ORIGINAL RESEARCH

Chronic psychiatric client: socio-cognitive reconstruction in the institutional care process

Leandro Andrade da Silva^I; Antonio Marcos Tosoli Gomes^II; Iraci dos Santos^III; Maria das Graças Gazel de Souza^IV; Adriana Loureiro da Cunha^V; Leonor Coelho da Silva^VI

^I Nurse. Post-Doctor. Professor at Veiga de Almeida University. Rio de Janeiro, Brazil. E- mail: proflandrade@gmail.com
^II Nurse. Post-Doctor. Professor at Universidade do Estado do Rio de Janeiro. Brazil. E-mail: mtosoli@gmail.com
^III Nurse. Post-Doctor. Professor at Universidade do Estado do Rio de Janeiro. Brazil. E-mail: iraci.s@terra.com.br
^IV Nurse. PhD. Technologist nurse at the National Cancer Institute Jose Alencar Gomes da Silva. Rio de Janeiro, Brazil. E-mail: mariagazel@hotmail.com
^V Nurse. Master in Nursing at EEAN / UFRJ. PhD student at PPGENF / UERJ. Rio de janeiro Brazil. E-mail: adrianaloureiro1@gmail.com
^VI Nurse. Captain-Lieutenant of the Marine health Service of Brazil. Master in Nursing (PPGENF / UERJ). Rio de janeiro Brazil. E-mail: lecos80@icloud.com
^VII Thanks to Coordenação de Aperfeiçoamento do Nível Superior (CAPES) for the master's and post-doctoral scholarship.

DOI: http://dx.doi.org/10.12957/reuerj.2017.31073

ABSTRACT

Objective: to analyze health personnel's socio-cognitive reconstruction about chronic psychiatric clients, contextualizing it with their time in the institution and the care process. Method: qualitative study conducted in 2013 with 159 participants at two hospitals in Rio de Janeiro, Brazil, applying a structural approach to social representations, using the free evocations technique and the software Group of Programs for the Analysis of Evoked Responses (Ensemble de Programmes Permettant L'analyze des Évocations, EVOC). Approved by the research ethics committee (opinions 13/2009 and 53/2010). Results: 795 words were evoked, the minimum frequency was 9, the mean was 17. The ranking of mean orders of evocation was 2.99. Five dimensions were constructed: imagery; positive affectivity; institutional care; mixed affectivity; and need. Conclusion: the study afforded an understanding of mental health personnel's social representations about clients who have aged in asylum spaces, victims of stigmatizing, exclusionary care.

Keywords: Aging; long-term care; mental health; pychiatric nursing.

INTRODUCTION

Approximately 30 years ago, Brazil was influenced by a social movement referring to the human rights and deinstitutionalization of the people in psychological distress (PD). Known as Brazilian Psychiatric Reform (BPR). Influenced by events generated after World War II, it was present in different continents, with America Central and Europe standing out, where the first proposals of attempts to change mental health (MH) care appeared and were motivated especially by complaints of acts of violence, abandonment and isolation, considered as favoring the chronification of mental illnesses¹. The inability to treat people in PD in the asylum environment was revealed².

For this emerging psychiatry, clients in a chronicity stage represented a problem, and the solution proposed for more than a century was the reclusion in psychiatric colonies. Throughout the years, it was found that this did not provide the desired therapeutic effects and the colonies served to occupy the idleness of these subjects, to exclude them and to chronify them³. By historicizing the social, academic and cultural practices that favored the institutionalization of mental suffering as an imperative for care, it is possible to understand the current situation of care in MH, as well as its emergent processes and constructors of a theoretical-practical knowledge, aiming at strategies to overcome the past and transform the future⁴.

This article aimed to analyze the socio-cognitive reconstruction of MH professionals about the chronic psychiatric client, contextualizing with their institutional permanence and the welfare process.

THEORETICAL FRAMEWORK

Considering that the specific theme is little explored and includes MH professionals who assist people with mental disorders who aged hospitalized in psychiatric institutions with asylum characteristics, the structural approach of the Theory of Social Representations (TSR) has been used to support this study.

