The concept of territory in Mental Health

Abstract:

The term "territory" and its correlates have become commonplace in the field of Mental Health since the psychiatric reform, a potentially emancipatory milestone in non-hospital-centered ideals. However, in a previous empirical study, we found a lack of consistent concepts and practices (corresponding to the use of this term) in the territorial reinsertion of persons with mental illness. To clarify the term's various uses and its possible correlations in practice, we have conducted a systematic survey of scientific articles and official documents, comparing them to each other and with the concept of territory from Critical Geography. We conclude that in the Mental Health field in Brazil, despite numerous and repeated critical efforts, a functional notion of territory has prevailed, overlooking power relations and symbolic appropriations, increasing the tendency of subjecting the reinsertion of persons with mental illness to a given territory rather than favoring socio-spatial transformations for the coexistence of differences.

Keywords:
Territoriality; Deinstitutionalization; Mental Health

Resumo:

O termo território e seus derivados se tornaram correntes no campo da Saúde Mental desde a reforma psiquiátrica, marco de ideário não hospitalocêntrico e potencialmente emancipatório. No entanto, constatamos em pesquisa empírica anterior que a essa incorporação terminológica não corresponderam concepções e práticas coerentes de reinserção territorial de pessoas com sofrimento mental. Para esclarecer os diversos usos do termo e suas possíveis correlações na prática, realizamos um levantamento sistemático de artigos científicos e documentos oficiais, confrontando-os entre si e com o conceito de território da Geografia Crítica. Concluímos que no campo da Saúde Mental brasileira, à revelia de muitos e sempre renovados esforços críticos, tem prevalecido uma noção funcional de território, que omite relações de poder e apropriações simbólicas, aumentando a tendência de a reinserção de pessoas com sofrimento mental desembocar na sua sujeição ao território dado, em vez de favorecer transformações socioespaciais para o convívio com as diferenças.

Palavras-chave:
Territorialidade; Desinstitucionalização; Saúde Mental

Resumen:

El término territorio y sus derivaciones se han hecho habituales en el campo de la Salud Mental desde la reforma psiquiátrica, marco del ideario no hospitalocéntrico y potencialmente emancipatorio. No obstante, constatamos en la investigación empírica precedente que a esa incorporación terminológica no le correspondieron concepciones y prácticas coherentes de reinserción territorial de personas con enfermedades mentales. Para aclarar los diversos usos del término, y sus posibles correlaciones en la práctica, realizamos una localización sistemática de artículos científicos y documentos oficiales, comparándolos entre sí y con el concepto de territorio de la Geografía Crítica. Concluimos que en el campo de la Salud Mental brasileña, a pesar de los muchos, y siempre renovados esfuerzos críticos, ha prevalecido una noción funcional de territorio, que omite relaciones de poder y apropiaciones simbólicas, aumentando la tendencia de la reinserción de personas con enfermedades mentales que desembocan en su sujeción a un territorio determinado, en vez de favorecer transformaciones socio-espaciales para la convivencia en diversidad.

Palabras-clave:
Territorialidad; Desinstitucionalización; Salud Mental

Introduction

In a previous empirical study on social insertion and housing of persons with severe mental illness, we found that their relationship to the urban space varies from one extreme to another: from those who feel more at ease on the street than in their homes to those that feel so exposed and unprotected that they prefer the old hospitals ¹. The fact that we found such drastic situations, which receive little attention from health services and staff, appears to indicate the lack of a fully established frame of reference on how territory affects users both subjectively and objectively. Hence our interest in understanding the concepts of territory that have taken hold explicitly or implicitly since the psychiatric reform.

In studies in the health field, words like space, environment, and territory have become common since the spatial turn in the Social Sciences. The words appear in all the discourses both inside and outside academia that wish to signal some awareness of the spatial dimension ⁽², while the same has applied to the historical dimension for some time. In Mental Health, the focus of the current discussion, the term territory became particularly relevant with the psychiatric reform and the opposition between hospital-centered and community services ^{3), (4}. But the incorporation of the term by Mental Health lacked concepts, principles, and operational modes that were shared by all the agents, as shown by a recent review ⁵. We find especially problematic the ambivalence between generic and operational notions and a concept of territory derived from critical social theory, in particular Critical Geography.

