Territory and mental health: conceptual contributions of geography to the psychosocial field

Aline Basso da Silva^I; Leandro Barbosa de Pinho^II

^I PhD Student in Nursing from the Federal University of Rio Grande do Sul. Porto Alegre, Rio Grande do Sul. E-mail alinee_basso@hotmail.com
^II Permanent Professor at the Federal University of Rio Grande do Sul. Porto Alegre, Rio Grande do Sul. Email: lbpinho@uol.com.br

DOI: http://dx.doi.org/10.12957/reuerj.2015.10091

ABSTRACT

The subject of this article is the territory and mental health. It discusses the contributions of geography to the psychosocial field, considering the territory as the place of mental health care. It briefly historicizes the psychiatric ideology of production of the common in hospices, presenting the need to think about care alternatives that reinforce the uniqueness of individuals and occur outside the walls of asylums. It develops the theme of the territory as a potent place for a deinstitutionalized care and focus, approaching Geography to analyze the space where human life is acted out. It concludes with a conceptual discussion of territory, based on authors from the conceptual field of Geography, and its interfaces with practice in the psychosocial care context. Lastly, the proposal is to rely on interdisciplinarity to enlarge the discussion of the deinstitutionalization of madness.

Keywords: Mental health; deinstitutionalization; nursing; geography.

INTRODUCTION

The roots that have sustained the hospice, as madness in the treatment scenario for centuries endured until this day. The traditional psychiatric ideology, born in these spaces, was important as a movement that sought a new understanding for something even misunderstood. However, total madness as an extension of human life as it is complex and multidimensional.

Elevated to the category of mental medicine disease, Cartesian, inspired madness entered the list of pathologies of which it was necessary to find the causes and outcomes. With Pinel, Esquirol, Falret and Morel, they developed new explanations showing the rationality about knowledge of madness, surpassing the empiricist's conceptions and founding a new clinic¹. It is in this direction that new spaces should be designed to understand facts and processes inherent to the disease².

From the Second World War, the questioning of the therapeutic role of hospice stirs up, denoting place of oppression, social exclusion and denial of singularities, as well as being a place that produces mortification by absorption of the entire individual, the hospice doesn't seem to reveal and understand the difference, producing the common, the patient³.

The (in) perception of madness as something of human nature seems to reveal our ignorance on the subject. Reduce the complexity of human rationality singularities of the disease seems a consistent explanation for the clinic, however, misguided when we see the differences that make people unique. In addition to the deconstruction of this perverse image upon the subject, it is necessary to demolish the walls of the asylum that isolate us from contact with the madness⁴.

The real de-institutionalization values diversity and encounters in addition to in the Madhouse, with their anti-therapeutic attitudes, this is not possible, it is necessary to enhance new spaces and scenarios that reflect the real life of people and absorbing their singularities. It is therefore in the territory that we exercise care practices. That's because we already know the clinic of madness, but we now know the new clinic, which invest in the singularity and the construction of interdisciplinary projects, producing new theoretical knowledge in the field and technical skills with workers. Thus, the objective of this study was to reflect on the contribution of geography to enrich the debate about the psychosocial field.

This is a theoretical study, reflective, which invests in a mooring to discuss interdisciplinary articulation of the concept of territory, from the point of view of geography, and their respective applications to the field of mental health.

TERRITORY AND MENTAL HEALTH

Thinking on the territory as care scenario is, before that, understand that traditional psychiatry needed to be reformed. In countries like England, France, USA and Italy, these discussions were more detailed. In them, there were innovative experiences of transformation of psychiatric care which resulted in proposals for community base, responsible for psychiatric care resignification centered on the hospital and the investment in the territory as an ideal setting for this care⁵.

Italy was the place in which these transformations could be felt with greater intensity. There was gradual and planned closure of psychiatric hospitals in operation, Constitution of psychiatric emergency room services in the community, restriction to hospitalizations and encouraging construction of compulsory services supplying temporary replacements, in the community, based on the principle of territoriality⁶.

In this process, the territory is the main place of care, running away from the homogenizing speeches of traditional psychiatric ideology. It is where you build the whole society, the political, economic and social processes, the fights and disputes, conflicts and relationships. Where families live and organize themselves, where we need to re-think projects that leverage the conviviality between the different and care for those in need.