According to this Theory, the social representations (SR) are important in the everyday life, because they guide people to nominate and to jointly define the different aspects of the reality, whether in the way individuals interpret, make decisions, or even position themselves. The SR allows phenomena to become directly observable or reconstructed by scientific work⁵.

The central nucleus is the only complementary approach that was constituted as a theory, allowing the SR to become more heuristic for the social practice and research⁶. It focuses on studying the cognitive contents of representations, conceiving them as a structured, organized set and not as a mere collection of ideas and values. Around the central nucleus (CN) the peripheral elements are organized, they are the essential constituents of the contents of the representations, the more accessible, the more alive and the more concrete. They have three primary functions: concretization, regulation and defense functions⁷.

The TSR was more suitable to understand the question of chronicity in psychiatry, which runs through the specialties of MH, questioning its epistemological foundations and its care structures. Chronicity in psychiatry refers to the evolution of a disease and its duration and persistence, but also to a social situation that establishes the forms of care⁸.

It is emphasized that the care provided in MH advanced the substitutive devices of the hospital-centered model, and made possible a great transformation in the national scenario allied to governmental proposals. However, many clients could not be reinserted in their families and linked to psychosocial care centers (CAPs - Centros de Atenção Psicossociais), remaining hospitalized in psychiatric hospitals⁹.

Silence seems to be the hallmark of chronification, about what little was said and/or written on subjects with mental disorders who lived or still live in psychiatric institutions with asylum characteristics². The development of this work was important and necessary for a better understanding of the perspective of the professionals regarding the care destined to the clientele that has aged in the hospital environment.

METHODOLOGY

It is a scientific research concerning the SR of MH professionals about people in PD, which are called psychiatric patients. For the construction of the methodological design, the methodological contributions of the TSR, in its structural approach, have been used.

The research was carried out in 2013 in two public psychiatric hospitals in the city of Rio de Janeiro - Brazil. Such a choice was made by the fact that both scenarios were created at the beginning of the last century to receive the so-called chronic, which, at that time, were presented as an impasse to emerging psychiatry. For ethical reasons, their names were kept confidential. The participants of the research were 159 health professionals, working in the MH hospital network. The total number of participants was defined by the following criteria: intentional convenience sample and minimum parameters adopted for statistical analysis.

Through the technique of free evocations, we sought to apprehend the perception of reality from a pre-existing semantic composition, a composition that is usually not only concrete but also imagistic, organized around some simple symbolic elements. In this sense, the practical application of the test consisted in asking the participants to associate other words, freely and quickly, from the hearing or visualization of inductive words⁷ or expressions, which, in the present study, was a chronic psychiatric patient. Then, they were asked to give an order to the words that have been evoked. This allowed us to analyze the correlations between the enunciations. It is important to highlight that the adoption of the expression chronic psychiatric patient, was only used because it is part of common sense. In view of the efforts of different MH actors in not classifying as patients the people in PD.

In the treatment of the data produced, the software Ensemble de Programmes Permettant L'analyse des Évocations (EVOC), version 2003 was used, which makes it possible to organize the words produced as a function of the implicit hierarchy to the combination of frequency and the natural order of evocation. The technique of analysis consists in the construction of a four-house table, through which the evoked words are distributed, considering the criteria of higher frequencies and Average Evocation Order (AEO)².

In addition to the analysis performed by the four-house table, the similarity analysis⁸, was also performed, from the co-occurrence of the words produced by the participants, with the quantification of their frequencies, generating an index of similarity. The result of this sequence is the construction of a similarity matrix, through which one obtains the similarity indexes for each pair of words, indicating the strength of the connections established between them.

The strength of the links between the categories is expressed by a graphic image, called tree of similitude, which reveals the links between all the categories produced based on EVOC. The tree was constructed from the words that had, among themselves, the highest indexes of similarity. It is emphasized that a maximum tree cannot, according to the graph theory, form a cycle, and if this occurs during its construction, the relation should be ignored, and the next connection should be found^7,8.

