyze the interviews in order to interpret the experiences narrated by the participants88 Schütze F. Pesquisa biográfica e entrevista narrativa. In: Weller W, Pfaff N, organizadores. Metodologias da pesquisa qualitativa em educação: teoria e prática. Petrópolis (RJ): Vozes; 2010. p. 211-22., composed of six steps: 1) formal analysis of the text; 2) structural description of the content; 3) analytical abstraction; 4) knowledge analysis; 5) contrastive comparison; 6) development of a theoretical model.

It should be noted that the full reading of the interview transcripts was done previously, at the beginning of the first stage, so that there was a better general understanding of the material to be analyzed.

The first step, the formal analysis of the text, initially consisted in eliminating all non-narrative passages, that is, the descriptive and argumentative ones, and then ordering the “pure” narrative text, identifying the life trajectories, marking the beginning and end of each one, according to the following example.

[1 – beginning] I, that I remember, lived with my grandmother, my grandmother on my father's side, in Mário Quintana. Then there was a debate with my mother about our custody. Then she went to the Guardianship Council, to the judge of the First Childhood and Youth Court, and gave my guardianship and that of my sister to our grandmother. Then my mother took advantage of the fact that there were only three of us alone and took and ran away with us. She took us to Good Jesus. There she picked up and left us there, in a house, and disappeared. There we were even with Ryan, a little baby that she also took, who is our brother. Then the woman who lived there picked us up and took us in. Then my grandmother went there with the Council, and took me and my sister, and Ryan stayed there. Then he was adopted by that family. And my sister and I picked him up and went to live with our grandmother. Then one day she was with a partner and he started drinking. Both of them, right? And out of nowhere he started to argue. Then he took her money, left and she went after him. Then he took it and pushed her on the lane and the car picked up and hit her. Then she passed away. Then our flight picked up and delivered us to the Council. My sister and I were going to be separated, adopted by a different family. Then our flight said that it was not good to separate the brothers, so we went to the shelter, to the Casa de Acolhimento. We stayed there for a year, then we went to an institution, a home, a Social of Faith. I stayed there until I was 18. [1 – ending]

In the second step, structural description of the content, each segment of the narration was analyzed in detail, already formally delimited in the previous step. This is the most detailed stage of the analysis process, in which not only what is being narrated, but also how the narrative is being constructed, should be verified. Therefore, the descriptive and argumentative dimensions, excluded in the previous stage, were considered at that time of the analysis. Based on this, we tried to identify the different procedural structures in the course of life, using the following formal markers: dramatic point; culminating situation; background construction; argumentative passage and explanatory passage, described below.

  1. a

    Dramatic point - event that generated transformations in the trajectory of the participant:

She sold me to this club. I was thirteen years old. (Geni)

Only Julio at that time, he started to get sick. (Geni)

  1. b

    Peak situation - repercussion resulting from the dramatic point:

I ended up leaving my mother's house. (Luis)

Then I was in the “crazy life”. I started to stay on the street, to live on the street. (Sarita)

  1. c

    Background construction - context in which the narrative passage is situated:

My father was a bus driver and my mother was a housewife. My father was my mother and my father. My mother lived in the hospital, she had nervous problems and my father bought things inside the house and my mother touched everything inside the well. (Sarita)

  1. d

    Argumentative passage - current reflections and justifications about past events:

Because I didn't have my mother to give me this help, do you understand? And I was ashamed to ask my father because I saw that he was very hard working. (Geni)

My childhood was good after all. It was good despite my mother's absence. (Rita)

  1. e

    Explanatory passage - information that describes and characterizes elements of the narrative:

When the person has a stroke, the person starts to feel sick. There is a part of the body that begins to become more difficult to move. (Geni)

Marta Rocha's collection is a little perfume, like this, little one, which has in the mansion. It is expensive. Each perfume now costs fifty reais, seventy. So in each little box I think it comes seven...six or seven perfume. (Geni)

The next stage, analytical abstraction, aimed at reconstructing the biography as a whole, ordering events and trajectories, verifying the abstract structural expressions of each period of life, placing them in a systematic relationship with each other. For this purpose, Chart 1 was elaborated, composed of the background construction, the dramatic point and the culminating situation of each trajectory.

