MENTAL HEALTH AND WORK: MEANINGS AND LIMITS OF THEORETICAL MODELS

Este texto se constitui em revisão das principais abordagens teóricas que fundamentam os estudos sobre Saúde Mental e Trabalho (SMT), apontando seus conceitos básicos, categorias de análise e respectivos limites. Propõe-se a oferecer alguns balizamentos conceituais acerca da temática SMT, na tentativa de equacionar problemas, questões e desafios impostos pela construção deste objeto de estudo. Para isso, o texto apóia-se na revisão crítica de alguns paradigmas teóricos predominantes nos estudos sobre a SMT. Finaliza apontando questões teóricas importantes sobre as relações entre a saúde mental dos indivíduos inseridos no mundo do trabalho.


INTRODUCTION
This theoretical and exploratory study aims to point out some conceptual aspects about the predominant theoretical approaches that explain the interrelation between Mental Health and Work, indicating their basic concepts, analytic categories and limits.
Mental Health and Work (MHW) is not a new, but a very current theme.It entails a controversial discussion about its concept and applicability.The theme is not only involving, but arouses reflections about the theoretical approaches that explain it, being considered a process where aggressions to the mental apparatus, originating from work, are confronted by the sources of vitality and health, represented by individual and collective resistance, in the preservation of workers' values and dignity.
Work organization has turned into a relevant social instance in the health-mental illness process.This organization exerts effects on the worker's body, including the mental apparatus, imposing a particular functioning mode, a certain model in the light of the demands, contents and requirements of the production mode's logic.
The mental apparatus is, therefore, the privileged location where the effects of work organization on the individual will be expressed (1) .
The complexity of the mental apparatus, in turn, requires analyses based on theoretical models that can guide studies aimed at understanding MHW, adopting a concrete historical man, located in time and space, as the fundamental analytic category.
Researchers have faced difficulties to put the adoption of this analytic category in practice.Workrelated mental disorders, despite high prevalence rates in the working population, frequently are not recognized as such during clinical assessments (1) .This difficulty does not only derive from the characteristics of mental disorders, often hidden by physical symptoms, but also from the complexity inherent in the task of clearly defining the association between these disorders and the individual's work.
Although workers' mental health is not a new issue, studies providing a deeper theoreticalconceptual discussion about this theme, identifying knowledge and methodological instruments, are still lacking.This gap is accentuated in the health area, which contains theoretical-conceptual and methodological difficulties related to MHW.These include the adoption of a theoretical-methodological axis to guide the analysis of findings and, also, the adoption of diverse and even contradictory theoretical premises in one and the same study, presenting different mutually conflicting elements in the results.
Another difficulty is the use of exhaustion, stress and suffering as synonymous terms.
In Brazil, few approaches look at situations and associations of workers' mental suffering through a perspective that integrates psychological and social dynamics with a political analysis.Important work psychopathology studies (2)(3)(4)(5)(6)(7) focus on groups of problems attributed to work organization, offering precious information and analyses for the study of workers' mental health and suffering.In the health area and more specifically in nursing, few studies (8-10)   exist in this approach.
In view of this lack of references for a more thorough theoretical-conceptual discussion of the relations between mental health and work, this article aims to offer conceptual indications of the predominant theoretical approaches in studies on MHW, pointing out their basic concepts, analytic categories and respective limits, in the attempt to contribute to the equation of problems, questions and challenges imposed by this area.Therefore, this paper is based on the critical review of some theoretical models that are predominant in health studies, without any claim on analyzing productions in this theme area.
Next, we highlight the main analytic branches supporting health studies on the relation between mental health and work.

THEORETICAL MODELS IN STUDIES ON MENTAL HEALTH AND WORK
The main model currents explaining relations between mental health and work are the exhaustion, general living and work conditions, stress, ergonomics and work psychopathology approaches.

