CLINICAL ETHNOGRAPHIC NARRATIVE INTERVIEW ABOUT THE EXPERIENCE OF WOMEN DISCHARGED FROM THE PRISON SYSTEM

ABSTRACT Objectives to analyze the perception of women discharged from the prison system about the main stressors that marked their life trajectories and to discuss the feasibility of the Clinical Ethnographic Narrative Interview technique to facilitate the narrative of this group. Method narrative research developed in a social protection center in the interior of São Paulo. Data were collected in 2021 (January and February) using the Clinical Ethnographic Narrative Interview technique, which intersperses narratives and visual aids. The synergy between the concepts of vulnerability and stress was adopted as a theoretical framework, and content analysis was performed. The discussion of viability was based on the criteria of acceptability and expansion. Results The narratives addressed psychosocial difficulties prior to incarceration and the hostile environment of the overcrowded prison as a place of conflict and abuse of power. Family helplessness, estrangement from children, negative emotions, somatic symptoms and traumas were mentioned as consequences of seclusion. The participants also reported coping processes with words that referred to the ideas of overcoming, hope, new beginning and gratitude. It is understood that this high point of the narratives may reflect the potential of the interview technique and corroborates its adequacy. Conclusion The undoubted painful character of the narratives about the different adversities experienced, especially as a result of seclusion, was also permeated by aspects that denoted resilient processes. The adoption of this interview technique made data collection more sensitive, welcoming and timely to expand the repertoire of words in the expression of feelings and revisit painful experiences, envisioning positive possibilities for the future.


INTRODUCTION
Recent studies on female vulnerability highlight issues such as violence, greater susceptibility to mental disorders, socioeconomic and racial aspects and gender inequality as significant stressors that permeate women's life trajectory [1][2][3][4] .These questions are configured as social markers that are intersected, especially in some specific subgroups, such as incarcerated women and/or discharged from the prison system [5][6] .Brazil, a country in which social and gender inequalities assume significant dimensions, has the fifth largest female prison population in the world 7 .The predominance of black people with low education in Brazilian prisons reflects the inequalities associated with the incarceration process in the country, both in women and in the general prison population [7][8][9] .
The complexity of criminal phenomena, added to the pressing sexist issues in the Brazilian scenario, tend to legitimize, in the social imaginary, a moral judgment.As a result, even before legal analyzes and decisions, women offenders already have their condemnation culturally guaranteed by society in general 8,[10][11] .Therefore, the establishment of new life projects, even as ex-convicts, is an even more challenging possibility for women than for the male population [12][13] .
Corroborating these conditions, there are numerous studies that deal with abandonment and the difficulties of reestablishing relationships as issues experienced in a more expressive way by the population of incarcerated women and/or those released from the prison system [9][10][11][13][14][15] . That i, this subgroup is described as even more vulnerable in terms of mental health, which demands the assumption of a priority position in terms of research development, public policies and the expansion of the spectrum of psychosocial interventions [8][9][10][11][13][14][15] .
Mental health is one of the focuses of the Sustainable Development Goals (SDGs) [16][17] and one of the items proposed in the annals of the current National Agenda of Priorities for Research in Health 18 .There are specific recommendations on the development of research that help consolidate effective strategies to combat stigma and prevent drug use, addressing aspects related to families, social support networks and gender-related vulnerabilities.Efforts are recommended to implement new technologies, methods and techniques both to investigate and to prevent and treat aspects of mental health 19-20 .Women's mental health has also been the subject of national and international public policy agendas 8,[11][12]21 . It s recommended that opportunities be provided for improving self-esteem, developing problem-solving skills, learning about assertiveness and expressing emotions, always considering the individual experiences and cultural specificities of women 22 .
Several studies have been developed with incarcerated women and women released from the prison system, considering both the different psychosocial aspects that permeate such conditions and the strategic themes on mental health advocated by the World Health Organization (WHO), such as prevention, treatment, tracking of symptoms, violence and vulnerabilities 8,10,[13][14][23][24][25] . Howeve, regarding the methodological approaches used in such studies, there is a tendency to adopt more traditional data collection techniques, such as questionnaires, interviews and focus groups.Therefore, a gap is identified regarding methodological approaches and collection techniques that are sensitive to different forms of language (oral, visual and artistic) and can "give voices" to these women.In other words, techniques that expand the expression potential of these women in exposing their perceptions and points of view, as well as in elucidating the most prominent stressors in the different stages of their life cycle, facilitating the identification of psychosocial needs and which collaborate in the planning of activities, health actions and policies.

