THE IMPLEMENTING PROCESS OF THERAPEUTIC HOMES IN VOLTA REDONDA – RIO DE JANEIRO

A historical-social study with the objective to describe the circumstances surrounding the creation of Therapeutic Homes in Volta Redonda, defining the structure and functioning of these homes and analyzing the nurses’ role during the implementation process. Laws, decrees, ordinances and reports, in addition to oral statements from the professionals involved in the process, were used as primary sources of information. Data collection occurred from December of 2009 to June of 2010. Findings were organized, classified and analyzed according to an historic method, supported by the literature regarding the theme. The implementation of Therapeutic homes was observed to represent a complex process in which nurses acted through outpatient institutions that comprise the mental health care network. The importance of these homes was shown as contributing to and increasing the clients’ autonomy and the fundamental participation of nurses was the link between these homes and the mental health primary care units. DESCRITORS: Nursing. Psychiatric nursing. Mental health. History of nursing. Assisted living facilities. EL PROCESO DE IMPLANTACIÓN DE RESIDENCIAS TERAPÉUTICAS EN VOLTA REDONDA –RIO DE JANEIRO RESUMEN: Estudio histórico-social. Los objetivos: describir las circunstancias de creación de las Residencias Terapéuticas en Volta Redonda-Rio de Janeiro; caracterizar la estructura y el funcionamiento de esas residencias y analizar la actuación del enfermero en el proceso de implantación. Tuve como fuentes primarias: leyes, decretos, portarías e informes, además de seis testigos orales de profesionales que participaron de ese proceso. La recogida de datos ocorió los meses de diciembre de 2009 hasta junio de 2010. Los hallazgos fueron organizados, clasificados y analizados conforme el método histórico con apoyo de la literatura sobre el tema. Los resultados evidenciaron que la implantación de las Residencias Terapéuticas representó un proceso complejo en el cual la actuación del enfermero ocurrió a través de instituciones extra hospitalarias que componen la red de atención a la salud mental. Se concluye sobre la importancia de esas residencias para el rescate de la autonomía del usuario y sobre la pertinencia de la participación del enfermero como ello entre esas residencias y las Unidades Básicas de Salud Mental. DESCRIPTORES: Enfermería. Enfermería psiquiátrica. Salud mental. Historia de la enfermería. Instituciones de vida asistida. 86


