RESEARCH ARTICLES

Treatment on hospital-centered model: perceptions of relatives and individuals affected by mental disturbance

Letícia de Oliveira Borba^I; Andréa Noeremberg Guimarães^II; Verônica de Azevedo Mazza^III; Mariluci Alves Maftum ^IV

^I Nurse. Ph.D. in Nursing by the Graduate Program in Nursing from the Federal University of Paraná. Member of the Study, Research and Extension Center of Human Care of Nursing. Curitiba, Paraná, Brazil. E-mail: leticia_ufpr@yahoo.com.br
^II Nurse. Ph.D. in Nursing by the Graduate Program in Nursing from the Federal University of Rio Grande do Sul. Assistant Professor from the Nursing Department from the State University of Santa Catarina. Chapecó, Santa Catarina, Brazil. E-mail: andrea.guimaraes@udesc.br
^III Nurse. Ph.D. in Nursing. Professor of the Nursing Department and Coordinator of the Graduate Program in Nursing from the Federal University of Paraná. Coordinator of the Study Group Family, Health and Development. Curitiba, Paraná, Brazil. E-mail: mazzas@ufpr.br
^IV Nurse. Ph.D. in Nursing. Professor of the Nursing Department from the Graduate Program in Nursing of the Federal University of Paraná. Vice-leader of the Study, Research and Extension Center in Human Health of Nursing, Curitiba, Paraná, Brazil. E-mail: maftum@ufpr.br

DOI: http://dx.doi.org/10.12957/reuerj.2015.4689

ABSTRACT

Thematic oral history-based research conducted in Curitiba, PR, Brazil, in 2009, with eight subjects in three families with a member affected by mental disturbance. The study aimed at describing the perception of both those affected by mental disturbance and of their relatives on hospital-centered assistance for mental health. Data were obtained through semi-structured interviews and treated on the basis of thematic analysis. Subjects charged the hospital-centered model with the successive internments in shelter-like institutions, and with the restrictive spaces such as strong cells used in the treatment of those affected by mental disturbance. They reported the use of the force, sedation, electro-convulse-therapy, physical contention in bed, and bandaging as some of the resources used lacking criteria. In conclusion, narratives help understand current changes in the assistance of those with mental disturbance.

Keywords: Mental health assistance; mental disorders; family; treatment.

INTRODUCTION

In the mid-eighteenth century, there were asylums to meet the demands of modernity as a specific institution to isolate beggars, prostitutes, vagrants, and crazy society. This was in accordance with the objectives of the industrial revolution, the rise of the bourgeois class and incompatibility between reason and madness disseminated by modern rationalist thoughts¹.

In the nineteenth century in Brazil, the Hospice Dom Pedro II was founded in Rio de Janeiro, opened in 1852, a large mental hospital which kept the tradition of asylum house of all kinds, subject to various interventions and arbitrariness. Thus, the process of institutionalization of madness was governed by the public discourse of legitimacy and necessity of exclusion of people who disturbed the order in specific locations².

Among the proposed interventions, there were the standardization of behavior, control time, the rigidity of rules, social isolation and loss of identity and reference of segregated people. These practices were intended to reprogram the existence of subjects meeting the requirements of good order and discipline^3,4.

With this reality of overcrowding, bad-treatment, therapeutic focused on force and punishment, a rethinking of practices in mental health began, starting in Brazil from the 1980s. Thus, practice and knowledge in this knowledge area have been transformed with changes in the way of understanding and dealing with mental patients and the creation of new treatment devices based on the community^1,5,6.

Thus, it is important to investigate the assistance that was offered to people with mental disorder before the proposal and implementation of the new health care model, in order to knowledge and reflection not to incur the mistake of changing the structure, breaking the walls, but not the thinking and archaic actions, in addition to preserve the history through the written record of the present facts in memory of subjects who experienced treatment in the asylum model.

In this study, the objective was to describe the perception of family members and patients with mental disorders on mental health assistance sustained in the hospital-centered model.

LITERATURE REVIEW

After creating Dom Pedro II Asylum in Rio de Janeiro in 1852, several regions of the country began the construction of large asylums in order to control and shape the behaviors through surveillance, control, discipline, punishment and institutional violence, which involved treating insane and stranded individuals^5,7,8.

In Republic Brazil, mental hospitals continued to be considered appropriate locations for the reprogramming of forms to exist, and the dynamics and functioning remained grounded in restoring order. Nowadays, this approach is reflected when faced with a considerable number of patients with chronically mental disorder, some still living in psychiatric hospitals, without identity and without family ties^7,8.

The care provided to patients with mental disorders in Brazil is similar to the one offered in European countries, based on institutionalization. Reports of the presidents of the states of São Paulo, Rio Grande do Sul, Pernambuco and Pará throughout the second half of the nineteenth century evidenced the precarious health and physical space in psychiatric institutions conditions, since asylums throughout Brazil soon became overcrowded and targets of constant complaints of bad-treatment to patients^1,2.