Thus, all the precepts and guidelines of the study period, defined by the Resolution number 466/2012 of the National Health Council, were followed. The project was approved by the Research Ethics Committee- Human Councils of the Municipal Institute Philippe Pinel, under the Opinion No. 53/2010, and by the Research Ethics Committee of the Municipal Institute of Health Care Juliano Moreira, under the Opinion No. 13/2009, both linked to the Superintendence of Municipal Institutes of the Sub-Secretariat of Hospital Support, Urgency and Emergency. All the participants signed a Free and Informed Consent Form.

RESULTS AND DISCUSSION

The results were organized to explain the socio-cognitive reconstruction of the chronic psychiatric patient through the related inductive expression that is the proper representational object of the study. For a better understanding of the representational structure, five dimensions have been created that relate to each other, understood by imaginary, positive affectivity, institutional care, mixed affection and need.

The results highlighted the SR structure of the health professionals participating in the study, generated from the evocations referring to the inductive expression. Thus, 795 words were evoked, of which 276 were different. The minimum frequency was 9, and the words evoked in smaller numbers were excluded from the composition of the four house-table. Then, the average frequency was calculated, resulting in a value of 17. The rang, also called AEO, was of 2.99. The four-house table was elaborated from these parameters. See Figure 1.

Caption: imagery (Bold); positive affectivity (italics); institutional care (Bold and italic); mixed affectivity (Underline); need (Underline and italics).
FIGURE 1: Four-house table referring to the evocation to the inducer term chronic psychiatric patient. Rio de Janeiro, 2010.

In the upper left quadrant are grouped the words forming the possible central nucleus (CN)¹⁰, composed by the words care, abandoned, patience, lack, and dependent that make up the imaginary, institutional care and necessity dimensions. It is notable that the SR of health professionals about the chronic psychiatric patient has in its CN normative and functional elements. The normative elements are expressed through the words: lack, dependent and abandoned. These elements are directly related to the value systems of individuals and their ideologies, and are related to the social character of the CN of the social representation^5,7. In the specific case of this study, these elements include the dimensions of institutional care, needs and imaginary.

The results revealed elements of this SR that reinforced the chronicity of these patients. Aging is an inherent condition of the human nature, but when this happens in a reclusive way, while hospitalized in institutions with asylum characteristics, it becomes a disastrous experience when compared to a regular aging process, in which there are dynamic changes in the biological, psychological and social environment. Studies indicate that the institutionalization favors pathological aging, also known as senility, and it includes senile dementias^11,12. The discrimination and stigmatization, intrinsic to mental disorders, are related to psychological distress and disability¹³.

As for the functional elements, they refer to the words patience and care, grouped in the institutional care dimension, see Figure 1. These elements are related to the descriptive characteristics and to the insertion of the object in social or operative practices, which are determinant in the conduct related to the object¹⁴. It is inferred that the words that form the possible CN present, in their majority, characteristics of negative positions and only two of positive character. The word care with the highest frequency in the CN, with AEO of 2, 773 should be highlighted; both indicated a positive evaluation in the SR of the professionals of MH. The term patience appeared with low frequency in the CN, AEO of 1,773; both indicated a positive evaluation in the SR of the MH professionals. Such lexicons maintain an intimate connection with the clientele that, due to the advanced age, need care that is consistent with the characteristics of the elderly person.

Such findings require reflection on what kind of care has been provided to the elderly population suffering from mental disorders in the current context of BPR. This is necessary, emphasizing that the reintegration of people who have gone through long years of hospitalization should not be tied to charitable or welfare actions. This is not a recent problem because, since the 1970s, official documents have been elaborated, with several critiques of the hospital-centered model with asylum characteristics, which institutions still portray a sad reality in all the states of the country⁸.

The lexicon lack obtained AEO of 2.833, having the enunciation lacking, according to Figure 1. The word lack would express, for mental health professionals, the affective and sentimental losses that patients had over the years of hospitalization in comprehensive institutions. In this sense, it is emphasized that, in the care proposals of the past, the hospitalization was valued and, in parallel, it generated the stigma on the subject in psychological suffering. In this process, upon being admitted to a comprehensive institution, the individual was stripped of their usual appearance, as well as the equipment and services with which they kept bonds promoting what was called a personal disfigurement¹⁵.