Notion is viewed here as an initial element in a process of knowledge, an immediate and intuitive idea on something, constituting the concept's content ⁶. Meanwhile, concepts constitute "fundamental explanatory units" on which theories are built ⁷. To name a concept, one can use a neologism, a foreign term, or simply a common word. However, this does not make the concept equivalent to the notions attributed to such a word in daily language. The concept of territory coined by Critical Geography - although even there it is not univocal or always used with due precision - designates reciprocal determinations of space and power. Souza ⁸ suggests that in an initial approach, territory can be understood as "a space defined and demarcated by, and based on, power relations" ⁸ (p. 78). To ask about territory, territoriality, or territorialization is to ask "who dominates or influences whom in this space, and how" ⁸ (p. 79). The concept of territory implies the awareness that power is always exercised in a given space and by means of it, whether a nation-state or by less evident territories, like the drug traffic or the high-end real estate industry. Later in the same text, the author states that territory should not be confused with the space concretely and objectively perceived, but as "spatially demarcated power relations, thus operating on a referential substrate" ⁸ (p. 97). Territorialized space is not only the scenario of power, but also one of its foundations and principal tools.

The critical and political concept of space condensed in this strong concept of territory was marginal in Geography as long as the latter featured preponderantly ahistorical, quantitative, and even positivist approaches, where geographic space constitutes a substrate from which societies extract resources and a stage on which they develop. The critical turnaround against these traditional approaches is due largely to unorthodox re-readings of Marx's works and Europe's cultural and political effervescence of the 1960s. In addition to critically reformulating geographic thinking, this turnaround inserted the spatial dimension into social theories and launched broad reformulations in many areas (a process generally called the spatial turn). Authors like Henri Lefebvre, Yves Lacoste, or even David Harvey later transformed the understanding of relations between society and space, showing that the issue was not one of harmonious fusion, but of a strained conjunction, full of clashes, conflicts, and contradictions.

Brazilian geographer Milton Santos inaugurated the approach to space as a social process and construction, also considering the particularities of global capitalism's peripheral or semi-peripheral territories. This allowed Epidemiology to more adequately address changes in the epidemiological profile resulting from globalization and to overcome the approaches that overlooked the socio-spatial implications in the health/disease process ^{9), (10}. But Santos also opened the way for a new generation of geographers that transcended his work in breadth, conceptual precision, empirical studies, and critical thrust ^{7), (8), (11}.

Our assumption is that to neglect the issues of power and struggle in territory dilutes it into a vague notion, and that to instrumentalize it as a territorial division of the Brazilian Unified National Health System (SUS) can have relevant implications for former long-term psychiatric inpatients and other persons with severe mental disorders. The latter, as members of the dominated pole in power relations, will tend to succumb to the risk (signaled by Bourdieu ¹², p. 124) of "accepting the dominant definition of their identity or the search for assimilation that assumes an effort to make disappear all the signs destined to recall the stigma". In other words, inclusion may come at the price of submission and the attempt to hide devalued resources ¹². Psychosocial rehabilitation work should thus overcome the tendency to normalize and force supposed deviants to fit in; rather, it should pursue society's transformation aimed at the coexistence of differences ¹³.

The following sections analyze the issue in detail, beginning with the concept of territory in Mental Health as applied in indexed scientific publications. Based on official documents from the federal sphere of the SUS, including conference proceedings, laws, rulings, and manuals, we analyze the explicit or tacit concepts of territory they contain, the importance of which lies precisely in their capacity to induce practices. We also contend that the clear demarcation of such a notion is desirable even in the bureaucratic field, since laws, plans, and legal instruments can often have ambivalent and slippery contents, allowing appropriation by opposing poles, as we observed in relation to the right to the city and the notion of community participation in urban planning ¹⁴.

We compared the scientific and bureaucratic discourses with the concepts of territory in Critical Geography and discussions by Bourdieu ¹⁵ concerning the notions of field, which in the current case allows distinguishing between the concepts in the scientific and bureaucratic fields. By showing convergences and divergences, we hope to understand how the term territory has been addressed by the Brazilian psychiatric reform, elucidating the term's various uses and identifying possible correlations for the so-called social reinsertion of persons with serious mental illness. Finally, we point to the possibilities of a more conceptually precise (and perhaps more politically powerful) approach.