INTRODUCTION
Nursing care of individuals with mental disorders in Brazil has been developing throughout the years, in an effort to meet the proposals resulting from Psychiatric Reform that requires from health professionals an opposing practice to the one initiated by traditional psychiatry featuring isolation, punishing treatments and physical and chemical restraint of patients. 1Psychiatric care practice has been evolving gradually and slowly, despite the ethical and legal implications that demonstrate the need for accelerating the process. 2 Brazilian Psychiatric Reform, initiated in 1980, implemented new proposals regarding the care provided to individuals with mental disorders, with a view to ensuring the right of citizenship. 3In order to ratify these proposals, Law No. 10.216/01 was issued with the objective to guide, once again, the mental health policy in Brazil, prioritizing the rights of individuals with mental disorders. 4long the path of guiding the mental health policy in the country once more, a process of transformation in the therapeutic conduct concerning individuals with mental disorders has been occurring, opposing psychiatric hospital admission.] CAPS provide a day-hospital milieu for therapeutic services for individuals or groups including: workshops, play activities, home visits, care for the family, and community activities. 5Moreover, CAPS promote the articulation among many outpatient services within the mental health care network of the city, comprising the General Hospital, Family Health Program (FHP), Therapeutic Homes, Community Centers, Neighbors Associations, and Clients' Rights Defense Institutions. 4nder this perspective, in 1993, an implementation process for psychiatric reform was initiated in the city of Volta Redonda, in the south region of the State of Rio de Janeiro.The process was quite complex, supported by political party interests, and based on the urgency of a needed intervention in the area of mental health that would be able to protect the citizenship rights of individuals with mental disorders residing in the city. 6e implementation process of psychiatric reform in Volta Redonda began with municipal intervention regarding the specialized institutions providing treatment to individuals with mental disorders.Since then, municipal authorities have invested in many actions such as the creation and implementation of CAPS, some integrative activities involving the use of public spaces for clients requiring mental health services, the creation of a support social network for clients and investment in the hospital discharge process, among other actions. 6herapeutic homes were implemented in 2009, and can be described as an environment in which individuals with mental disorders prepare for their eventual return to home, progressively taking on more of their "normal" routines and becoming able to exercise their rights and duties in common life.
Therapeutic Homes, instituted by Regulation/GM No. 106, of February 11, 2000, have the main objective of providing housing; however, they should not be mistaken as being a place for the provision of health services, since they are associated with other services comprising the mental health care network of the city.They can benefit individuals with mental disorders who have no family support, individuals from Psychiatric Secure Units sent to the home by judicial mandate, people supported by CAPS with housing issues identified by the interdisciplinary team and homeless people supported by CAPS who present with mental disorders. 7enerally, a Type I Home is suitable for more autonomous individuals with mental disorders; in other words, people who require daily activities supervision inside and outside of the home, and who are attending social integration activities promoted by CAPS.Individuals living in the Home do not require specific health care.Type II Homes are suitable for clients who are dependent on direct care; for instance, senior citizens who are physically disabled and/or those with other conditions requiring daily care from a nursing aid professional 7 .
Acknowledging that nurses working in the mental health field must follow the mandates required by health services, mental health nurses are following a new path where rethinking nursing care requires viewing mental health care provision in a broader and more humanized way, walking away from the old illness model that was demonstrated as being insufficient to deal with the The implementing process of therapeutic homes in Volta Redonda... complex issues involved in mental health care, towards a model of interdisciplinary care which is necessary and crucial 8 .The implementation of Therapeutic Homes has become one more challenge in the work of these professionals, along with the other members of the mental health team.
In view of these facts, and with an eye to continuing the research in order to better understand the historical phenomena regarding the expansion of strategies to meet the needs of those who have mental disorders, this study regarding the implementation process of Therapeutic Homes for individuals with mental disorders in the city of Volta Redonda in the year of 2009 is presented.
This present study has the following objectives: describe the circumstances involving the creation of Therapeutic Homes in Volta Redonda-RJ, define the structure and functioning of Therapeutic Homes in Volta Redonda-RJ and analyze the work of nurses in the implementation process.

METHODOLOGy
The study utilizes an historical-social guided research method, since it includes the study of human groups within their temporal space with a view to discussing the different aspects involving the routine of different classes and social groups.The historical-social research is, therefore, understood as a synthesis and allows for demonstrating the principle that, in history, every approach is socially registered and interconnected, and also limits specific fields of issues that are formulated due to its historical discipline. 9ata collection took place between the months of December of 2009 to February of 2010 and was composed of written documents and oral statements.Primary sources were identified from written documents such as laws, decrees, regulations and reports available on the Ministry of health site, in addition to the formal Implementation Project of Therapeutic Homes of the city of Volta Redonda-RJ, located in the Center for Mental Health Studies of the Volta Redonda Health Hospital (CSVR in Brazilian acronyms).
Oral statements were also used and were fully transcribed from the people involved in the creation and implementation process of Therapeutic Homes, including: a social worker (E1) who is part of the Technical Coordination of CSVR; the nurse (E2) who has held the position of Volta Redonda Mental Health Program Coordinator since 2008, and is responsible for conducting mental health in the city; an entertainment professional (E3); a nursing aid (E4) who works in one of the Therapeutic Homes; a nurse (E5) who works in one of CAPS units; and a nursing manager (E6) from the Family Health Program (FHP) team who is responsible for one of the Therapeutic Homes.The instrument used to guide interviews included questions regarding the challenge of professionals and the city public authorities in the implementation of Therapeutic Homes, and the strategies used to overcome difficulties.
For data analysis, secondary sources that approached Psychiatric Reform, its implications for nursing and society and the historical nursing studies surrounding the subject were used.These sources were found in an essay located in the Mental Health Studies Center (CESAM in Brazilian acronyms) of CSVR and in the Anna Nery Nursing School Sector Library of Postgraduate Degree of the Federal University of Rio de Janeiro; and in scientific articles indexed on the SciELO data base, identified by searches using the following descriptors: Psychiatric Nursing, Therapeutic Homes and Nursing History.This study discusses the implementation of Therapeutic Homes in Volta Redonda and contributes to the analysis regarding the implementation of Psychiatric Reform in Brazil and how the work of nurses was performed in regards to the care of individuals with mental disorders in Volta Redonda, contributing towards disseminating reform to one more working space and consequently ensuring its importance for society.
Also, it is important to state that, due to Resolution 196/96 of the National Health Council, this present study was subjected in September 18 th of 2009 to the Research Ethics Committee of the Anna Nery Nursing School/Teaching Hospital São Francisco de Assis and was subsequently approved according to protocol No. 058/2009.
Every subject in the study signed a Free and Informed Consent Form and authorized the recording of statements and their use, fully or segmented, for this study and its products under the format of a publication and/or scientific work presented in national and international events.
After repeatedly reading the document corpus, findings were organized, classified, contextualized and analyzed according to the historical method and supported by the literature regarding Psychiatric Reform and the care of individuals with mental disorders, allowing for the construction of an original version of the participation of nurses in the implementation and functioning of Therapeutic Homes for people with mental disorders in the city of Volta Redonda-RJ.