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Thus, an innovative aspect of the present study is the use of the CENI (Clinical Ethnographic Narrative Interview) [26][27] technique to investigate the experiences of women who have left the Brazilian prison system.The proposed research questions are: "What is the perception of these women about the main stressors that marked their life trajectories?Does the CENI technique help to qualify the narrative in this group?".Thus, this study aimed to analyze these women's perception of the main stressors that marked their life trajectories and, based on this analysis, discuss the feasibility of CENI to facilitate the narrative of this group.
CENI consists of an approach authored by an American researcher named Denise Saint-Arnault 26 , which uses visual techniques as triggers for qualitative interviews.It is a set of strategies that provide the connection between the object of study and aspects of the participant's life, based on a variability of angles.In addition to the proposal to improve the collection of qualitative data, the author understands that CENI has the potential to help the subject to process the articulation between the meaning that he attributes to a certain event/experience and the meaning of the cure / recovery 6 .Thus, the use of CENI, in addition to providing more fluid interviews, has the potential to raise important reflections in relation to self-perception and current emotions, motivating participants in relation to future projects 22,[27][28] .
Previous studies have revealed that this technique enables a chronological rereading of the experiences lived by women victims of trauma, encouraging them to develop an internal and external movement.This results in both a more accurate narrative of events and the reorganization of feelings related to such experiences.In addition, it values the timeline perspective as a continuum, including visual data as a way to expand the participants' repertoire of emotional expression, providing them with an opportunity to ventilate their traumatic experiences [26][27][28] .
Although the CENI technique has been used to collect data from women trauma victims in international studies 22,[26][27][28] , the condition of being discharged from the prison system and living in a country like Brazil, marked by strong gender violence, wide social inequality and high prevalence of female incarceration [7][8] , provides an even greater character of novelty to the present study.In addition, it may contribute to expand the list of research that examines the use of innovative strategies in qualitative research.

