RESEARCH ARTICLES

 
Meanings of the Madness Festival: perspective of professionals from the Psychosocial Care Center

Nadja Cristiane Lappann Botti^I; Michele Cecília Silva Torrézio^II
INurse. Psychologist. Adjunct Professor II from the Graduate Nursing Course at the Federal University of São João Del Rei. PHD in Psychiatric Nursing from the Nursing School of Ribeirão Preto at the University of São Paulo. São João Del Rei, Minas Gerais, Brazil. E-mail: nadjaclb@terra.com.br
^IIAcademic Student from the Graduate Nursing Course at the Federal University of São João Del Rei. Scientific Initiation Scholarship Student from the National Council for Scientific and Technological Development. E-mail: micheletorrezio@yahoo.com.br
^IIIThis is a study linked to the research project History and Meanings of the Madness Festival of the municipality of Barbacena, funded by the Ministry of Science and Technology, through the National Council for Scientific and Technological Development.

ABSTRACT: The Brazilian Psychiatric Reform is considered one of the most sucessful, promising and vigorous worldwide processes of transformation in the mental health and psychiatry, but a large proprotion of the production of experiences, projects and reflections of the social dimension of the reform are not formally published. This research aimed at analyzing the meanings of the Madness Festival. It is an exploratory, descriptive and qualitative study, conducted together with 11 professionals from the Psychosocial Care Center at the municipality of Barbacena, Minas Gerais State, Brazil. The data was collected in November of 2011 by means of recorded interviews. In order to analyze the responses, we have applied the collective subject discourse technique. The identified meanings of the Madness Festival were: historical event, strategy of the deinstitutionalization process, anti-asylum expression and paradigm shift. The Madness Festival is characterized as a sociocultural expression of the Psychiatric Reform, where cultural resources are raised with the purpose of enabling social insertion and allowing the review of excluding and stigmatizing values ​​and beliefs in a dynamic, unusual and playfully way in the community scope.

Keywords: Culture; mental health; deinstitutionalization; health services reform. 

INTRODUCTION

The psychiatric care in Barbacena, municipality of the Minas Gerais State, was grounded on the asylum-based paradigm. In this model, the hospital was the therapeutic place characterized by isolation, surveillance and repression. The hospital, in principle, for the treatment of mentally ill patients had a gradual increase of customers because of the welcoming of socially excluded people¹. Barbacena is historically known as the Fools’ City because of the significant number of psychiatric hospitals. The first, called Colony Hospital, was built in 1903, and nowadays is known as the Psychiatric Hospital Center of Barbacena (CHPB)².

For several years, Barbacena was responsible for the psychiatric demand of the Minas Gerais State, thus becoming the reference for psychiatric care actions. As a result of the Psychiatric Reform process, there was a set of changes that led to the municipal restructuring of the mental health system. This restructuring began with the deployment of the first therapeutic residential service, in 2000, followed by the inauguration of the Psychosocial Care Center (CAPS), in 2002, which started to act as a regulatory gateway of the system, which was a previously CHPB’s function. Subsequently, other services were deployed, as the Day Hospital - Alcohol and Drugs, CHPB Outpatient Unit, living center and other therapeutic residences².

In addition to the mental health services, Barbacena also has the Madness Festival. The first edition was in 2006, and since then is annually held for four days. It is characterized as a cultural, artistic and scientific event with diversified and free programming in the main streets and squares of the city. The scheduling activities give social visibility to the issue of madness beyond the restricted space of the treatment to which historically it has always been closely related. This study aimed at analyzing the meanings of Madness Festival of Barbacena, from the perspective of professionals working in the CAPS of the city at stake.

LITERATURE REVIEW

The Brazilian Psychiatric Reform is considered one of the most successful, promising and vigorous worldwide processes of transformation in the field of mental health and psychiatry³. In Brazil, in the last few decades, this process has been advancing in the field of ideas and in municipal, state and federal practices, as part of a public policy aimed at transforming the hospital-centered model, focused on medical shares and medicalizing¹. In this scenario, it becomes strategic having production of actions aimed at transforming the social imaginary in order to modify the relationship between society and madness⁴.