Method

We assume as true for Brazil's Mental Health institutions what Vieira-da-Silva ¹⁶ observed for Public Health in general, namely that they represent a social space characterized by the circulation of agents between the scientific and bureaucratic fields. We thus draw on the concurrent analysis of scientific articles and official documents. This allows showing which formulations emerge and impact these two fields and how they influence each other. Scientific articles in Mental Health were surveyed in indexed periodicals in the LILACS, SciELO, Scopus, and PubMed bases, using the search terms territory and territoriality from January 2005 to December 2015, seeking to reveal contemporary thinking on the theme during phases in the psychiatric reform, characterized respectively by their consolidation and expansion ^{17), (18} (Table 1).

Table 1:
Boolean terms and connectors used in the article search.

A search was conducted by two researchers independently according to the following steps: (1) reading the abstracts from all the articles identified by the descriptors; (2) exclusion of texts in formats other than articles, from other countries, duplicate articles, or those unrelated to activities by specific mental health services, since in the latter cases they would not fit the target health area in this study; (3) comparison of the lists produced by the two researchers; (4) discussion and consensus between the two researchers; (5) calling on a third researcher in case of disagreement; and (6) reading the full text of the remaining articles. Of the 187 articles originally identified, 136 were excluded according to the above criteria. The remaining 51 articles (Table 2) were read separately by the two researchers, seeking to identify the meanings with which the term "territory" was used and the corresponding theoretical references.

Table 2:
Articles analyzed.

The review of official mental health policy documents used the website of the National Division of Mental Health of the Ministry of Health and the Virtual Health Library (BVS) in its mental health thematic area. The review covered 1992 to 2015, the period covering important mobilizations and policy advances (from 1992 to 2000) and the consolidation and expansion of the psychosocial care network (beginning in 2001) through the enactment of a law and rulings and an important growth in mental health services, according to the chronological classification proposed by the cited authors ^{17), (18}. A total of 22 documents comprised the analytical corpus, which investigated the occurrence and uses of the term "territory". The analysis covered the national law and the set of rulings on Mental Health during the above-mentioned period, the reports from the last three national mental health conferences, and an intentional sample of manuals for strategic services (Psychosocial Care Centers - CAPS, Residential Therapeutic Services - SRT, Primary Care, Solidarity Economy, Children and Adolescents, and Alcohol and Drugs) in addition to those focusing on model and policy discussions (Table 3).

Table 3:
Official documents analyzed.

Results and discussion

In the scientific field

The overall analysis of scientific articles revealed three distinct situations. The first included quite sophisticated concepts of territory, with discussions on de-territorialization, existential territory, cartography, etc. The second involved 28 articles which did not include territory or territoriality in the key words and did not explain the concept of territory they used, nor did they make reference to the relevant authors or schools. Finally, the group in which some articles present a notion of territory allusively or descriptively, not as an explanatory or critical concept. This is less obvious than may appear at first sight, given the possibility of a concept establishing itself among experts in a field, to the point of dispensing with explanations. In such circumstances, such a concept would be used with precision, without being presented in detail in each new text.

The inference that this does not occur in fact in the scientific field of Mental Health is corroborated by the relationship between the articles' publication dates and their conceptual precision or imprecision as to the term territory. The two types of articles are distributed equivalently over the course of the 11-year period (Figure 1). The field appears not to have matured steadily in this regard. There was also an obvious absence of any correlation between the precision in the concept of territory and the stratification of publications in the Capes Qualis-Periodicals base, either in Public Health or Psychology. The proportion of articles in which the term was (or was not) reported and used precisely is nearly the same in all the strata.

Figure 1:
Year of publication (2005-2015) of articles with and without definition of the term territory.

As for the term's contents, an analysis of the articles identified four relevant meanings, partly presented explicitly by the authors and partly deduced by us based on the respective semantic context (meaning defined here as the sense a word or even concept presents in a given context ¹⁹⁾⁾. As expected, such meanings appeared side by side in some articles, but even then one or the other clearly predominated. We rule out the articles with a polysemous notion of territory, with no predominant sense (articles 5, 14, 28, 31, and 41 in Table 2) or when the term was used as a synonym for state or municipality ²⁰. We now present the four meanings and the respective classification of articles.