Therapeutic Homes for Volta Redonda -Rio de Janeiro
The implementation of Therapeutic Homes in the city of Volta Redonda was precipitated by the fact that municipal authorities lost, in 2009, the right to administrate the Volta Redonda Health Hospital (CSVR), the last institution used for inpatient care of individuals with mental disorders and that was kept under the threat of closure for the past 15 years.This situation required an immediate solution for the referral of clients who were in the hospital, after the Volta Redonda Health Hospital was closed down.The following statements demonstrate the desperate nature of the end of the municipal intervention in CSRV, showing the need to relocate all clients from the institution within a short period of time, requiring the municipal authorities to provide for the creation and implementation of Therapeutic Homes.
[...] We thought about a Therapeutic Home, but everything was set; however, everything had to be done fast because they asked for the house [CSVR] back, we were already working on the closing of this mental institution […] (E4).
[...] Everything happened so fast; they had from January to June to get organized when they received the judicial order that the Volta Redonda Health Hospital had to be emptied.[…] but I believe the city was not helping it [Therapeutic Home] in any way.They were not caught by surprise because the hospital was under threat of closure for 15 years (E3).
Considering the short period of time allowed for transferring the admitted clients, there was a need to actively involve the clients, families, neighbors of the Homes and the professionals working in mental health.As with any change, this social transformation in the city presented possibilities and limitations for its development.
The implementation of Therapeutic Homes became a necessary solution to relocate clients and, at the same time, remain congruent with the Psychiatric Reform guidelines.The mental health service had the support of CAPSs which, in their turn, contributed towards building an outpatient mental health network and other services that favor the implementation of the Homes, as evidenced by the following statements: [...] the mental health support of the State [Rio de Janeiro] indicated that it could build Therapeutic Homes because Volta Redonda had the support of a consolidated outpatient mental health network (E1).
[...] of course the therapeutic home is not a usual home, but there is a tendency for the client to become as well adjusted as possible in these Homes and the caretaker can use these other services as much as possible to make the therapeutic home worthy as a model for a Therapeutic Home (E2).
We can observe that the implementation process of Therapeutic Homes in Volta Redonda was closely related to the existing mental health network in the city and that, within the health policies perspectives, it could support and follow up these new services.Hence, the implementation proposal for these homes followed the guidelines of the mental health policy set forth by the Ministry of Health and was part of the Psychiatric Reform development actions in the city.Therefore, in June of 2009, three Therapeutic Homes were created in Volta Redonda.
In the initial phase of the implementation project, during the process of analyzing and selecting real estate, some difficulties were immediately detected regarding the purchase of property.The houses that most closely met the clients' needs were located in the center portion of the neighborhoods, since they would facilitate transportation; however, these houses were very expensive to rent, as the following statement reports: [...] we decided to get the first house we found in an accessible location that met our needs and was in good condition […] We found three houses in excellent condition […] But they were all in extremely central areas of the neighborhood […] (E2).
In addition, opposed to the psychiatric hospitals that could house many patients, Therapeutic Homes Services (SRT in Brazilian acronyms) must hold no more than eight clients per home, with no more than three clients per bedroom. 10By the determination of the Ministry of Health, these houses must have at least three bedrooms and provide basic comfort conditions in every room, in addition to appropriate furniture for the clients' needs.
Another difficult issue regarding the rentals concerned the resistance of the real state agencies and owners to enter into a rental agreement with a public organization, the mayor's office, because they feared that it would not honor the agreement, let alone pay the rent.In addition, they believed that there would be difficulties in breaking the agreements and with the immediate availability of these houses as the following statements explain: The implementing process of therapeutic homes in Volta Redonda...

