(Re)significando os espaços assistenciais em saúde mental: relato de experiência

This article is the report of an experience of graduate students from the School of Nursing of the Federal University of Minas Gerais, as part of the subject "Health, disease, and space". The article aims to report the discussion regarding the link between mental health and care centers, based on the experience in that subject. Dynamic resources have been used, such as music, letters and exploration of the physical space in order to raise awareness and reflection on the topic. Results are presented by means of letters that express the reflective dialogues on mental health from each perspective. We conclude that the experience contributed to the construction of knowledge and the awareness regarding this subject. These contributions are essential for the training of new teachers who should be able to foster the training of nurses who would be co-responsible for the construction of new ways to understand the individual experiencing psychological suffering and the care provided to them.


INTRODUCTION
Spatial configurations, not considering their symbolic variations, are an element that has been related to western medicine and public health for over two thousand years, and that is also important in the field of epidemiology. 1 Over the course of time, different conceptions regarding the effects of space on health and Disease have appeared, which usually define space as a place referred to by geographic coordinates and characterized by both a physical and an environmental structure. 2hus, we can say that the concept of space is synonymous with landscape. 3lthough they are often considered to be synonymous, the concepts of space and landscape have different meanings, given the properties of time and materiality.Landscape is related to the relationship established between man and nature, a material system of concrete forms spread across the planet.Space is replete with features of time, and may be thought of as the moment when men and social relationships converge with landscape forms.Broadly speaking, space is an essence, an abstraction, or a network of symbols that is impossible to express in concrete shapes but that paradoxically interacts with the landscape.
This interaction between space and landscape leads us to the concept of topophilia, a neologism that relates the emotional bonds of human beings to their material environment. 4The reaction to the environment may include different connotations, but the most permanent expressions of this relationship are supported by the contemplation of space elements, which are built from affection, feelings and values organized in a system of symbols based on individual experience. 2 In the field of health, particularly in psychiatry, the approach to space is mainly approached from a landscape point of view, where the contributions of technological and geographic resources prevail in terms of early diagnosis, clinical management, availability and access to mental health services.] In terms of the distinction made between landscape and space, some authors maintain a symbolic and humanistic distinction between 'place' and 'space' in terms of mental health.The 'place' refers to a geometric conception of distance between objects, while 'space' is related to a social feature, linked to the individuals' experiences within the social structures. 7he interaction between space and place/ landscape holds special importance when considering the architecture of care centers for individuals experiencing psychic suffering, since its inception is an important element in the implementation of care models. 8The well-grounded places in psychiatric landscapes are driven by a superior logic, founded on conceptions of mental health-Disease processes and also on conceptions of the individuals who are suffering.
This article aims to report on the discussion surrounding the link between mental health care and care centers.This discussion derives from the experience report of two students, the authors of this article, regarding their participation in the subject "Health, disease and space" from the stricto sensu graduate program of the School of Nursing of the Federal University of Minas Gerais.This experience was the result of the presentation of a term paper on the subject, in which the link between mental health care and care centers used as a therapeutic environment was discussed.We believe that this study, because it comes from a graduate program, can contribute to knowledge development in the fields of health and nursing.
It is believed that the topic of this article fits into three important mainstreams within the current context of health: the first refers to the increase of studies that regard spatial matters in the field of health and focus on the temporal and relational concept of space; 3 the second addresses Psychiatric Reform, which approaches the principle and practice changes in mental health care spanning the structural and relational re-organization of therapeutic loci; [9][10] and the third refers to the current need for higher education docents in health 11 and nursing, 12 who would have a new profile and would be in line with the socio-economic, political and technological demands and be able to mediate a teaching-learning process that fosters questioning, reflection, critical analysis and a sensitive interaction with the world.