Exhaustion approach
The analytic branch of exhaustion is based on the conception that adopts the work process as the fundamental element for analysis (11)(12) .Work process and work load are seen as analytic categories in the understanding of the biopsychosocial aspects influencing the (mental) health-disease process, seeking to move beyond the notion of risk.An interdisciplinary area is identified, which analyzes the connections between mental health and work, presenting the exhaustion concept as the integrative conceptual option.
Exhaustion is considered to be the loss of actual and/or potential biological and mental capacity, to the extent that work turned into an activity whose exhaustive component is much more effective than the replacement of this capacity and the development of worker potentials (13)(14) .
Mental exhaustion is associated with the image of "consumed mind", joining three areas: the first covers clinical pictures related with the organic exhaustion of the mind (whether through work accidents or the action of toxic products); the second includes variations of "indisposition", including (mental and physical) fatigue; the third identifies exhaustion that influences worker identity, affecting values and beliefs that can hurt his dignity and hope (13) .
The following clinical problems or neurotic syndromes stand out, identified through the exhaustion approach: the burn out syndrome; the chronic (pathologic) fatigue syndrome; post-traumatic, depressive and paranoid syndromes (15) .
The exhaustion and chronic fatigue syndrome corresponds to the fatigue accumulated across work periods of variable duration, which do not allow for sufficient recovery through sleep and rest.The main characteristic is constant physical and mental fatigue, accompanied by sleep disorders, tiredness, irritability and discouragement (15)(16) .
Post-traumatic neurosis is marked by irritability, anguish and exaggerated emotional reactions.Moreover, the individual mentally relives the traumatic scene, accompanied by indisposition, sometimes including sweating and tachycardia.
Nightmares also repeat the trauma event, marked by sleep disorders, irritability and a state of tension with disruptions, as if the person were in a permanent state of alertness (17) .
The paranoid syndrome is a neurotic picture in which strong feelings of insecurity develop, experiencing threat in situations where potentially persecutory aspects and pressures are identified, with rigid control devices.The greater the waged worker's communication barriers and isolation, the easier it will become for these manifestations to develop.

Manifestations of persecutory anxiety can intensify
to the extent of seriously disturbing interpersonal relations and performance.In parallel, different degrees of irritability and, frequently, sleep disorders may appear (15) .
The origins, development and evolution of depressive syndromes can be clearly associated with work situations.Depression can manifest itself in typical acute or chronic situations (sadness, experiences of loss or failure and lack of hope).
However, work-associated depressive pictures often are not typical and are revealed in a subtle way, with discouragement about life and the future as the main manifestation (15) .
The understanding of exhaustion as a mental disorder factor does not refer to any isolated process in particular, but to a set of biopsychic processes, and is not necessarily related to irreversible processes.It is exactly this lack of specificity of exhaustion in MHW analyses that limits the aspects of its measurement, to the extent that this starts to be realized through signs and symptoms that are not specific of the psychopathological picture the worker presents.
Therefore, studies adopting the exhaustion approach to outline the relation between work and (mental) health face difficulties, as exhaustion has to be measured through non-specific signs and symptoms, many of which are caused by countless factors throughout the individuals' lives.

General living and work conditions approach
The general living and work conditions or way of life model is based on the conception that adopts occupation as the central element in the understanding of the (mental) health-disease process.The concept of occupation, understood on the basis of individuals' insertion in a given occupational structure and labor market, is considered of fundamental importance to understand differentiated exposure to psychic risks, whether in continued exposure to a specific work process or in the mobility between distinct work processes (18) .
Through this approach, general living conditions are visualized as analytic categories, in the understanding of biopsychosocial aspects that influence the (mental) health-disease process.It is emphasized that this process is mediated, on the one hand, by factors associated with the way of life and, on the other, by the individual's insertion in the occupational structure (18) .In view of the diversity of occupations and their structural heterogeneity, general work conditions occur at the same time as problems related to living conditions.Thus, a series of aspects in the work and overwork situation can act together in the development of mental disorders, with several interrelated aspects.

Occupation
Thus, in this analytic branch, aspects related to workers' mental health cannot be restricted to the identification, to their mere intensity, based on the work burden related to each work process, but mainly need to explain the nature of the mental risks specific work processes expose workers to.
In this perspective, the general living and work conditions or way of life approach differs from the theoretical model of exhaustion.While the general living and work conditions or way of life approach adopts the work process as the central analysis axis, the exhaustion approach adopts the occupational structure.They are similar to the extent that both adopt social tissue as the background, taking distance from traditional approaches that deal with the MHW process from an Occupational Health perspective (19) .