After unsuccessful attempts to recover the therapeutic function of the psychiatric institution, the presented reality was a not resolved care model. Patients were described as passive agents, deprived of basic human needs, and limited in their most legitimate rights. There was evidence of a true madness industry⁵.

METHODOLOGY

This is a History Thematic Oral Research, held in 2009 with families who had a member with a mental disorder and living in Curitiba/PR and metropolitan area. In this work, it was considered by the family, mental patients and the people referred as their family.

The methodological reference Oral History was used in the research for both the interview and to establish the target community, the colony and the network⁹.

The target community is determined by considering people with common dramas, experienced with intensity and consequences that somehow impose changes in the dynamics of the group life⁹. The target community was represented by families who experienced the treatment of a member with a mental disorder in the hospital-centered model.

The colony is the first target community division, facilitating the understanding of the whole and making possible the realization of the study⁹. The colony was represented by families who experienced the treatment of a member with a mental disorder in the hospital-centered model in Curitiba and metropolitan region.

Network is the subdivision of the colony. It should be plural, because the internal differences of the groups are exposed in diverse ways to understand the phenomenon⁹. The network was constituted of families who experienced the person´s treatment with previous mental disorder to 1980 until 1994 residents in Curitiba and metropolitan region.

Inclusion criteria were families with at least one person with a mental disorder who became ill before 1980, decade where various events mark the beginning of the psychiatric reform in the country, until 1994, when effectively a support network in mental health area was established, guided by the principles of psychosocial model in Curitiba/PR; family members who followed up the person treatment with mental disorder, referred by the mental patients as a family and be 18 years old.

To establish a network of informants, contact with the responsible was held with the two family associations and people with mental disorders, indicated by the collaborators. Participants indicated were invited and agreed to participate, being three families, with eight collaborators. Families were called F1, F2, F3, people with mental disorders identified with fictitious names and family relationship, as shown in Figure 1.

FIGURE 1: Collaborators´ characteristics. Curitiba, 2009

The project was approved by the Research Ethics Committee of the Sector of the Health Sciences Federal University of Paraná, under CAAE 3168.0.000.091-08. The ethical aspects were followed accordance with Resolution No. 196/96 of the National Health Council.

The data were collected through semi-structured interviews guided by a script composed of identification data and two open questions:Report how you perceived the treatment received by your family member in mental health before 1994 (addressed to family members), and Report how you perceived the treatment received mental health before 1994 (addressed to the person with mental disorder).

The interviews were conducted according to the availability of each collaborator and the locations indicated by them - associations and in their homes. Before starting the interviews, each collaborator was asked if he wanted to tell his story together or separately from other family members. Some preferred to be interviewed alone and others have chosen to be together. Five interviews were conducted recorded on tape from April to June 2009 with an hour term average.

Each interview went through the transcription process, textualization and transcreation according to the methodological reference of oral history. The transcription involved the conversion from oral to writing. In textualization, there was a refinement of the material to identify the vital tone of the interview. In transcreation, the text was recreated following a logical reasoning, which was validated with each collaborator in order not to change the direction of their narratives⁹.

The narratives after transcreation were analyzed according to the thematic analysis of Minayo¹⁰. The three themes categories that emerged were Successive hospitalizations; Therapeutic used by the psychiatric institution; and the (lack of) care of the person hospitalized to hospital-centered institution.

RESULTS AND DISCUSSION

Here, there are the themes exemplified with the speech of some of the collaborators who participated in this study.

Sucessive hospitalizations

Collaborators mentioned the successive hospitalizations to psychiatric hospitals, known as the phenomenon of the revolving door and non-adherence to pharmacological treatment, as follows in these narratives:

He did not accept treatment, in the hospital he took the medication and he was right, he came back home, he did not take the medicine, was bad again, he had to be hospitalized again .. (F2Mother)

I lived [...] in a psychiatric hospital, was on average six months hospitalized. I was hospitalized, I was right, I came home, I felt bad again, I was hospitalized again. (F3Gustavo)

The hospitalization was very difficult for me, to go to the psychiatric hospital with all those patients together, stay away from the family. When I was discharged, I returned home, but stopped taking the medicine, so I had to be hospitalized again. (F2Paulo)

The phenomenon of the revolving door in the mental health area shows the failure of the predominantly biomedical model of health, supported in object-healing relationship. This model considers only the biological aspects and not the complexity of relationships, of subjectivity, the environment and social area on people´s health. Thus, the production of health services is compromised in closed and the chronicity of production is predominant. A relationship of dependency between the subject and the health service was established that weakens the autonomy and social reintegration capacity of the patient after the period he was institutionalized^11,12.