The subject "Health, disease and space"
The subject "Health, disease and space" is taught in the stricto sensu Graduate Program at the School of Nursing of the Federal University of Minas Gerais.One of its goals is to analyze the concept of space and its application to the study of the health-disease process.The total subject workload is 30 hours, and in the first semester of 2012, which is the period when the focused work was carried out, 23 students were registered.
As a requirement for obtaining credit for this subject, it was proposed that the students complete a project that involved spatial dimension within any context of health.Following the previous experience of two students in the theoretical-practical scope of mental health, and the importance of landscapes and care centers to the implementation of care strategies, we chose to carry out a study focusing on the link between mental health care and care centers employed as therapeutic environments.Thanks to readings and discussions about space, we realized that the subject fostered reflection and awoke the students' desire to consider space as a component of health.

Presentation of the work: a metalinguistic approach to space
To spatially represent the ideas that were developed, the students' experiences approached a different way to manage physical space in the classroom, so they used the audience layout to promote a better view and put the topic into context.
To better describe this experience, we decided to use Figures in order to represent the students' layout at the time of each presentation.Thus, the students are represented in the Figures and in the text by A1, A2, A3 and A4.The other students, that is, the audience, are represented by "chairs".
The experience is represented at five different times.The first time represents the jarring presence of the "insane" in society (Figure 1); the second represents the introduction of the concept of topophilia and the purpose of the work (Figure 2); the third represents the beginning of the "dialogue" between Foucault, Goffman, Tenório and comtemporary society, introduced by Foucault and Goffman's ideas, expressed in letters that were read (Figure 3); the fourth represents the reading, also from letters, of Tenorio's ideas about Psychiatric Reform (Figure 4); and the fifth represents the coexistence of the asylum model and psychiatric reform, and the actual care model intended by comtemporary society (Figure 5).

Figure 2 -The jarring presence of the "insane" in society
Firstly, in figure 1, the aim was to surprise the classroom students and raise awareness regarding the stigma faced by individuals with mental disorders within society.To illustrate this, the students used a musical feature to present the topic; student A1 sang the song "Balada do Louco" a cappella. 13his student was sitting on one of the chairs in the semi-circle and suddenly began singing the song, surprising all of the participants.The insertion of a member with differing behavior was shocking in this context and represented the "insane" individual within the social context.Topocide is the elimination of the cultural meaning of a particular landscape by a particular society.It is a point of no return for the annihilation of a culture, as it shows its fragility related to topocidal forces. 4Psychiatric reform offers a proposal for a break with the hospital-oriented logic and with mental health care founded on domination, obscurity and subjugation, aiming at new psychosocial and care centers models.

Figure 3 -Foucault and Goffman's point of view in their dialogues with Tenório and comtemporary society
The third step, represented by figure 3, aimed to show the dichotomy between mental health care models -the asylum and its substitution -and to carry out a reflection regarding space.The layout shown represents the beginning of a critical discussion about the evolution of Brazilian mental health, based on the dialogues between Foucault, Goffman, Tenório and comtemporary society, which exposed the dichotomous relationship between the asylum model and the care model intended.The discussion and reflection regarding space raised by the subject allowed the achievement of results which are presented by means of letters in the results section.
In the step represented by figure 3, the results were presented by the reading of Letter 1, called "Revisiting Foucault and Goffman to understand Tenório's misunderstanding".For this stage of the presentation, student A3 stood in the center of the circle and reflected on the main concepts related to the topic that were developed in Foucault and Goffman's works.The central position of A3 represents the features of a traditionalist logic that is still present today, despite the fact that flexibility has already been presented at this stage.

Figure 4 -Tenório's point of view in his dialogues with Goffman, Foucault and comtemporary society
The fourth stage aimed to present Psychiatric Reform and the mobility featured in its therapeutic proposal.Figure 4 shows the beginning of the reading of Letter 2, entitled "Our reports evoke Tenório and call for freedom", which led to a reflection on Tenório's ideas.This letter, read by A4, discusses Psychiatric Reform proposals and substitution services in mental health.
When A4 began to read the letter, she made a sudden movement towards A3, reader of the previous letter, forcing her to sit on the floor, as a way to represent the proposed paradigm transition.While A4 was reading the second letter, she walked around the classroom, indicating the spatial mobility of the reformist proposal.Mobility is represented in Figure 4 by the surrounding line.