[...] even when the real estate agency is agreeable to renting to a public organization, most owners will not because it's for psychiatric patients [...] (E2).
[...] according to the real estate agencies, the mayor's office is not well known for paying the rents on time and they could not be evicted due to overdue rent because it is a public organization, so this process was very difficult.Purchasing the houses also was delayed due to public tender (E3).
The implementation project of Therapeutic Homes in the city of Volta Redonda was created in 2005, by a social worker who was the Technical Coordinator of CSVR at the time.It called for the creation of four Therapeutic Homes according to the statement by the Ministry of Health. 17However, only three were implemented, culminating in their overpopulation.According to one of the interviewees: [...] the CSVR had 29 patients and each Home could only hold, according to the Ministry of Health, six or eight clients.Therefore, four Therapeutic Homes were needed and there would still be space for CAPS clients identified as in need of support, homeless with no family support (E1).
The creation of Therapeutic Homes, due to the fact that they received a higher number of clients than the predicted number as per the Ministry of Health, resulted in refusal of registration by the SUS and, therefore, they were exclusively maintained by financial resources from the mayor's office, as the following statement illustrates: [...] they are not registered because the number of clients is above what is allowed by the mayor's office; this is specifically why we need one more house, because we have one more client in each home.[...] these homes are being financed by the city, purely and basically because they are not registered (E2).
The reorganization of mental health care in Volta Redonda was a very delicate and difficult process.It required taking measures that influenced the life of clients and professionals, since the proposal, at the same time it presented the current hospital model, also required the implementation of alternative therapeutic practices that would stimulate clients' potentials and avoid the arbitrary control of their behaviors, as expected in legal determinations. 11The understanding of an interviewee demonstrates the differences between these two care proposals: [...] in the psychiatric hospital, if the guy [client] is agitated, the nurse or the doctor is called, medication is administered, the patient is tied down and that's it.

In the Homes, there is a bond, it is a process, it is totally different from the hospital […] currently, a very large change is observed in clients in relation to those in Therapeutic Homes, both in autonomy and in the CAPS treatment […] (E2).
The implementation project of Therapeutic Homes for the city of Volta Redonda established that housing must have the necessary human resources for its functioning: one Therapeutic Home coordinator who would be able to oversee the coordination between the Home and CAPS, training and supervision of services; six general service assistants for performing the tasks of assisting and monitoring domestic activities in the Type I and II Homes; four night caretakers (only for Type II Homes); and one driver for transporting the clients. 11

Therapeutic Homes functioning and dynamics in Volta Redonda-Rio de Janeiro
The process of transferring clients from a psychiatric facility to the Therapeutic Homes requires them to have psychiatric conditions that allow them to establish new interpersonal bonds and bonds with their new environment, because they face a different city than the one they were accustomed to before being hospitalized, particularly if they were hospitalized for a long period of time.Moreover, other challenges pervade the new routine of Therapeutic Home clients, since they must become acquainted with neighbors, the neighborhood and the daily paths around the city, generating a feeling of inclusion in the territory. 12ith the implementation of Therapeutic Homes, professionals working within these facilities identified a few of the clients' difficulties related to adjusting to the available physical space, since it was very different from where they were previously admitted.

In the first two months, it was very complicated for both clients and professionals. Clients had adjustment issues, including aggressiveness towards professionals and family members, a great rejection […] (E2).
The space is quite small, since they left a large psychiatric facility; inside the psychiatric facility, they were always in close proximity, but not as close.Due to the small space, sometimes some conflicts occur […] (E4).
Nursing aids who chose to be relocated from the psychiatric hospital to the new housing facilities spoke of their difficulties, mainly in controlling the psychotic crises of some clients, since the physical space was smaller and clients experiencing a crisis should be referred to the General Hospital, or to the Intermediary Health Care Center (CAIS in Brazilian acronyms) for urgent psychiatric care.The following statements illustrate this situation: [...] the ideal situation would be to hire all caretakers, but we can't do that officially.So we ended up making some adjustments, which caused much confusion and awkwardness regarding the professionals.First, since it regards a new service in Volta Redonda, and second, the people had no experience at all in working in a therapeutic home (E2). [