The situations to the need for hospitalization in psychiatric institution deal with non-adherence to medicine treatment, lack of follow-up after hospital discharge, information and guidance available to the family, social exclusion by the stigma of madness and the difficulty in ensure continuity of treatment in the outpatient services that provide care and intervention during a crisis^12-14.

One way to break the cycle of hospitalizations is to implement and expand community health services in which the subject is treated in their social environment, incorporating actions that will help them to develop new ways of autonomy and increase their power of contractuality^6,12,14.

Activities related to leisure, culture, crafts, physical activity, union with social support such as churches, schools, community centers and clubs should be part of mental health treatment. These areas of care combined with the change in lifestyle, pharmacological therapy and follow-up on substitute services, essential to the process of rehabilitation and rescue and construction of new links⁴.

As for adherence to medicine therapy, a study with 167 people with mental disorders showed that 60% had irregular use of medication¹⁵. Non-adherence implies new crises, increasing the number of hospitalizations/re-hospitalizations with losses in several spheres of life of the individual^16,17. The importance of pharmacological treatment not in an isolation way was highlighted, but together with other available resources enabling the individual to express themselves and gain the greatest possible level of autonomy.

Therapeutic used by the psychiatric institution

Collaborators mentioned physical strength, sedation, strong cells and electroconvulsive therapy as used by the psychiatric institutions. The strong cell was described as a small room in which the person was isolated without supervision of a health professional and when going out again, the person was confused and disoriented.

I worked 10 years in a psychiatric hospital, the treatment was shock-based, strength. I was tired of seeing mistreat people. They prescribed electroshock, applied injection that knocked the person. (F1Father)

The cubicle was a small room with a door with a hole to look inside and an iron window. They took the person by the neck and arms and threw in there to calm down for 3 to 4 hours. There was a stone bed and a blanket. The person was without eating or drinking. If it was after dinner, they played in the cubicle and the person dawn there. I went to the cubicle once, they caught me and threw me there, in the dark I fell asleep when I left I was kind of clueless. (F3Gustavo)

I received electroshock because I did not feel happy, sadness, they put a mattress there, one was holding the legs to not shake, other was holding my arms, they put a rubber so I can bite it and two things in the head [electrodes] that came from a similar device with a radio. When they dialed it up, I felt a punch and slept. Then, I was improving. (F3Gustavo)

He was getting worse, about three months he stood there and did not improve, they gave him electroshocks, he has improved. (F3Mother)

Thank God, she never took electroshock. (F1Mother)

The mental hospital was intended to use devices to correct abnormalities. There were supervisory relationships, discipline and control, inflexible as to the power of choice for inmates. In the asylum institution, they have the responsibility for eliminating the symptoms of mental disorder. Therefore, they used a collection of resources ranging from hospitalization, hydrotherapy techniques, excessive administration of psychotropic medicine, to application of electrical stimulus or the use of surgical procedures¹⁸.

The use of cubicles was banned by SNAS Ordinance No. 224, of January 29, 1992, which established the prohibition of the existence of restrictive spaces, and strong cells with a view to the need to humanize the assistance and ensure the rights of citizenship of mental patients hospitalized in psychiatric institutions¹⁹.

Electroconvulsive therapy was introduced as a treatment in mental health in 1937, and by the easy application of the method. This news was immediately adopted by psychiatric hospitals, however, they were using it indiscriminately, associated to physical punishment and disciplinary control^18,20.

Today, this practice is indicated as a therapeutic resource in situations where the patient does not react with improvement to any other measure of intervention in cases of deep depression and catatonic pictures^18-21. The practice of electroconvulsive therapy should be considered after careful assessment and measurement of the potential benefits and risks, including: risk of anesthesia, physical condition, previous adverse events, especially cognitive loss. It should be administered only after obtaining informed consent from patients who have capacity to do so or their legal caregivers²².

Collaborators also expressed physical restraint in bed with cotton fabric bands and strapping as therapeutic used by hospital-centered model.

I was restrained because I wanted to escape. I spent a night contained, they injected me tranquilizer and had no more trouble, but it was very traumatic for me. (F2Paulo)

In [name of a psychiatric hospital] they forbade go from one place to another, when I was admitted I used to cry and could not, if I screamed, sang loud, they always contained me. I did not want to go to sleep, then they take me and contained me. During the day, I do not remember what I was doing, but they also contained me. (F3Gustavo)

I went through the bandage, and felt bad when I was out of range they tied me with a wet bandage. The bandage is made with wet tissue, then over two more dry. It was two hours bandaged, sometimes even three. (F1Eduarda)

I had the bandaging. It was like a mummy, I do not remember if it's a first wet cloth, then dry for another person to be calm, it was three hours. (F3Gustavo)

Regarding the technique of physical restraint in bed with cotton fabric bands, this practice was often performed inadequately and without evaluation of their need to consider that the inappropriate and indiscriminate use of physical restraint technique configured the first choose the bearer´s approach to mental disorder, over a practice that valued sustained approach to therapeutic communication.