Figure 5 -The coexistence of the asylum and substitutionary models in mental health
Figure 5 represents the coexistence of the asylum alongside substitutionary models and the actual mental health care provided in comtemporary society.A1 read Letter 3, called "Foucault, Goffman, Tenório and Comtemporary Society: intersecting parallels", which critically appraises the dialectic between these models.
At the beginning of the reading, A4 (reader of Letter 2) sat on the floor facing A3 (reader of Letter 1), which represented the opposition between both concepts, as shown in figure 5.It was noted that, even though the chronological evolution presented represents a major progress in the use of spaces where comtemporary society is represented, different models still coexist, albeit on a smaller scale than previously.
At this final stage, previous steps of the experience are revisited and new perceptions of space in terms of mental health are brought to light by the students, based on reflections fostered by the subject which led to the creation of the concept of "self-space".

RESULTS: THE LETTERS
A letter is a free composition model where a message is transmitted from a sender to a receiver; its characteristics are determined by these two parties and by the content of the message exchanged.The use of letters in this presentation aimed to bring these parties closer in understanding the paradigm, focusing on the content and on the language employed.
As mentioned previously, the letters are presented below, where the thoughtful dialogues regarding mental health are approached from every angle: asylum, substitute services and current care models.

Letter 1 -Revisiting Foucault and Goffman to understand Tenório's misunderstanding
To address psychiatric care during the 20th century up until now, we must revisit the "history of insanity" and view it from the perspective of that time, but with contemporary eyes.
When, how and why did society begin to examine insanity?Is it possible that a process that started 400 or 500 years ago is still occurring today?Where did the concept of the alienated and violent individual come from, for whom the only way to live is to be isolated and segregated from social coexistence?
The sixteenth and seventeenth centuries were a time of great religiosity and control in society, in which the search for control of the pathological or the abnormal was completely acceptable.It was thought that the best way to normalize the 'abnormals' of society was to control them by keeping watch over them constantly, adjusting their behaviors and thoughts.But how can we do this within society if everyone is supposedly free?Nothing is more convenient and efficient than confinement, where it is possible to watch the inmates and normalize them in accordance with social and societal rules.] This building was ring-shaped, with a courtyard and an imposing central tower strategically placed to isolate and tame its inmates.The field of vision was unilateral: the watchman had complete control of the inmates, but the reverse was not true.It is worth mentioning that punishment was connected to vigilance: punishment of body and soul, enforced by this oppressive landscape. 14imilarities with 21st century psychiatric institutions are not a mere coincidence.
Panopticism is characterized by the complete and total surveillance of people, by discipline and control, thus being a true institution.][16] Given this scenario of restriction and inadequacy, mental health professionals, users of the service and their relatives began to question this "treatment" within the insanity model.Was it really necessary for inmates to sleep on bunks, to be fed behind bars, to be naked and die of exposure?How many individuals would suffer neglect and how many lives would be taken by this punishing system?
In Brazil, reports of physical and psychological abuse began to appear in the end of the 1970s, following the Mental Health Workers' Movement.Abuse cases were made public and there were requests for new forms of care and treatment of individuals experiencing psychic suffering. 17At this historical point, an interaction was seen between individuals involved in the process and the care framework.Therefore, does a new layout for care of the mentally ill arise?
Giving (new) meaning to mental health care centers… This paradigm and shift in care practices later became known as the Psychiatric Reform.The intervention of public health in Santa Casa de Anchieta was a milestone; cells were removed, electroshock therapy was forbidden, visiting hours were permitted and, most importantly, the doors were opened to the public. 17hus a new vision of insanity was created, with a new approach.The initial concept of community care for individuals with mental health disorders began with the conversion of a human stockroom into a care center.
The evolution of psychiatry/mental health presented in this letter helps to illuminate the proposal for transforming psychiatric landscapes/ care centers for the "insane"/individuals experiencing psychic suffering.A break with these places is suggested, as they regulate, limit, control, normalize, watch and punish.