The most frequent meaning of territory is a catchment or coverage area for non-hospital health services. The articles in which this meaning predominates identify territory as the space outside the hospital (by extension, as opposed to hospital-centered psychiatry) and adjacent to the health service, whose residents or circulating public can make use of this service. Even when this is not the main meaning, the articles take it for granted, as if it were common sense in the field.

"Since CAPSad is a state unit, the option was to work with the concept of 'CAPSad territory', considering the geographic are closest to this health unit, including the Pernambués neighborhood, keeping in view its physical area and the life present there, its territory with a pulsating life" ²¹ (p. 466).

According to a second meaning, territory is a set of treatment resources, in the broad sense and not always well-demarcated, i.e., the result of potential interactions to be explored and linked by the health services at levels that do not belong directly to these services (public spaces, neighborhoods, associations, etc.). Articles that use this meaning emphasize social inclusion of persons with severe mental illness. However, such therapeutic resources are nearly always mentioned vaguely, with no reference to inherent conflicts, resistance, and disputes over access to goods and services. The following quote illustrates this characteristic.

"It is important for health professionals working in the CAPS to find the user's other daily scenarios, that is, outside the setting of the mental health institution. They thus take a position as mediators and facilitators of relations and resources in the territory to produce social networks with solidarity for lifetime follow-up of users. This means creating spaces for affectivity and encounters, which requires fostering skills for people to achieve autonomy and emancipation" ²² (p. 106).

The third sense is existential territory, based on each individual's personal history. It denotes the space for symbolic constructions and belonging, linking ethological, subjective, sociological, and geographic meanings. The articles that primarily adopt this meaning refer to Deleuze and Guattari, whose concept of existential territory encompass such relations between the clinic, space, and subjectivity. The following passage characterizes the argumentative context in which this meaning appears.

"Thus, deinstitutionalization and comprehensiveness are conceptual operators that affirm territory as an ethical premise in health actions. A healthcare practice can only be consequential if it relates to subjects in their existential context. In the field of public healthcare policies, some technologies have operated by shifting the users' life territories to develop actions" ²³ (p. 10).

The fourth meaning sees territory as a system of objects and actions, derived especially from Milton Santos' theories. In articles that take these theories as their implicit or explicit reference, territory is the interface between the political and the cultural, with frontiers ranging from those between countries to those between individuals, at their physical limits. Central to such cases is the interdependence between the material space and its use, between the historical process and the material and social base of human action (Table 4).

Table 4:
Relevant meanings found in scientific articles.

"In order for healthcare dealing with the individual's mental disorder to contemplate the complexity of the subject's needs, health professionals must draw on new technologies of care. One such technology is care for individuals in their life context, within their territory, the space resulting from the inseparability between systems of objects and actions" ²⁴ (p. 658).

Considering that a strong concept of territory, as noted by Haesbaert ¹¹ (p. 95-6), "unfolds across a continuum from the more 'concrete' and 'functional' political and economic predominance to the more subjective and/or 'cultural/symbolic' appropriation", the meanings presented above tend toward different poles in this continuum. Territory seen as a catchment area for health services, structuring the functioning of psychosocial care networks and possessing resources for individual care (meanings 1 and 2), corresponds to the predominantly functional pole. Territory viewed from the users' perspective or as resulting from multiple material and immaterial power relations (meanings 3 and 4) tends toward the predominantly symbolic pole. One way or another, the scientific field encompasses such a continuum, although not always or in each particular text.

In the bureaucratic field

The Ministry of Health's normative and technical guidelines emphasize territory's importance in the technical organization of patient care in Mental Health initiatives in the Brazilian Unified National Health System (SUS). A typical formulation is "the idea of territory as organizer of the mental healthcare system, which should orient the actions by all its services" ²⁵ (p. 25). However, in the official documents analyzed here (laws, rulings, reports, and manuals), the notion of territory is often reduced precisely to such a category of administrative organization of the health system or to coverage by services, as illustrated by a document from the second National Conference on Mental Health, in 1992, which proposes: "To adopt the concepts of territory and responsibility as a way of assigning a break from the hospital-centered model to the district-based distribution of mental health, guaranteeing users' rights to receive or refuse care, as well as the obligation by the health service not to abandon users to their own devices" ²⁶ (p. 12).