Stress approach
The approach that privileges the relation between stress and work is another analytic current dedicated to the interrelation between mental health and work.This approach, based on stress theory (20) , presents stress as disequilibrium between work demands and the workers' response capacity.
In the understanding of the biopsychosocial aspects that influence the (mental) health-disease process, the stress approach adopts social organization, the worker's alienation process, the work environment and specific occupations as the explanatory axes or analytic categories (21) .
Despite the importance of the stress concept to understand the links between the (mental) healthdisease process and work, there exists a consensus that it is difficult to delimit the explanatory axes or analytic categories in the stress approach.This difficulty has put up theoretical-methodological barriers to this analytic branch.
The stress notion has been understood as a set of reactions an organism develops when submitted to situations that challenge its adaptive balance, expressing the vicissitudes and impacts of urbanindustrial life on subjectivities.This notion covers atmospheres prevailing in large cities, such as rapid and varied stimuli, hyper-alert senses, confrontation with diffuse threats, feeling of urgency to attend to demands, among others (1)   .
In view of the range of this notion and the need to balance frontiers between different kinds of knowledge, in clinical practice as well as in research, psychopathology, psychosomatics and psychopharmacology have attempted to clarify differences between the notions of stress, emotion, emotiveness, anguish and anxiety, in the attempt to preserve the scientific status of the term.In this balancing, the notion of stress starts to be related to situations of extreme psychosensory-motor subjection, bordering on direct damage to the subject's integrity (5) .It is a notion that indicates a state resulting from the organism's interaction with harmful stimuli, which is therefore a dynamic state, interior to the organism.Thus, neither the student's expectation about an exam, nor the patient's emotions about an expected surgery, or difficult situations like morning or failure can be considered as stress.An aggression by stimuli, symbols of oppression or any aspect in the internal or external environment, whether social or not, cannot be considered as stress either (22) .
In the Mental Health area, the alterations determined by psychosocial stress are characterized by a picture that lies closer to a syndrome of sharper activation or physiological vigor, mediated by the interpretation formulated by the mental apparatus in view of a particular situation.The psychosocial factor of stress emerges when an interpretation indicates insufficient interior resources to face something that is experienced as a threat (1) .
Sources of stress at work and their effects on the mental health-illness process are studied through analytic categories affected by factors inherent in the work process, the individual's function in the organization, work relations and the institutional structure and atmosphere (1) .The category function of the individual in the organization refers to the function bias (when the worker gets confused by demands issued unclearly), the conflict between functions (requirements are contradictory and attending to one of them implies ignoring another), responsibility with respect the other people's security and life, generating additional concerns (1) .
Work relations involve social support from colleagues, heads and subordinates, and are considered an important variable in workers' mental health.In this sense, the social support theory points towards the importance of having a network of relations for mental health maintenance and recovery strategies (1) .
The institutional structure and atmosphere processes (1) .
The analytic branch of stress has contributed to the understanding of the relation between mental indisposition and work, permitting the identification of anomalies that not necessarily are syndromes or disorders, bordering on indisposition.This approach allows us to understand the non specificity of the suffering called mental indisposition.
Despite innumerous attempts to perform empirical analyses according to the stress approach, difficulties involve not only the conceptual bases and delimitation of the study object, but also methodological aspects.Thus, in spite of the stress approach contributions to understand the health-work process, its conceptual limitations or analytic reductionism has been criticized (20) .Criticism is directed at the limitations of epidemiological research adopted in workers' mental health assessment, allowing companies to eliminate subjects suffering from even light mental symptoms or behavioral disorders (3, 5-6)   .
In fact, the stress approach advances in studies on workers' mental phenomena by using social epidemiology in its investigations, specifying the social aspects and analyzing stress as a mediator between the social and the biological.However, in using somatic and biological criteria in the assessment, this approach does not address the elements inherent in the meaning process, nor the workers' subjective experience, getting distant from a theoretical formulation of the social process.