Letter 2 -Our reports evoke Tenório and call for freedom
Today, our reports are permeated by new views; we foresee new goals and describe a new era.This is a time of enlightenment, of overthrowing, of breaking with tradition.We break with an obscure and normative history, one that takes away from the individual what is most valued and intimate, that takes them away from themselves.This new era highlights the embodiment of the individual; their own insight and the acknowledgment of themselves and of others.
The liberation of the other, of the rigid, of the cold and of the obscure is underlined so they are found in a new place, a place of their own.A place as a moment to be lived and lived again within social relationships, inside an open and dynamic landscape, where they can exploit instead of being exploited; where they can handle instead of being handled; where they can live instead of living according to others.
The crisis of the classic asylum model began after the War, resulting from a need for revision of rules and a redefinition of psychiatry as a source of knowledge and as an institution.The mechanization that exists between a psychiatric diagnosis and chronicity, exclusion and condemnation gave way to a new psychiatric order, both in ideology and practice. 18he Italian experience began a process of paradigmatic and practice overhaul in mental health, as it suggested caring for individuals with mental health disorders within society.In this way, alternative community services were born which were opposed to compulsory confinement and changed the logic of categorization of disorders, favoring treatment and follow-up of these individuals. 18n Brazil, this opening began in the 1970s, in a political and economic climate marked by the end of the "Brazilian economic miracle", when mental health professionals and other members of civil society spoke up against the appalling conditions in which individuals with mental health disorders were being treated at the time. 19s this movement grew, national mental health conferences were held, which led to the creation of definitions of Psychiatric Reform proposals, as well as proposals for substitutive care instead of the hospital-oriented model, 19 focusing on comprehensive efforts and respect of citizenship and following the health-Disease pattern closely related to quality of life.
On a legislative level, this era began in 1989 when then-congressman Paulo Delgado sponsored a bill that was passed in 2001.The bill prevented the creation or allocation of new psychiatric hospital beds. 17Therefore, it was a legal break with an obscure and dominating landscape which, although it was static, had a harsh impact on inmates' lives.
The withdrawal of the individual from these places led to the need for the creation of new environments.These new places would be part of a network in which the individuals could move freely, being a part of these therapeutic spaces that used to be social spaces.
In 2011, according to Law n. 10.216 and resolution n. 339, resolution n. 3.088 established the Psychosocial Care Network (RAPS, as per its acronym in Portuguese) to provide care for individuals experiencing psychic suffering, whether they abuse psychoactive substances or not.RAPS is a strategy of creation and coordination of health services, as per the Psychiatric Reform. 20APS represents humanized care in mental health.It also stands for the diversity of care strategies that are based on individual therapeutic care and on community services, such as CAPS, companionship centers, therapeutic centers and street clinics, among others. 20APS is the core of specialized emergency mental health care and respects every individual's space, whether they require intensive, semi-intensive or regular care.According to the number of individuals listed and their profile (adult/child, addict or not), CAPS can be classified as follows: CAPS I, CAPS II, CAPS III, CAPS ad, CAPS ad III and CAPSI. 20APS is an outpatient care center that can only operate in a specific physical space during the day and must be separate from other hospital facilities.This service must provide the individual with a mental disorder with a new routine, made up of individual and group activities which include psychotherapy, operative groups, therapeutic workshops, sociotherapeutic activities, home visits, family care and community activities. 20perating only during the day is a semiintensive strategy which is an intermediate and transitory asset, falling somewhere in between intensive care (continuous care provided around the clock) and regular care (outpatient follow-up).It aims to assist in acute cases as a temporary measure in postoperative cases or as a way to avoid hospitalization. 21nother type of substitutive care which can help to avoid hospitalization is the Home Therapeutic Service (SRT, as per its acronym in Portuguese), which is a home located in an urban area designed to meet the needs of individuals with severe mental disorders who may have been inpatients in a psychiatric hospital.The goal is to help them reintegrate into their community. 20he Companionship Center is also a substitutive space providing care to individuals with mental disorders, founded on the creation of therapeutics aimed at sociability, productivity and intervention.In these places, workshops and activities are carried out aimed at developing relationships, respecting differences and creating social bonds. 20his approach, afforded by a treatment that keeps the individual within the community, suggests that the individuals experiencing psychic suffering are deserving of the opportunity to live socially and not be confined in an institution.The acceptance of these particularities and differences supported on the social network is built as a relevant strategy against the therapeutic space centered in asylums and against the segregation of these individuals from the social environment. 17hese substitutive spaces embody freedom, social integration and subjective motion.This letter expresses the timeline of rebirth, reinvention and the restructuring of mental health care.It is about creating flexible spaces that favor freedom and autonomy, as well as social, family and community interaction of individuals experiencing psychic distress.However, the idea of flexible spaces often brings to mind vestiges of the panopticon, represented by social inflexibility; rigidity in professionals' education and practice and in the nursing staff and human standardization.