METHOD
Qualitative research called narrative research was implemented, which aims to explore the experiences of a person based on the story they tell.The process of talking about the events of one's own life allows the individual to reveal themselves in their own story and attribute a new meaning to the experience [29][30][31][32] .
The focus given by narrative research is the chronological sequence of events experienced by the person and their consequences.This is because the process of narrating one's own story evokes the feeling of being heard and requires the subject to organize their thoughts in order to attribute a certain cohesion and coherence between the episodes, articulating present, past and future [29][30][31][32] .
The present study was developed in a social protection center linked to the city of a municipality in the interior of the state of São Paulo.Among other attributions, this center is responsible for promoting actions for the inclusion and/or social reintegration of people in situations of social vulnerability, including women who have left the prison system.
The study population consisted of women who had left the prison system and were assisted by the aforementioned agency.The eligibility criteria were: attendance at activities in the last six months; be over 18 years of age; and be literate, considering that part of the data collection technique used 5/16 requires reading skills.At the time the study was carried out, there were approximately 12 eligible women released from the prison system.Regarding participant recruitment, a meeting was held with the person in charge of the place and individual meetings were scheduled with potential participants, in order to invite them to participate in the study, present the research objectives and clarify possible doubts.As for the sample, the data saturation criterion was adopted, resulting in the participation of five women.The invitation was made as each interview was completed; there were no refusals.
Data were collected from January 17 to February 15, 2021 by the main author, who was previously trained in the use of the CENI technique in a 12-hour theoretical-practical course taught by Professor Denise Saint-Arnault, author of this technique.The interviews were conducted in person, were audio-recorded and lasted approximately one hour.The script and procedures for implementing the CENI were developed and validated by the author of the technique with women from different countries around the world, including Brazilian women residing in Japan 33 .
This research is the first study in Brazilian territory developed with CENI.It was supervised by Professor Denise Saint-Arnault, who provided the main researcher with all the necessary material, previously translated into Portuguese.That is, the CENI script is inherent to the technique itself, and its implementation takes place through four main approaches that intersperse triggering questions and specific visual resources to enable narratives by women who have experienced traumatic situations and/or with a high level of stress.Such approaches are Social Network Map, Card Sort, Body-mapping and Timeline.The use of the CENI technique requires a license that is obtained after theoretical-practical training with the author of the technique.
The Social Network Map addresses interpersonal relationships and aims to identify the main supporters.Card sort refers to emotions.It consists of using cards with names of feelings, and its uses aims to encourage participants to name their feelings, causes, consequences and meanings of current events and/or future prospects 22,26 .
On the other hand, the Body-mapping technique, deals with somatic issues and provides the visual representation of the body, so that the woman can communicate the main points of tension, scars and "marks" of her life experiences 22,26 .
Finally, the Timeline is a retrospective of the individual's trajectory and gives rise to a systematic graphic representation of the various stages of his life.The responsible researcher must provide a blank sheet of paper to the subjects, in which the main events, symptoms and feelings must be located and the ups and downs of their life must be indicated 22,26 .
According to the instructions for implementing the CENI technique, all approaches must take place in a single meeting, individually and in a place that guarantees the participant's privacy.In addition, the sequence and content of the script must be rigorously considered, as the issues and procedures form a specific logical chain.
It is worth mentioning that, in addition to the CENI script, the participants were presented with the guiding question: what were the main difficulties/tensions they experienced throughout their life trajectory?
As for the theoretical framework, propositions related to the synergy between the concepts of vulnerability and stress 21,[34][35][36][37] supported the entire development of this study (choice of data collection technique, interpretation of results and discussion).In such propositions 21,[34][35][36][37] , vulnerability is apprehended as the tendency of a group, system or individual to suffer the impacts of a stressor, appearing as a complex interaction between risk (probability of a "danger" occurring) and adaptive capacity 21,[34][35][36][37][38] .Regarding the theoretical framework, propositions related to the synergy between the concepts of vulnerability and stress 21,[34][35][36][37] supported the entire development of the present study 6/16 (choice of data collection technique, interpretation of results and discussion).In such propositions 21,[34][35][36][37] , vulnerability is apprehended as the tendency of a group, system or individual to suffer the impacts of a stressor, figuring as a complex interaction between risk (probability of a "danger" occurring) and adaptive capacity 21,[34][35][36][37][38] .
Based on these assertions, it is recommended that the study of vulnerable situations start from the analysis of stressors (hazards and threats), their causes and effects 35 .In this context, it is highlighted that situations related to lack of access to basic human rights are configured as stressors that can culminate in damage to life, social, economic and environmental factors.Therefore, these situations contribute to social vulnerability, marked, for example, by conditions of poverty, illiteracy and low social capital 21,26,35,[37][38] .Figure 1 presents the conceptual framework adopted from this framework.Given that the Brazilian female prison population has a profile that goes back to several social markers related to vulnerability and poverty -race-color, low education and family of origin with typical characteristics of socioeconomic deprivation 7 -, the present study was developed considering the intersection of these different factors and their influence on aspects of women's life and health.
The narratives derived from the used approaches were transcribed and analyzed through the content analysis technique 39 and under the umbrella of the theoretical framework adopted.The information provided by the women from the visual data was also transcribed and considered in the content analysis process, as well as used to illustrate the Meanings expressed in the narratives.
With regard to CENI's feasibility, the adopted criteria were adapted from a study with methodological recommendations for the feasibility analysis 40 and comprise: a) acceptability: concerns how participants react to the approach 40 ; for this, the willingness of the participants to respond to the proposed contents, the engagement in the approaches, the ease of understanding and the possible 7/16 difficulties during the process were considered; b) expansion: corresponds to identifying the potential of the approach with a population different from that previously tested, in order to verify the possibility of expanding its use to new groups 40 .In this case, the quality and depth of the data obtained were considered, as well as their coherence in relation to the objectives of the technique.
The researcher's impressions regarding these items were noted shortly after the end of each interview.The evaluation of these criteria also considered the results obtained in the content analysis, and all weightings were timely discussed with the team of researchers and reported to the developer of the technique, who endorsed these weightings.
The present study received approval from the Research Ethics Committee of the institution of origin and all ethical aspects provided for by Resolution No. 466/12 of the National Health Council were considered.The participants signed the Free and Informed Consent Form and, in order to guarantee anonymity, the letter P followed by a number corresponding to the sequence in which the participants were approached during data collection was used to identify the statements.