Ergonomic approach
Ergonomics is an interdisciplinary field, involving engineering, medicine, psychology, sociology, psychophysiology and economics.Initially, it is considered as the relation between man and machine.This understanding was expanded through a change of focus in studies about work, where the human factor starts to be faced as an important element in the man versus machine binomial.
The analytic branch of ergonomics is based on the adoption of psychosocial factors as the analytic axis in the health-disease process (22-23)   .The physical, cognitive and mental factors stand out, in which one aspect interacts and determines another.Each of these factors can determine an overload or suffering.They are interrelated and, as a rule, an overload in one of these aspects is accompanied by an increased burden in the other two areas (22) .
The ergonomic approach is marked by three distinct moments: 1-concerns mainly focus on physiologic modifications exercised by the work process, privileging physical fatigue; 2-the focus is directed at the investigation of psycho-physiological aspects; 3-studies look at psychosocial factors and their repercussions for chronic mental fatigue (24) .
In the analysis work and its repercussions for individuals' health, it is highlighted that work with cognitive burdens, whose contents imply increased mental effort, can lead to the emergence of neurotic syndromes.One example is health work, which requires rapid thinking and decision making, difficult relations with clients, very close or restrictive control by heads (22) .
Ergonomics studies have been criticized, especially related to the understanding of mental health on the basis of the physiologic effects of work.
Criticism indicates that the original stress concept is limited to understand the complex relations between Mental health and work: meanings... Fernandes JD, Melo CMM, Gusmão MCCM, Fernandes A, Guimarães A. Rev Latino-am Enfermagem 2006 setembro-outubro; 14(5):803-11 www.eerp.usp.br/rlaeaspects of mental health at work and the socialpolitical-economic context it is inserted in (25) .
Limitations of this approach refer to the multiple natures of work tension sources -physical, chemical, biological, social, economic, cultural and politicalgenerally exercising their effects through simultaneous actions or, quite frequently, interactions, rendering difficult the specific effects of one or another tension-producing agent in real conditions (24) .
Despite different criticisms against the limits of the ergonomic approach, whether due to the theoretical framework, the delimitation of the study object or the adopted methodological strategies, its contributions to the study of workers' mental health are undeniable, especially in defining how it is influenced by work conditions.

Work psychopathology approach
The analytic branch of work psychopathology covers the analysis of the dynamics of mental processes mobilized by the subject's confrontation with the work reality, base don studies (2)(3)(4)(5)(6)(7) that adopt In Dejourian studies (2)(3)(4)(5)(6)(7)(8) , the worker's suffering is expressed by feelings of dissatisfaction and anxiety, deriving from the work contents' lack of meaning for the subject, fatigue, as well as the ergonomic contents and burdens of work.These studies distinguish between the dissatisfaction produced by the ergonomic contents (suffering related to the contents' lack of adequacy to the worker's aptitudes and needs) and the suffering caused by the "significant contents" or "symbolic contents of work".
Dissatisfaction related to the significant contents of the job produces suffering with a mental impact, as opposed to the suffering that results from the ergonomic contents.However, it should be highlighted that mental suffering resulting from frustration at the level of the significant contents of the job can equally lead to somatic diseases (3) .
The difference between the theoretical model of Work Psychopathology and the previous models (way of life, exhaustion, stress and ergonomics) is that the former adopts methodological strategies that privilege the report of workers' subjective experiences and their feelings of anxiety, fear, dissatisfaction, in short, their suffering about work, as material for analysis.
The ergonomic model privileges the objective aspects of the work condition, using analytic models that attempt to identify observable elements in the environment.
The psychosocial stress model also differs suffering" that is unavoidably generalized to life outside work (3) .
In psychiatry, workers' mental health aspects are concentrated in mental changes when they are already evidenced, acknowledged and labeled by diagnostic actions.To overcome this reality, Work Psychopathology seeks to advance on the preclinical horizon of mental illness, incorporating a wide range of alterations into the research area which, although not characterized as typical diseases, are already unmistakable signs of mental suffering, or even active forms of struggling against the disease that is threatening to install.
Two basic concepts illustrate this advance in Work Psychopathology.These are: "Health and mental illness are not stagnant poles, but a dynamic process, permeated by intermediary nuances and subject to destabilization and rebalancing" (1) and "The mind is not indifferent to the live work scene, as could be suggested by the silence about the subject.On the contrary, it constitutes its first point of incidence.When inserted into a work process, the individual establishes a constant interaction between his psychobiological program (considered as a set of biological and mental variables and aptitudes, expectations, needs etc.) and the work loads originating from the immediate technological materiality and the forms of work organization and management, with their different degrees of physical and mental impact" Until recently, mental suffering was only considered in relation to the worker's mental health when it was tumultuous, explicit and excessive.Any other suffering that escaped from this framework seemed without evidence, below the reach of the clinical look and the listening needed to decipher it.
Not acknowledged as a disease in the light of already coded knowledge, this suffering escaped from any theoretical or clinical thematization, as if it lacked legitimacy to become an object of concern or research (1) .character or psychosomatic traits (2) .