Yet we note the need for overrun of the asylum, although it has advanced beyond its walls. But the hospice is still present in the imagination and culture of society. Therefore, the de-institutionalization must be seen as a process that starts, but that does not end in dialectic of go-and-see.

One of those out-patient treatment alternatives replace the asylum and work in the territory are the Centers for psychosocial care (CAPS). These are strategic devices in the process of consolidation of the psychiatric reform, but which do not amount to care for the individual. That's because he must act on the network, whereas the completeness of the subject and the understanding that madness dispenses various looks. Thereby, the CAPS should act in partnership with other network devices⁷.

When discussing network of services, devices, and locations of care arranged in the territory deals with much more than a physical mapping of a community which we must care for. It constitutes a new concept of mental health, marked by the space where life happens and if processes, each with its characteristics and peculiarities.

Each territory is a territory, so note the necessity of interdisciplinary theoretical support to better understand its importance in the discussion of mental health care. When it comes to a spatial scenario, but also geopolitical, is in the geography where we can find better supports^8-10.

Understand and incorporate this territory that transcends the physical is essential to move forward on the Constitution of public policies on mental health. Territory is the place of power, marked by power relations, social relations, and history.

CONTINUING THE DEBATE

The expansion of information and networking aimed at health care in the context of the Unified Health System (SUS) permeate the organization of the flows in the territory. Therefore, we believe that our approach with the geography, as science that interprets and analyzes the performance space of human life, can be a substantive contribution to discussing mental health care in community spaces.

Historically, the geography articulates with the health sector from the globalization and environmental problems, generating broad international discussions without the dynamic of the networked world that brought reflections on the role of geographical space, the possibility of very fast flows of viruses and bacteria and the spread of epidemics¹¹.

Known as separate from the field and people, the geographical space predisposes the occurrence of diseases. However, from the theory of Pavlovsky, called Landscape Epidemiology parasitologist, is believed to a new relationship between space/disease by the idea of movement of agents¹².

With Landscape Epidemiology, space becomes seen as interdependent, i.e. product and producer relations. However, there was a criticism of this model of failure analysis on non-communicable diseases, emerging in visuality theories of multiple causes and the concept of risk¹³. In the multicausality theory, human populations are placed second, in which the focus is on behavior as the main factor that causes people to fall ill and die ¹³.

In this sense, in the 1970's, with the firm configuration of a new globalized society, which was launched a movement criticizing the epidemiology of risk factors and the ecological concepts of illness. This movement became known as social epidemiology, critical epidemiology, with major repercussions in Latin America¹².

Note-If greater strengthening of category space in public health studies, not only by the change in the profile of morbidity and mortality from infectious causes for chronic-degenerative diseases, but also by the growth of the acquired immune deficiency syndrome in the population. It was necessary to better know the collectives. In this perspective, the geography becomes a powerful ally of health for being closely tied to the object, geographical space ¹⁴.

In Brazil, Milton Santos presents itself as the leading author on the diffusion of the concept of geographical space or socially organized who brought the look of sanitarians a refocusing its work, considering the space as a process, a social construct, in other words, the space alive and can be lived ¹².

In this sense, we understand that the Historicizing of the concept of space allowed resigning the look that we have about the health/disease process reflecting on experiences that reinforce that health and disease depend on multiple social dimensions.

Other than the space, the concept of territory has come up with the health reform and with the SUS deployment, where the territory is structured as political and administrative area, being a distribution of spaces and of the processes that they develop¹².

Formed from a given space, the territory is marked by a projection and power and by production modalities. For example, we have the national territory as a physical space of a nation, which delimits a political-administrative order, an area measured and marked by human labor. The space is regionalized by the actor, showing that the territory supports in space, but its not⁹.

This design helps to sustain certain Brazilian healthcare system organization. In this case, the spatial delimitation of the field of health approach is applied to various services of the SUS, how the family health strategy, the health surveillance programs and mental health, through the Centers for psychosocial care (CAPS). However, although leverage and facilitate the management of local services space, this strategy can reduce the concept of space only a matter of political and administrative modernization, weakening the potential of the concept of territory for the understanding of singularities of the populations and the health problems of a certain area¹⁵.

In addition to a political-administrative issue, the goal is to get to know this territory delimited to that as well, it is possible to know the life of the people. So, it is the territory of organization of health practices, support services, supports the life of the people, the conformation of the contexts that explain the production of healthcare and wellness issues¹⁶.