RESULTS
The interviewees were between 30 and 37 years old, having been deprived of liberty for periods ranging from four months to 12 years, for penalties related to involvement in drug trafficking and other crimes, as can be seen in Chart 1. Data analysis resulted in three major themes.Figure 2 shows the code tree of the categories listed based on content analysis.

Category 1 -The causes and consequences of incarceration
It was identified that the participants were involved with both drug use and trafficking in childhood, culminating, later, in penalties and incarcerations.

Oh! In my life trajectory, I think that at the age of seven I was addicted to drugs, I lived in XXX [vulnerable neighborhood of the participant's municipality of origin] ... When my mother went to find out, I was already completely addicted to drugs [...] my mother became desperate, how can a child of seven, eight years old be addicted to crack? (P1).
Once deprived of their liberty, they were faced with a hostile environment marked by abuse of power, difficulty in living with other women and other adversities intensified by overcrowding.

So a lot of the time, they [cellmates] would mutilate themselves because of everything they went through, what they were feeling, they couldn't get it out [...]. One of the most difficult things was
dealing with people, many women in the same space [...].In my cell there were on average 18 to 25 women, but the capacity was for eight women, many were on the floor, on the "beach" as they say inside.The larger cells, on the other hand, held up to 45 people (P3).
In addition, breakdowns of family ties and friendship due to incarceration were mentioned.

Because you think you have friends being inside or outside, but we don't, it's betrayal of friends and family in general, then there's no reason to be together (P2).
The estrangement of the children was referred to as a significant suffering, also resulting from incarceration.
At first I was a little desperate, because they took my young daughter [...].I am still trying to get custody of my son, it is a a stronger relationship.When I was arrested, he was small, so I had no contact with him, because I did not receive visitors (P4).

9/16 Category 2 -Previous social vulnerabilities aggravated by incarceration
The participants emphasized situations of violence, social, financial and learning difficulties in their life trajectories.