Work
The Dejourian approach evidences the role of work organization in workers' mental health, which should be an element of concern for experts and professionals in research as well as services.
Health studies have frequently adopted the

FINAL COMMENTS
The health area studies the interrelation In view of these difficulties, there is an urgent need for studies that look at work load and contents through articulations between these elements and workers' personality structure, as the mental work load is undoubtedly very complex and involves neurophysiologic, cognitive and psychological phenomena.
Another important aspect is the development of interdisciplinary studies that permit an understanding of the psychosocial dimension of work and its relation with mental health, as this process involves psychological, sociological and physiological aspects.Thus, analyses in a multidisciplinary field must attempt to understand the relations between the work process and mental health, using an approach that seeks to apprehend the psycho-affective, sociocultural, economic and political determinants inherent in the work process, as well as its repercussions for workers' mental health.
With respect to theoretical approaches that support the analysis of workers' mental health, a new study agenda has to be organized, which integrates different perspectives on the object (the work process, occupational insertion, the work environment and the mental health-disease process) and allows for new methodological alternatives at the level of research and organizational intervention.
Finally, we recommend that multiple approaches be adopted, provided that they are not contradictory, in future MHW studies.These studies, in turn, should take into account that work is a part of the construction of individual identities and, therefore, not only a mere way of making a living, but also a creative process.Thus, work and its consequences for individuals' mental health should also make sense to the workers, that is, give pleasure and a certain degree of satisfaction.
For MHW researchers, overcoming the barriers appointed for each approach in this article indicates that, in order to cope with such a complex theme, there is a need to move beyond the use of approaches that emphasize only one of the multiple sides of this complex theme.
-related psychic risks are not uniformly distributed, as they are associated with general living and work conditions the individual is exposed to.Exposure to the work process does not happen continuously, what prevails is the worker's exposure to differentiated work processes.The health sector itself is marked by a wide range of structurally heterogeneous occupations (physician, nurse, nursing auxiliary, physiotherapist).
category refers to the internal work policy, in terms of the mechanism to participate in decision making, restriction of behaviors, pressure from heads, control of work rhythm and the work process.Most of these factors are obviously related to the way production is organized and to how social relations inside the labor world are oriented towards workers' participation in or exclusion from decision making the organization of work and mental suffering as the central analytic categories, emphasizing the role of the defenses workers adopt as mechanisms to maintain mental equilibrium.In selecting mental suffering as the category, this approach takes distance from theoretical conceptions that address the relation between work and (mental) health/disease from the perspective of classical psychiatric nosology, constructing psychopathological profiles.It also takes distance from conceptions that adopt the framework of occupational medicine and relate risks with specific mental diseases.
from the Work Psychopathology model to the extent that it privileges quantification, without considering the suffering subject's experience.Stress measurement ignores the experiences of the stressed subject and values neither the suffering nor ways of mentally metabolizing it.The privilege of quantification favors the identification of deviations, excesses or deficits in certain parameters, but dedicates little attention to the qualitative subjective experience.Work Psychopathology adopts concepts like work load, free behavior, stereotyped behavior, significant and ergonomic contents of work in relation to personality structure, mental suffering, flow and destination of vibrations, structuring of the operative mode, psychosomatic economy, defense strategies, among others.By means of these concepts, Work Psychopathology identifies the psychopathological effects of the scientific organization of work on the worker's mental apparatus, in function of the triple division: division of the operative mode, division of the organism between execution and intellectual conception organs and division between men.Workers' mental apparatus does not adhere to the organization of repetitive and meaningless work.Thus, these individuals' experiences give rise to a "mental Psychopathology is opposed to this movement of neutralizing indisposition and neutralizing suffering.It takes interest exactly in the workers' discourse, in their experiences, in what is not explicit in behavior, in what was silenced by the disguise of productive and stereotyped conduct.Thus, from a methodological viewpoint, this analytic branch privileges