The quote is inspired by the Italian concept of presa in carico ²⁷, translated in some texts as taking charge of ²⁸. However, it limits mental health care to services and the catchment population to a given geographic territory, the above-mentioned district-based distribution.

More than a decade later a document by the Ministry of Health ²⁵ on Reforma Psiquiátrica e Política de Saúde Mental no Brasil expanded the notion of territory beyond the physical space but reinforced its concept as a synergistic resource, overlooking factors that are contrary to the proposed inclusion: "Territory designates not only a geographic area, but the people, institutions, networks, and scenarios in which community life takes place. Thus, to work in the territory is not the same as to work in the community, but to work with the community's components, knowledge, and forces that propose solutions, raise demands, and can build common objectives. To work in the territory thus means to reclaim all the knowledge and potentialities of the community's resources, building solutions collectively, the multiplicity of exchanges between persons and mental health care" ²⁵ (p. 25).

The above definition of territory, possibly inspired by Milton Santos ²⁹, alludes to networks, proposing forces, exchanges among persons, and an assumed community or collectivity, but effacing the political dimension or the power issue, key to a critical understanding of territory. The social space in which the Mental Health sector operates appears as if politically neutral, or at best, self-governed. The economic, clinical, and moral forces that may resist the social reinsertion of persons with severe mental disorders are not mentioned.

The spaces now inhabited by these persons and who receive institutional support, whether SRT or CAPS, are largely located in large cities. Such metropolises may be the most complex territories humankind has ever produced, and the ones that are most difficult to decipher and interact with for anyone, with or without a mental disorder. Thus, "to work in the territory" by making use of "all the knowledge and potentialities" existing there, as suggested by the above quote, assumes a critical reflection on the possibilities and difficulties involved in the non-submissive insertion of persons with mental disorders in the power relations that define the territory.

In other words, although occasionally referring to the existential territory and considering the disputes there, the official documents operate essentially with the concepts of territory as a space for catchment or coverage of services and networks (meaning 1 from the scientific field) or as a set of resources that move the follow-up and rehabilitation of persons with severe mental disorders (meaning 2 from the scientific field). Finally, there is the above-mentioned emphasis on organization of the network of care, which appears to underlie the vague expression "territorial logic" and constitute a meaning not found in the same way in the scientific field.

These meanings refer mainly to typical state functions. They all tend towards the predominantly functional pole. In a coverage area, the relationship between given services and a given clientele allows improving their distribution, hierarchical organization, and linkage, with a view towards rehabilitation and reinsertion. Territory is synonymous with "place of reference and care, promoter of life, with the mission of guaranteeing the exercise of citizenship and social inclusion of users and their family members" ³⁰ (p. 3). In a word, it represents a resource, whether clinical, rehabilitative, or administrative. Although there is no functional concept of territory that does not include some symbolic element - and vice versa - it is evident that according to the official documents, territory is something narrower, more immediate, simpler, and more manageable than the concept that emerges from the scientific articles as a whole.

Insertion in the territory or in the service?

The mere elimination of confinement facilities such as psychiatric hospitals is obviously not enough to guarantee social inclusion of the excluded or their emancipation from tutorship. Contrary to the intentions and intuition of all those who embraced the Brazilian psychiatric reform, the establishment of a health services network "in the territory" even runs the risk of acting in the opposite direction, since it provides the state with additional legitimacy to exercise surveillance over the entire population in a given area, i.e., a given "territory". Lima & Yasui ³¹ (p. 599) warned, referring to Deleuze (1992), that "in the transition from the asylum to new substitute services, we might merely move from discipline to control".

To mitigate this risk, Lima & Yasui ³¹ recommend sensitive and attentive clinical practice, capable of embracing the multiplicity of ways of life and networks of meaning that create new territories. However, such intended pluralism often runs up against the logic of imposition of social order and standardization embedded in the functioning of the state apparatus, through moral integration and the production of social identities according to acts by state agents ³². Regardless of health professionals' ethical and political positions or clinical practice in the mental health system, they are subject to control by the institution that employs them and whose determinations they feel in the skin whenever they deal with its immense bureaucracy. The frequency and natural way with which scientific articles use territory as coverage area also suggest that many mental health specialists have incorporated something of the automatisms of the "administered world". This refers us back to the definition by Souza ^{7), (8}: to ask about territory is to ask about power. And with Bourdieu we could add that the genesis of every modern state is a long and complex process of concentration of a society's material and symbolic resources, the result of intense power struggles 89 which can take on different forms, but which inexorably corresponds to a process of establishing order and appropriating symbolic resources in the relations between agents in the social and physical spaces in which they act ³³.