In healthcare, we need to understand the various physical characteristics of an area, but also man-made marks, their social relations, the way you organize and transiting through this territory. There is a structural, functional and procedural inseparability between the company and the geographical space, and that man needs to know¹⁰.

We consider that the territory is the sum of innovative experiences in the field of administrative management of services, as well as in the management of the processes of everyday life. Since you cannot just seek the political reorganization of technical services, without considering the existence of human life, its history and political and social organization.

Given this, we understand the territory as an important locus for mental healthcare and a powerful component for analysis and action planning in healthcare. The size of the space given to contemplate the relational issues, socio-cultural and political society that will configuring another territory, or marking it as a dynamic, active and versatile territory.

With this in mind, when we want to set any piece of territory, we must take into account the interdependence and inseparability between materiality, which includes the nature and its use, which includes human action, i.e. the work and politics. Therefore, the territory is an excerpt or fraction of space qualified by subject, a territory used, because it is the space lived by man¹⁷.

Thus, we visualize theoretical contributions that sustain the territory as a space of exchange and social relations, pervaded by economic, political and loco regional. To review it, it should be noted the elementary characteristics of the subjects who inhabit them and admit that the territory is qualified by the lives of people and their relationships built over time.

This is the line of reasoning that it is believed that the territory is connected to power and social relations. However, goes beyond this understanding, considering the territory as full autonomy and discontinuities, and formed by networks of organized groups in various schedules and shifts¹⁰.

The territories may be formed and dispelled quickly, most unstable to stable. Among these flexible territories, for example, include the territories of prostitution, in which specific groups if appropriate the territory overnight, and in the days are occupied by other people, for trade and for residents of the region. Another would be the territory of drug trafficking whose territoriality demonstrates certain characteristic structure of mafia organizations, where we would have the friend and enemy territories. A territoriality complex, attached by belonging to the same command, and, in this concrete space, the nodes are inserted with other networks, they all overlap in the same space and vying for the same area¹⁰.

Thus, the concept of territoriality helps us understand the process of Constitution of the territory. Is a kind of interaction between human beings, mediated through space. This idea is relevant in the debate on mental healthcare, as it is in the spaces of the health services and network devices, which the actor territorializes the place with their actions, making part of the process of Constitution of the territory and the network¹⁰.

In this context, cites the health worker who, by incorporating themselves into space and services network community, becomes a part of the territory of discontinuously, being in that space on certain days and hours of the week, but part of the cultural, economic and social Constitution of the place, contributing to the re(constitution) of that space.

One of the relevant concepts in the debate of the territory on mental health is the concept of territory-networking, which is brought as the discontinuous territory¹⁰. Is a network that articulates two or more contiguous territories. The complexity of the territorial network refers to overcome classic design territory, observing the superposition of several, with varied shapes and limits do not coincide. In them, there may be several territorialities which complement or contradict each other, giving a character of different power relations and movement.

The territorial network is an important concept in understanding the territory on mental health. Does that mean that care is distributed in the territories of people's lives, forming networks of complex and parallel universes, mediated by modern trends, space management with local characteristics and unique needs of the population.

We realize the importance of health services think and rethink their practices, understanding that caution should advance out of services, aimed at the deinstitutionalization of madness. De-institutionalization involves policies that look to the subjective aspects, the condition of citizenship and freedom, aimed at retaking of the sociability of the user¹⁸. Thus, the concepts of contemporary geography help recognize that the territory is also marked by the presence of the human and of their action. We believe that the practice in mental health gets more sophisticated and focused on care in freedom, in the case of singularities and the fundamental premises of the exchanges, psychosocial and psychiatric reform modality.

CONCLUSION

Thinking on the territory and on a network out of services is to create means to de-institutionalize the care people, recognizing their singularities and complexities, because, in that context, it is inserted the existence of diversity and in homogeneities of the subjects. Each subject has a territory, laden with history, power relations, social relations, forms of organization and economy. The territory is autonomous and has movement, marked by incremental transformations of this historical and social organization of the people.

We hope this study encourages interdisciplinary contributions to expand discussions on the theme of mental health territory, linking with other areas of knowledge, such as geography, so that, as well, Flash forward in the debate of de-institutionalization of madness.

Working with the territory is betting on the creation of alternative care. Looking for places where people live and relate to one another, and how these places show their uniqueness, diversity and realities, concepts essential to the care in the psychosocial field.

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