qualitative over quantitative aspects, according to its epistemological nature.It looks at the subjective experience of suffering, whose expression necessarily involves symbolic mediation and intersubjective relations.Work Psychopathology examines individuals' pleasure/suffering equation in their daily and repeated relations with work.It seeks the effects of this equation and workers' mental dynamics.In short, it emphasizes the centrality of work in subjects' lives, analyzing aspects of this activity that can favor health or illness.The point of intersection between Work Psychopathology and psychoanalysis is the act of privileging individuals' statements about their work, listening to their discourse about their experiences and their silences related to certain points or issues that are considered crucial for work performance.If the individual remains silent about a certain subject, or refuses to talk about it, or does not even mention anything about this subject, according to psychoanalytic perception, this constitutes a defense device to fight against the perception of suffering.At this point, another fundamental concept of Work Psychopathology appears: defense strategies and particularly sublimation.These strategies contribute to join workers, unite the work group and minimize mental suffering.They also benefit the formation of a value system that starts to construct the so-called "defensive ideology of the profession "(6) .These collective strategies are formulated on the basis of workers' group experience, seeking to maintain a mental balance, even if precariously, in view of the threats present in the work environment.The Work Psychopathology approach considers work, particularly work organization, in two dimensions: one pathogenic and another protecting mental health.The mental health-protecting dimension depends on the existence, between the worker and the prescribed work, of some room for negotiation, some possibility to adjust the operative mode to the profile of the executor.When work organization is rigidly structured, ignoring the importance of sociotechnical systems, and attributing absolute primacy to the economic aspect, this will result in disagreement, in incompatibility between the worker and the operative mode.For Work Psychopathology, this process always works impoverishing, because it restricts, disfigures, stiffens the entire versatility of the mental apparatus, producing suffering and creating possibilities for decompensation of workers' mental health, which, depending on the preferred psychological mechanisms, will acquire neurotic, between mental health and work through the analytic branches of exhaustion, general living and work conditions, stress, ergonomics and work psychopathology.These theoretical models present important contributions to the processual understanding of this interrelation, covering psychiatric indisposition, which includes mental suffering, conceived as an intermediary space between mental comfort or well-being and decompensated mental illness.These contributions offer possibilities for research and intervention in the work place, especially in terms of work organization and its structuring role, that is, its role in mental health promotion, which can support the adoption of prevention strategies aimed at workers' mental health.Theoretical branches supporting studies about the interrelation between mental health and work assume different conceptions in the sphere of this binomial, offering the possibility of a more contextualized research to specialists.These models, however, face a consensual difficulty with respect to the adopted theoretical conceptions, affecting both the delimitation of the object, the choice of analytic categories and the adopted methodological strategies.This entails implications for researchers' intellectual production in this area.When adopting one or another theoretical model, they are confronted with conceptual difficulties, deriving from the unspecific character of the involved categories, which may lead to unavoidable harmful repercussions for the methodological aspect of these studies.This consensual difficulty to apprehend the link between mental illness and the work situation constitutes a process that is specific for each individual, involving his/her life and work history.This implies the identification of the work situation in terms of environment, organization and perception of work's influence in the mental illness process.This difficulty is also present in the association between clinical and work situation, which complicates the establishment of a taxonomy of work-related mental disorders.Despite agreement about the etiological importance of work, there is no consensus about the way work and mind are connected.This could offer a theoretical framework to analyze this connection.
Mental health and work: meanings... Fernandes JD, Melo CMM, Gusmão MCCM, Fernandes A, Guimarães A. Rev Latino-am Enfermagem 2006 setembro-outubro; 14(5):803-11 www.eerp.usp.br/rlaesubject's confrontation with the work reality.They address work as a dynamic locus, in which identity is constructed and continuously transformed, evidencing differentiated work relations (as an effect of work organization) that interfere in workers' mental health.
Work Psychopathology approach.These analyze the dynamics of mental processes mobilized by the