But when I was four, he [uncle] tried to rape me and it was like that until I was eight. [...] I didn't go to school properly and didn't even know how to read (P4).
Events such as fights and separation from parents and numerous negative emotions (helplessness, anger, revolt, disappointment) were emphasized when describing childhood and adolescence.
So from the age of six to 10 was the frustrating part...I saw the fights, from my father to my mother, he came with a knife [...] I felt nervous and restless [...] A lot of anger, because I recorded everything my father did with my mother [...] I cried in the room, silent about it, from six to 10 years old (P2).
All of these emotions were intensified by incarceration and translated into physical symptoms such as pain, weakness, menstrual problems, tremors, and post-traumatic stress symptoms.
My hands, my feet were cold [...] here on my legs I will draw them swollen, because it was like that inside (P3).There were many traumas, when I hear a lot of noise I go into despair... sleeping is very rare, I have too much difficulty sleeping, for me it's all inside (P4) Sensations such as emptiness, fear, helplessness, sadness, frustration, loneliness, despair, shame, nervousness, regret and trauma were reported in relation to the context of the prison.
The first was frustration, I spent eight years without accepting my condition of being trapped, everything inside was a reason to get tired and suffer.I lived with irritability/nerves at the surface of the skin, cold hands and was always worried, excessively worried, heart racing, [...] I remembered that I did not deserve to go through this, if I had denounced it, I would not have stayed away from my daughter (P3).
The main characteristics attributed to the period as ex-convicts were unemployment, stigma and prejudice.
[...] and I can be qualified there for a certain type of job opening, I am there at that opportunity, I am the most qualified person, I am telling you about cases that have already happened, at the time they pull my criminal record, I do not have the slightest chance, and that person who was there being discarded, being passed in front of me, she does not have that competence they are asking for and does not have any of the skills they are wanting, but she will be passed in front of me because I will be excluded (P4).

Category 3 -Resilience, future perspectives and social supporters
The participants also reported coping processes marked by spirituality and life projects.Overcoming and starting over delimited part of the participants' speeches in relation to the current moment, in which they demonstrated to be imbued with hope and gratitude despite the whole history of suffering.Some also mentioned that they are proud of the way they are today.
It is enough to have faith, to have confidence in God and to want to change [...].I have a lot of gratitude for all the people I met [...], I am very grateful to the pastoral class, for having known God and finding myself (P5).

I feel proud of the woman I am today and of everything I learned and saw inside (P3).
In addition, one of the main priorities listed by the participants was related to the process of self-acceptance as a path to change.The appreciation and importance of the family and marriage were highlighted, which were described as the basis for restarting their lives.

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Ah, the important thing now is that I can put it into practice, for everything I went through, I changed a lot (P1).

Today, because I am married, I have another vision of what it is to be a family [...]. Although I didn't get it at the moment I wanted to, I have to fight and keep fighting, just like I did and have been doing (P5).
Social support was a recurrent theme in the different phases of the life cycle, according to the participants' reports.They also identified the family as the main provider of different forms of support, especially emotional and material.
So I had help from my godmother, my daughter to think about her and wanting to be with her was very wonderful (P3).
The spiritual support and actions of the church played an important role in the trajectory of these women.Despite this, some reported not perceiving a supporter in their social environment.
And the psychological help and the services they had inside the church with the pastor.Without them I would not be able to, not even, their help was without explanation, I am so grateful,[...] I thank his team [the pastor of the church] who helped a lot and welcomed me (P3).

Feasibility of the CENI technique
Chart 2 presents the opinion that the researchers involved issued for each of the criteria adopted in the feasibility analysis.

DISCUSSION
The profile of the participants presents social issues that precede involvement with crime and imprisonment, corroborating several studies that highlight the issue of the cycle of vulnerability and poverty experienced by this group -which is also characteristic of the working class, especially in countries of low and middle income  . These apects ratify the question of the synergy between the concepts of vulnerability and stress, given that the intersection between being a woman, being from a peripheral and poor family and being released from the prison system imprints on their trajectories a set of susceptibilities to suffer even more, as well as such as personal, social, economic and environmental damage, corroborating the theoretical framework adopted 21,26,35,[37][38] .
The participants' narrative revealed a trajectory marked by hostile environments, both in relation to structural issues -negative family and social experiences experienced in childhood and adolescence