As for the institutional care dimension expressed in the CN, which has the highest number of evoked words, namely dependent (frequency 18 and AEO 2.333), patience (frequency 19 and AEO 1.737) e care (frequency 42 and AEO 2.643), see Figure 1. They indicate the care practices aimed at the chronic psychiatric patient. The long years of hospitalization generated in this clientele a high degree of institutional dependence that sometimes interferes in a decisive way with the deinstitutionalization process.

With the presence of the element dependence in the CN, it can be inferred that it is closely related to the SR of the MH professional on this type of client, that is, that of dependence on the services offered , which substantially reduces the implementation of actions that can generate (greater) autonomy and freedom in the institutional everyday life, as well as the possibility of living outside this environment. At this moment, it should be questioned if the professional action does not tend to resemble a charitable and pious act in several situations, in which their care practices may privilege the stay of the hospitalized patient. Going back in history is a way of understanding a person's mental production, which anchors the history of medical practices in psychiatry that privilege the institutionalization of madness, reinforcing it, even to the detriment of the autonomy and freedom of the person⁸.

Contrary to the evocations already described, the word care is highlighted, belonging to the institutional care dimension, present in the CN with AEO of 2.64. This word had the highest frequency (42) and is imbued with values. For the health professionals, there are different forms of expressing care and to care, and for nursing, they are considered as the essence of the profession and a genuine and peculiar act¹⁶.

Mental health care should be an attitude of accountability¹. Therefore, to take an act like their own is to take responsibility for the care of the other in an act of mutual surrender. Caring should be understood as an attitude that goes beyond a moment of attention, zeal, and care, representing an attitude of occupation, concern, responsibility and affective involvement with the other¹⁷. Broadening this discussion about care, there is a great tension between care and lack of care that opposes, on the one hand, the care provided by mental health professionals, and, on the other hand, the singular demand presented by the individual in psychic suffering, resulting in two different conceptions of life and care¹⁸.

The imaging dimension of the chronic psychiatric patient is filled with negative evocations, being highlighted the word disease linked to the negative character of the dimension. For part of the research participants, the chronic psychiatric patient would reveal an image anchored in negative aspects, in accordance with past care proposals, which privileged the institutionalization and the illness, especially when valuing the pathology to the detriment of the person in psychic suffering. In this imaginary, the years of chronifying and exclusionary mental health care would be present, strongly linked not only to the biological nature of madness but also to political perspectives of the last century.

Present in the contrast element, the institutional care dimension reflects the words institution, treatment and long hospitalization . Negative elements predominate and there is a tenuous relationship with the imaginary dimension. The word long hospitalization has revealed a negative and stigmatizing representation. Such evocations could evidence the lack of perspective on the part of the professionals concerning the resocialization of these subjects, which configures a serious impasse to the process of psychosocial rehabilitation. The evocation treatment points out an ambivalence in relation to the previous word, meaning an welfare possibility for this clientele, because it is anchored in the word care, present in the CN.

In the first periphery, the institutional care dimensions (comprising the word attention) and the affective-positive word (sheltering the words love and affection), more prevalent in this upper-right quadrant. In the lower right quadrant, the positive elements of this SR are recorded. Regarding the second periphery, less frequent and less readily evoked elements are shown, but, like the CN, which has three dimensions, namely, positive-affectivity represented by the wordsregard and respect; imaginary with the words without and alone; and the dimension of mixed affectivity with the word family.

For a more in-depth understanding of the SR structure of the chronic psychiatric patient for mental health professionals, the maximum tree generated by the similitude analysis is represented next. See Figure 2.

FIGURE 2: Tree of similarity referring to the inducer term chronic psychiatric patient.

As it can be seen, the lexicons that are connected horizontally by the indexes generated by the graphs about the chronic psychiatric patient are patience, love e attention, all of them with indices of similitude of 0.08, that, from now on, will only be indicated with the placement of the respective numbers. From these words come out connections of meaning that will serve as the basis for the understanding of the representational structure. The strongest link, in its quantitative aspect, was constituted between the words attention and affection (0.20) and between affection and respect (0.10). An interesting fact that should be highlighted is that all these lexicons are present in the peripheries of the four-house table. This fact seems to indicate that the peripheral elements have the normative character of the representation studied, that is, what was politically correct and expected for this group. See Figure 2.