In the current environment of care in mental health, it is not acceptable that physical restraint is constituted a routine procedure in health services. It is recommended to use it as last resource, after having exhausted all possibilities of approach to the patient for therapeutic communication. In psychiatric emergencies, it is recommended the use of active and respectful listening, acceptance of suffering, therapeutic communication and, if necessary, physical restraint²³.

When it is needed the use of physical restraint in bed, it is important to clarify the patient at the time of the procedure its reason, allowing and enabling them to express feelings regarding the situation that they are experiencing, so that in fact the technique is therapeutic^23-25.

The prescription of physical restraint technique is legally a medical assignment, as stated in Resolution No. 1,598/2000 of the Federal Medical Council ²⁶. The Federal Nursing Council in 2012 through Resolution No. 427/2012 has standardized nursing procedures in the mechanical containment and employment established between the care, with the patient during the period of restraint, the monitoring of their state of awareness, vital signs and blood flow conditions. It also points out that physical restraint should be used as a last resource, and not being used as punishment, discipline and coercion ²⁷.

The bandaging technique described by collaborators was to contain the patient with several layers of wide bands of cotton fabric, needed at least eight people to its realization. The two inner layers were soaked in warm water and the two outer laps made with dry fabric^13,25.

Bandage of the person was from the ends of the legs, leaving the feet free to control the blood circulation. The band was wrapped around the body upward spiral to their shoulders, going over the arms, keeping in anatomical position. This procedure was repeated four times^4,25.

This type of physical restraint was indicated for very agitated, aggressive patients, where the approach for communication, recreational activities and medication were insufficient at that time to protect them and protect others^13,24,25.

The (lack of) care to the person hospitalized in hospital-centered institution

One of the collaborators said that people in institutions with asylums characteristics remained dirty, barefoot, and even naked. He mentioned the overcrowding in psychiatric hospitals, the loss of identity and the power of choice for patients.

We came into the hospital and he was dirty, barefoot, naked. It was many people, there were bars on the windows, huge high, they stuck there asking for food, we were coming and they asking for food. It was many people, all mixed together. The first time he was hospitalized, I took food for him, I got there, he was naked. (F3Mother)

In these collaborative narratives, it is clear expressed the image of the asylum institution, segregated and overcrowded. This was already evident in reports on the situation of asylums in Brazil throughout the mid-nineteenth century, where it was recorded that the amount of internal grew at an alarming rate, vacancy rates were not enough, the internal lived in subhuman conditions and had not qualified for their job. When entering into the mental hospital, it could be seen hundreds of naked, filthy and stinking people².

In this context, there is the discussion about bad-treatment in psychiatric institutions in order to not allow the use of such practices in these institutions by the National Assessment Program Hospital/Psychiatry System, with the objectives of searching humanization practices of person´s care with mental disorders, monitoring and closure of unhealthy institutions that still have a therapeutic institutional violence²⁸.

From the Ordinance number 251, of January 31, 2002, the term psychiatric hospital, is an institution in which most of the beds are for specialized treatment of psychiatric clients in hospitalization regime. These services should offer, according to the needs of each patient, activities of medical and psychological and social assessment, brief psychotherapy, occupational therapy, group therapy, and offer and have physical space available for sports, games, rooms with television, music and environment for leisure time¹⁹.

It should be noted that at a time of expansion and solidification of a network of mental health services, there is not denied the existence of situations that require hospitalization, but there is the understanding that the crisis treatment can be performed by CAPS III, with beds in psychiatric and general hospitals. Considering the difficulties of implementation of these services and service capacity, the psychiatric hospital is now used as a health device after exhausting all other possibilities of intervention by outpatient services.

CONCLUSION

The perception of the contributors to this study to hospital-centered model has been presented in thematic categories: Successive hospitalizations; Therapeutic used by the psychiatric institution; and the (lack of) care of the person hospitalized to hospital-centered institution. Through them, the collaborators showed facts that reflect the historic moment that experienced, characterized by therapeutic employed by force, strong discipline, corrective measures, unhealthy environments, overcrowded, coercion and isolation.

It was also mentioned the phenomenon of successive hospitalizations to asylums, which shows that without interdisciplinary and complementary actions it is not possible meet the demands and resolution provided from a chronic course of disease such as mental disorder.

The narratives of the collaborators contribute to reclaim the memory of care provided to people with mental disorders by hospital-centered institution over the years. This contributes to the understanding of the changes taking place in the present, highlighting the importance of the current discussions, to offer community-based and resolute services to promote social reintegration and autonomy of people with mental disorders.

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