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-and to prison itself in adult life.These are aspects that culminated in feelings and manifestations of suffering and trauma, corroborating previous studies carried out with this population 8,[10][11]14,23 .
In general, in childhood and adolescence, this perception was reflected in parental figures; in adult life, it was reflected in their children, friends and other women with whom they lived while incarcerated.In the light of the theoretical framework, it appears that such relationships form the basis of the low social capital 38 reported by them, since the contingency of interpersonal relationships in these contexts demarcate a low repertoire of possibilities for changes, transcendences and/or expansion of social resources and access to basic health rights and social protection.
Furthermore, the trajectory of these women passes through the intensification of feelings such as helplessness, emptiness and fear, which are translated into somatic manifestations such as pain, tremor and weakness.Even though they share traits of resilience and a positive perception of potential supporters of their social environment, as ex-convicts, these women experienced the raw reality of unemployment, stigma and prejudice.In the case of this subgroup, these points are intensified by the issue of gender and the condition of social inequality in the country.
That is, the participants described the period experienced in prison as permeated by traumatic episodes resulting from a hostile and violent environment, as well as feelings that refer to situations of terror and extreme loneliness, framed by an environment with precarious infrastructure conditions, overcrowding and no place for their emotions.Additionally, imprisonment culminated in the distancing of children and family abandonment.As ex-convicts, the precariousness of work and stigma were highlighted as significant stressors.In these aspects, the results were similar to those found in previous studies [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23] , including those that used a quantitative methodology.
Therefore, based on the importance of apprehending the phenomena from a perspective that considers the interaction between risks and adaptive capacity, as pointed out in the theoretical framework 8,[10][11]14,23 , it is worth highlighting a result different from those presented in previous studies and, certainly, resulting from the study design.
This result concerns aspects related to resilient processes evidenced in the narratives.That is, despite all the suffering experiences, vulnerability conditions and stressors mentioned, the narrative of these women was permeated with words that denote feelings of hope and overcoming.There are, for example, numerous mentions of social supporters, with emphasis on those related to their spirituality and religiosity, which seem to have been decisive for them to re-signify their roles and identity and establish life projects.
It is worth pointing out that spirituality was mentioned as an important aspect in relation to the installation of hope and reflections on future projects.Thus, it is worth highlighting the action of various religious groups in the scope of Brazilian prisons and their repercussion on the life and beliefs of this public -aspects also described in a previous study 12 .
As for the use of the CENI technique as a facilitator of the narrative of the women studied, due to the fact that the proposed script is based on reflections on social and family relationships and considering the community context where they live, it is understood that such a technique enables the interviewer and interviewee to have a exchange of cultural information, as well as providing opportunities for reflection on the multiple roles attributed to such women in their life contexts.Furthermore, as previously described, the interview interweaves the narratives with visual tools, such as the network map, the body map and the lifeline.The researchers perceived this aspect as providing a lighter environment and, in a way, that evokes the ludic -even when approaching a painful topic for the participants.
The Card Sort step was the most challenging, as the participants were reluctant to rename what they felt.On the one hand, this can be interpreted as resulting from a more restricted linguistic repertoire of most participants; on the other hand, it denotes how much more vulnerable contexts in 12/16 socioeconomic terms have "space" for reflections on the subjects' more subjective expressions or even for the appreciation of their emotions, given that the urgency for the "basic", in terms of "survival", is the priority listed by the group in most cases.
Despite these challenges, the technique proved to be very powerful for studies on stressful events, life and health trajectories, as it helps to approach topics related to human suffering in a sensitive, welcoming and non-invasive way.It is a technique that is strongly recommended for studies with populations in situations of social and emotional vulnerability, as is the case with women released from the prison system.
In short, the potential of the technique lies in enabling participants to understand their life trajectory based on the narrative of remarkable events and as a continuum of challenging (but positive) experiences, allowing for a fluid and consistent interview on psychosocial issues that permeate their trajectories.It is also noteworthy that the sequence proposed by the script enables the end of the interview to focus on aspects related to future expectations, promoting a less painful outcome for the women's speech.It is a type of invitation for them to reframe their experiences of pain and suffering.
The main limitation of the study is the composition of the sample in terms of number of participants and the mode of recruitment, as well as the challenges of developing studies like this in a period as troubled and marked by social distancing measures, such as the covid-19 pandemic.