Letter 3 -Foucault, Goffman, Tenório and Comtemporary Society: "intersecting parallels"
Is it possible to interact with the past?Angst... What about when this past still remains in the form of institutions, in the wide-open/ veiled prejudice that lies within every member of comtemporary society?Oh, Foucault... Oh, Goffman... how can we not remember both of you when we see places such as substitutive services that are supposedly open and dialectic but in truth are still close to the panopticon of old?Should they be spaces or landscapes?Vigilance or autonomy?Punishment or freedom?
We confess our concern.We belong to comtemporary society and, as health professionals, as nurses, we shall think about those who view space in mental health as a relational moment... Are there still traces deeply ingrained in our care routine?We can see Foucault and Goffman alive in the frames of these institutional buildings.
We look at the central tower and the full institutions and we shout loudly in the search for a dialogue with Tenório.We are frightened by this reality!We search for a new way to understand and deal with psychic suffering in which care centers are also places of construction of relationships, of others and of oneself.Don't we?
We want open physical facilities where the individuals can move freely, so they can build and rebuild relationships with others and with the environment, bringing together their own movements.Our conscience is a burden.Do we want that?And what have we done to make it happen?
We are a comtemporary society.Do we understand our self-space enough so as to request something that we are actually not sure about ourselves in favor of others?Do we search for the individual's deepest inner self?Do we want to search for it?We want to find, live, feel the space that is filled with ourselves in the relationship with others and the world; the space where wishes, angst, interests and determination dwell.This is the space that we underscore and that discloses the significance of life, for us and for the individual experiencing psychic suffering!Self-space!

FINAL CONSIDERATIONS
The first advance, made possible because of this work, is the distinction made between the concepts of landscape and space.This is related to psychiatric care and goes beyond the notion that mental health services, according to asylum logic, are simply facilities intended to implement treatment technologies.
The strategy chosen to present this study permitted a dynamic and interactive approach due to the metalinguistic use of space, and also due to the use of audio-visual aids.The speeches and facial expressions of the participants showed that the work aroused different emotions, gave rise to different perceptions and stimulated reflection and awareness regarding the topic.These potentials of the developed strategy are essential to future teachers' training, as teachers must be capable of encouraging an education in nursing founded on questioning, reflection, critical analysis and a sensitive interaction with the world.
We believe that an actual paradigm shift in mental health requires awareness about the different aspects related to care, among which care centers and the attitude of care givers, that is, nursing professionals' space, approached here in its macro and micro senses, is an essential element that allows the individual experiencing psychic suffering to exercise the rights and opportunities offered by Psychiatric Reform.

Figure 2 -
Figure 2 -The introduction of the concept of topophilia and the purpose of the work