...] there is the difficulty in keeping a client inside the house who is experiencing a crisis, the other clients don't understand it […] we don't want the clients to stay in the psychiatric hospital, but how can we deal with a client experiencing a crisis in the house? (E4)
[...] there were a lot of physical assaults by some clients.But there were some professionals who were not assaulted; I believe it happened due to their conduct, their speech and the way they talked to clients.

They know exactly what people want to tell them […]. There were 30 days of hard work in which we had to rethink if it was worth it, but not due to the clients, but to the lack of support from the team (E3).
These statements point out the complexity of care for mentally ill clients when there are very significant changes in their daily routine.:216 Therefore, each patient attributes a distinct meaning to the new home, despite being in the same physical space. 13nother important factor was the lack of experience within the team to work in the Implementation Project of Therapeutic Homes for the city of Volta Redonda.It is a factor that increased the difficulty, since the success of this project requires the understanding that clients, after years of seclusion, had a constructed a subjectivity that fit within the modes adopted by the psychiatric institution; therefore, this subjectivity had to be re-elaborated in its range of meanings. 13lso, the unfavorable reaction of neighbors to the Therapeutic Homes became an obstacle, mainly when a client was experiencing a crisis.Although the employees had a few meetings with the Neighborhood Associations where these homes were located, many neighbors negatively reacted to the clients' presence and were, many times, prejudiced towards them, demonstrating dissatisfaction with the new situation.The most extreme case was the suggestion of a petition (an application with the signature of several neighbors) as a measure to force the municipal authorities to rethink the continuity of the Therapeutic Homes Project.The following statements illustrate this situation: [...] they were mobilizing a petition so that these clients would be taken out of there.[...] the 30 days I spent there were very difficult, we had the intervention of the Secretary of Health, meetings with the neighborhood association so that they could understand a little, help and collaborate with the arrival of these clients in the neighborhood (E3).
[...] they wanted to sign a petition to prevent these clients from moving into their neighborhood.Since we were already working on it, we intensified the work, having many meetings with the community, using the spaces in the church so that these people could become more acquainted with the clients and feel calmer about the situation(E2).
[...] another role of the nurse is to guide the community to avoid prejudice (E6).
The individuals with mental disorders also have an attribute of undesirability due to their psychiatric condition that generates consequences that make re-socialization difficult.The patient is still rejected and is seen as unfit to live in society.This stigma may lead individuals with mental disorders to confine themselves, consequently making their illness a chronic disorder, excluding them from their right to citizenship 14 .Therefore, the professionals' actions in creating awareness and breaking down the negative images involving these people are needed.
In the homes, the purpose was to make it work as a common home; in other words, with no rules or routines such as those practiced in a mental institution.Clients were encouraged to perform household tasks and no specific times were established for baths or meals; however, they required the attendance of a professional who would help them in their routine, always adopting an encouraging position towards the development of their autonomy. 7The following statement excerpts demonstrate some positive results in regards to clients' autonomy: [...] and, some of the patients who were obligated to wake up early there [in the mental facility] were already feeling better because they could sleep a little The implementing process of therapeutic homes in Volta Redonda... later.[...] Some clients wanted to clean the kitchen, they began to wash their own dishes, and they helped to set the table for lunch (E3).
[...] the home, house and family issues.Most of them felt this, especially at Christmas.We were able to build a family here, despite all conflicts (E4).
Therefore, clients must be encouraged to perform household tasks, but the risk for accidents must be managed during the process; they should also have autonomy in performing personal tasks, taking into consideration the specific needs and insecurities these clients have and respecting their limitations.It is necessary for clients to create their own residential habits, not conforming to an ideal model of living. 7Also, in view of the clients' lack of autonomy and the high degree of dependency for care due to long years spent in a mental institution, the experience of nursing aids as caretakers in the Homes is necessary, since they communicate directly to nurses from the outpatient services, as revealed in the following statements: [...] the patients in the homes had not been prepared as hoped and, at that time, the city, the mental health program, felt the need to place these caretakers as nursing aids, due to the low degree of autonomy these clients in Therapeutic Homes had […] (E5).