The deinstitutionalization movement in Italy in the 1970s - which heavily influenced the Brazilian psychiatric reform - confronted not only the psychiatric hospital but also the English therapeutic community model and the French mental health policy. From the English model, the Italians in Trieste kept the principle of democratization of relations, while from the French model they inherited the idea of territoriality, counter to the notion of community ³⁴. In the Mental Health context the term community - so positively connoted in everyday language - is inseparable from the American preventivist ideals, which see community as the functional system and mental illness the failure to adapt to the system's interactive mechanisms ³⁵. For the Italians, on the contrary, the institution to be overcome was not simply the psychiatric hospital, but the "the set of scientific, legislative, and administrative devices, codes of reference, and power relations structured around the object 'disease'" ²⁷ (p. 30), where the struggle for freedom is associated with the struggle for resources that allow social exchanges, the lack of which condemns the excluded to a life of continuing exclusion ³⁶. In this sense, the Italian process of psychiatric deinstitutionalization and territorial inclusion assumes disputes and clashes in no way aligned with the functional notion of territory. The same can be said for the principles behind the Brazilian psychiatric reform.

However, this functional notion's hegemony in the documents (and operations) of the Brazilian Ministry of Health and its repeated appearance in scientific articles indicate a gradual loss of power in the strong concept of territory, i.e., territory as a space for exercise of both power and resistance. We are at a crossroads of the true insertion in the territory and a trans-institutionalization ³⁷. If the former represents conflicts, the difficult coexistence of difference and advances that are sometimes slow and always partial, the latter represents only a move away from the psychiatric hospital and towards tutorship in the community, conducted by professionals in institutions like the CAPS and the SRT.

Overcoming ostracism by social reinsertion helps protect former long-term inpatients (and patients who have been followed in substitute services since the beginning) from feeling out of place, forced to meet tacitly required conditions in order to be accepted ¹². A critical concept of territory means distinguishing between insertion in the psychosocial and healthcare network and inclusion in physical, social, and relational spaces.

Conclusion

In Mental Health, the word "territory" has always been used in a hybrid way, oscillating between meanings with or without a theoretical reference. Territory and territoriality function as allusions to an advanced set of ideals, without necessarily dealing with the respective political and social implications. The lack of conceptual progress with this important signifier means that each new research output on the theme is forced to either explain the term anew or accept it in its more instrumental and less critical meanings. In addition, the conceptual imprecision does not appear to disqualify a text in the eyes of specialists, whether in Public Health or in Psychology.

As for the discourse in official documents, the prevailing concept of territory is a physical and social space capable of catalyzing the process of psychosocial rehabilitation and social reinsertion of persons with severe mental disorders. By abstractly removing territory from power relations and thus from various orders of disputes and resistance, the official concept induces both clinical practice and reflection to neglect what is central to any process of inclusion, namely social relations and their consequences for each of the so-called insane individuals.

The critical concept of territory contrasts with the commonsense notion, the meanings of which are varied and sometimes vague or superficial (territory as synonymous with area or region, for example). There appears to be a gradual loss of power and discernment, which attenuates the concept of territory used by the Italian psychiatric reform and reinforced in Brazil by Critical Geography and the work of Milton Santos. By blunting the concept's critical and analytical capacity, omitting the characterization of the encounter/avoidance between persons with serious mental illness and the urban and social space in contemporary Brazilian society, both the scientific field and the bureaucracy make mental health services staff and users more vulnerable. Users that try to belong in society run a huge risk of subjecting themselves to hegemonic values and behaviors.

Acknowledgments

We wish to thank Rosana Onocko Campos, Gabriel Peters, Márcia Carvalho, and Nina Isabel Soalheiro for reading and discussing the article's initial drafts.

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Publication Dates

• Publication in this collection
  2016

History

• Received
  06 Apr 2016
• Reviewed
  25 July 2016
• Accepted
  28 July 2016