Chart 1
Analytical Abstraction: reconstruction of life history.

The fourth step, the analysis of knowledge, allowed us to explain the participant's theoretical argumentative contributions about his or her life history, identity and trajectories. The analysis was made from both narrative and argumentative and descriptive passages, since these contributions are the result of the participant's interpretation of him/herself and of the events and experiences present in his/her trajectories, representing his/her opinions, concepts, general theories and reflections.

In this step of the analysis, elements of the narrative were sought that would allow the construction of each participant's TI, considering his or her conceptions of care, how and where he or she sought it, the actors involved in this search, and the interpretations of the disease that permeated these choices.

From these axes a contrastive comparison was made, which consisted of grouping and analyzing all the interviews, looking for similarities and differences between the cases, individually; making a contrastive comparison of different interview texts when analyzing parallel situations to those found in the analysis of the first interview. Thus, a greater degree of abstraction was obtained in relation to the analyses carried out, as the case ceased to be treated as individual, and the conditions that were behind the particularity of each one started to be analyzed. In Chart 2, below, we exemplify the comparison made in relation to TIs.

Chart 2
Contrastive comparison.

The last step was the construction of a theoretical model, the result of the comparison of individual trajectories, which, after its exhaustive comparison, established similarities that allowed the recognition of collective trajectories.

Thus, at the end of the analysis,

procedural models of specific types of life courses, their phases, their conditions and problem areas, or even procedural models of specific elementary phases; general modules of life courses or of the constitutive conditions and structure of biographical training as a whole 8 8 Schütze F. Pesquisa biográfica e entrevista narrativa. In: Weller W, Pfaff N, organizadores. Metodologias da pesquisa qualitativa em educação: teoria e prática. Petrópolis (RJ): Vozes; 2010. p. 211-22. :215

The analysis of narratives allowed access, in depth, to the account of experiences through the free speech of the participants, with the objective of building the TIs of homeless persons with mental disorders, and the senses and meanings of the disease and care that may have determined the choices in their life trajectories.

CONCLUSIONS

The narrative interview, as a methodological tool for the construction of therapeutic itineraries of homeless persons with mental disorders, besides being a data production technique, brings a perspective that makes it possible to “make oneself heard” in stories that are often neglected. This method has as a central focus the construction of meaning(s) by those who experience a certain reality, considering actions, decisions and choices mobilized and that confer the outlines to their biography.

The narrative interview also allows the reconstruction of these senses, allowing new looks and insights in relation to the very experience of those who report, considering that sometimes, due to certain crystallized interpretations, blockages occur in the biographical trajectory. In the search for the visibility of this group, which needs a singularized look, the narrative interview makes it possible to themetize situations, with sensitivity, by proposing a dialogic and understanding method. In addition, the analysis of the biographies and trajectories of homeless persons and with mental disorders can boost the movement of (re)thinking about mental health care, considering aspects that may configure the place of psychosocial attention in the inclusion and access of this group.

The limits found in the use of the narrative interview with this group concern some specificities: the interviewees were people with stories predominantly related to deprivation, loss, and trauma, and the construction of narratives involved resuming these situations. In this direction, there were moments in which the deepening of some of these narratives was not appropriate, which, at least at that moment, would not have relevance for the objective of this research. This required sensitivity on the part of the researcher in order to be able to differentiate at what moments it was appropriate or not to stimulate the report. Another limiting issue was the itinerancy of the group and the difficulty of approaching and establishing a relationship of trust. In order to minimize this limitation, it is recommended to foresee a continuous and long insertion in the field in future studies.

The limited experience of using narrative interviews is also presented as a limit. Despite having mastered qualitative research and semi-structured interviews, it was realized that understanding how people on the street with mental disorders sought their care would require an approach to how they interpreted that experience and how they acted on it in the context of specific situations in their life. It was necessary to use a research method that would allow participants to address the topic and provide a way to describe their personal experiences as a complex social phenomenon; the question and answer format of conventional semi-structured interviews would not work.

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Edited by

ASSOCIATE EDITOR

Cristina Rosa Baixinho

Publication Dates

  • Publication in this collection
    24 Feb 2021
  • Date of issue
    2021

History

  • Received
    04 Feb 2020
  • Accepted
    30 Nov 2020
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