From the statements above, we can infer that the caretaker work in the Therapeutic Homes required, apart from a previous knowledge regarding the care and the treatment of mental disorders, experience in dealing with the individuals with mental disorders and their daily routine.However, due to the urgent situation caused by the CSVR closing, there was no time for appropriate planning for the implementation of the Therapeutic Homes in the city of Volta Redonda.
In 2009 the mental health network was organized in Volta Redonda as follows: three adult CAPS (one of the CAPS was in the transformation process of becoming a CAPS III); one CAPSi (for children and adolescents); one CAPSad (for the treatment of alcohol and drug abuse); one urgent care service for psychiatric crisis situations and/ or alcohol and drug detoxification; one CAIS Aterrado; and the General Hospital.CAIS Aterrado is a care service for emergency psychiatric treatment, where individuals with mental disorders are admitted for 72 hours for treatment and control of psychiatric crisis situations; however, since it can only admit clients for a short period of time, it does not refer to the nursing home model of psychiatric hospitals. 11onsidering the proposal for the Therapeutic Homes, the presence of nurses within them is not justified.However, it does not lessen the importance of the nurses' work as the link between the Homes and the health services that provide care for individuals with mental disorders.This is possible through their participation within interdisciplinary teams, both in CAPS and in FHP, in home visits and in the interaction with nursing aids who work directly in the Therapeutic Homes.
We must emphasize that CAPSs hold a fundamental position within the Therapeutic Homes, since they promote the possibility for clients to improve or resume family bonding and encourage participation in household tasks, generating more autonomy and promoting psychosocial rehabilitation through placing clients in public activities. 6Under this context, nurses participate in the Therapeutic Homes, meeting the clients' needs by making home visits.In this way, a bond of trust is built between professionals and clients, and between clients and the services that support them.These relationships can be observed in the following statements: [...] this is crucial, since it comprises a multidisciplinary team that is not present within the Homes.It is important to build the clients' autonomy, so they find their own abilities as human beings (E3).
[...] I think it means performing other types of activities that are not performed in a house and the acquaintance with colleagues and me.I think this is important to them; so are the workshops (E4).
Regarding the Family Health Program (FHP) in Primary Health Units, the care must be explained within this program as being guided by the attention to chronic and acute diseases clinical issues; in other words, routine clinical care for diseases and/or prevention of exacerbation of chronic disease and health promotion 4 .Therefore, nurses and other health professionals of the FHP perform monthly home visits according to the needs of the Home.Meanwhile, clients are mainly referred to the Unit for care, because the care performed by the FHP team does not give priority to Therapeutic Home clients because of their psychiatric illnesses.They are all cared for equally within the range area of each team, as illustrated by the following statements: [...] if they are feeling ill, the client goes to our unit, is cared for and is referred according to necessity.
There is no difference in our work approach because they are special; we see it as a normal home (E6).
[home visits] are for control and for a better quality of life for these people, guiding and bonding, so they know they can count on us […] (E6).
Home Visits performed both by nurses and by CAPS originated from FHP and meant a new way of working within mental health, favoring the establishment of a bond with clients and requiring training from the nurses to cope with difficult situations that must be dealt with, in addition to creating new strategies for care. 15

FINAL CONSIDERATIONS
The fact that individuals with mental disorders can live in a house, without being in a hospital setting, clashes with the image that these patients must be isolated from society, which goes against their rights, supported by the law, as citizens.Moreover, living in a home may encourage bonding with their family, since clients are seen as having the ability to live within a home, and that family care can be enough.If the mental health network is consolidated in the city, if there is a crisis or emergency episode, the individuals with mental disorders must be transferred to the urgent care beds reserved for this purpose in CAIS Aterrado.
The nursing professional performs an important role within Therapeutic Homes.This role is indirect; in other words, it occurs through the city services that integrate the mental health network and are associated with the Homes, such as the Psychosocial Care Centers (CAPSs) and the Family Health program (FHP).The support given by nurses to nursing aids who work directly in the Homes favors the network consolidation of mental health care, in addition to being fundamental for the integration of clients into society.The social rehabilitation work is now guiding the care provided by these services.