The words attention, affection and respect express the sensitivity of the immediate context for the group studied referring to the chronic psychiatric patient. All these lexicons are present in the dimension of positive affectivity. Possibly, this representation is influenced by the physical limitations that the old age and the time of institutionalization entailed to this clientele, whereas these evocations express actions that the care proposals of the past did not allow. In an exclusionary perspective, tempered by the asylum proposals, the client in psychic suffering was deprived of attention, of affection and of respect.

The paradigm that understands madness as synonymous with incapacity and danger, justifying tutelage and exclusion must be broken. The rupture with a paradigm that does not recognize the singularities and therefore does not tolerate the autonomy and, thus being, stigmatizes and excludes different positions¹⁹.

It is observed that the lexicon love possesses the largest number of connections (6), however, it does not express high similarity indexes (0.02). Is possible to infer that love is in the center of a first line of irradiation of meaning and defense of this possible nucleus. This lexicon is part of the dimension of positive affectivity and is present in the first periphery of the quadrant of four houses. Although love is a positive element, it is possible to observe, in the tree of similarity, that the graphs derived from it have negative traits, such as suffering, abandoned, disease and long hospitalization.

The practices of hospitalization in the past have designated a new relationship of the man with that which may be inhuman in his existence. The sense of hospitalization ended up in an obscure social purpose, excluding all those who disagree with socially acceptable behavior in comprehensive institutions³. Such institutions generate in their inmates a variety of negative feelings. For there is a violation of the reservation of information about the self, generated in the act of admission to the institution, followed by the family and affective abandonment over the years, a fact that further accentuated this deficiency²⁰.

It is interesting to point out the load of meaning existing between these words, that are almost chained, revealing a representation linked to the collective image that these professionals have of the chronic psychiatric patient. The only word with a positive characteristic is tenderness, but then it is linked to a lexicon with a negative characteristic, without, which aggregates a quantitative of negative words and expressions, as described above. Also worthy of note is the lexicon patience, presenting the CN, which, then, is linked to the word care, which reached the highest frequency (42), also present in the CN and pointing to a centrality of this term. There are links between some words present in the CN, such as patience and care, which was already highlighted and had a strong similarity index (0.14), followed by dependence (0.06) and institution (0.02).

The lexicon patience forms a triad with the words treatment, present in the contrast elements, and family, located in the second periphery. Due to the institutionalization and the serious institutional dependence, this is a clientele that requires more professional care and consequently requires patience to offer a more singular care. Precisely, it is the patience that is lacking to many families that abandoned their relatives in the hospital. Such family abandonment was justified by past care proposals, which encouraged the hospitalization and the consequent loss of social bonds and affection.

CONCLUSION

Aspects that would indicate that institutionalized aging could contribute to chronicity and senility were evidenced, increasing the stigma in relation to the people. It would justify, in part, the negative and pejorative character of the SR revealed by the MH professionals, besides the welfare losses and affective implications implicit therein.

Through the socio-cognitive reconstruction of the MH professionals, concerning the person in PD, there was a need to reflect on the care provided to these clients in the context of BPR, since chronicity in psychiatry has historically been considered as an obstacle to different care proposals. Madness has haunted the imagination of men due to the fear of the unknown, the uncontrolled, the foolish and the different.

However, not only the negative aspects made the SR. It revealed that the professionals' discourse also had positive and affective elements, which denoted care, a charitable look, which could try to improve the quality of life of the patients in the everyday life. However, it could not materialize a daily work towards the deinstitutionalization of this clientele who have been long hospitalized.

This work did not aim to end the discussion on this topic. In order to overcome the limitations of this study, it is necessary to replicate the research in different scenarios of the Brazilian reality, with the respective health professionals, aiming at the generalization of the findings. This subject must be discussed in the different environments of interlocution in MH. Several researches are necessary, and the situation of the chronic patients must appear in the mental health discussion tables.

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