A broader view on the Psychiatric Reform defines it from the technical-assistential, epistemological, legal-political and sociocultural dimensions. The first implies in changing the way of caring and the assistential services; the second refers to the changes in the paradigm that underlies psychiatry by shifting the privileged knowledge asylum-based model for other ways of understanding the madness; the third dimension includes the concept of citizenship and of social and human rights to oppose the notions of dangerousness, alienation and unaccountability that underlie and sustain the traditional psychiatric model, and the sociocultural dimension aims at transforming the social imaginary, in other words, representations and prejudices of society about madness⁴.

A particularity of the Psychiatric Reform in the country is the great production of formally unpublished experiences, projects and reflections associated to the fact that this production strictly deals with the social dimension of the Psychiatric Reform process⁵.

METHODOLOGY

It is an exploratory, descriptive and qualitative study, performed in November 2011, with 11 professionals from the CAPS of the municipality of Barbacema. We have observed the following inclusion criteria for composing the sample: working regularly in CAPS, having participated in the Madness Festival and agree to participate in the research. The data were collected through recorded interviews from the guiding question: What does the Madness Festival of Barbacema mean to you?
The data were analyzed by means of the collective subject discourse technique (CSD). This is a technique that uses methodological approaches to organize and tabulate data, producing a discourse-synthesis that represents the set of subjects. The CSD is a modality of presentation of results of qualitative researches that expresses the thought of the collectivity, as if this last one was exactly the issuer of a single discourse⁶. In this study, the constructed discourses were identified with CSD, followed by sequential numbering.

The study was approved by the Research Ethics Committee from the Federal University of São João Del Rei (Opinion nº 0001/2011), and the interviewees expressed acquiescence by signing the Free and Informed Consent Form.
Among the participants, there are eight professionals with higher education (four nurses, two social workers and two psychologists) and three professionals with high school (two nursing technicians and one administrative assistant). The found average age was of 37,42±7,64 years; the average working time in mental health was of 8,68±6,13 years, and it has reached 5,70 ±4,96 years in CAPS. Among the surveyed professionals, eight (72,73%) are females and three (27,27%) are males. Among the interviewees, it is identified that five (45,45%) participated in all editions of the Madness Festival, two (18,18%) in four editions, three (27,28%) in three or two editions of the event, and one professional (9,09%) only participated in a single edition.

RESULTS AND DISCUSSION

Historically, Barbacena was the headquarter of the first psychiatric hospital in Minas Gerais, fulfilling its role with proper treatment until 1930⁷. Gradually, overcrowding began to be a reality, since it was turning into the reference hospital for the State. Until the 1960s, the hospital reached the point to host five thousand patients, where the criterion only responded to what was contrary to society⁸. With the increase in the number of residents, the hospital beds have become insufficient, and the shortage of financial, materials and, especially, human resources, has produced a serious problem. The treatment started to be inhuman and degrading, thus producing high mortality rates. At that time, the hospital became deposit of patients and warehouse trade of corpses. As a result, the town at stake wins the stigma of Fools’ City. Over the history of the hospital, there are registrations of more than 60.000 deaths, being that cold, hunger, as well as pulmonary and intestinal infections were found among the leading causes⁹.

Nonetheless, in the 1970s, due to the reaction of health care professionals, journalists and intellectuals, the reassessment of the prevailing treatment was begun7, in line with the assumptions of critical and practical formulation aimed at transforming the psychiatric paradigm¹⁰. Accordingly, the interviewees highlighted the relevance of the Madness Festival as an event that recalls the history of the Psychiatric Reform process in the municipality of Barbacena:

Barbacena is important in the history of psychiatry, and the Festival is an opportunity to tell the story of the city that for a long time was hidden in the ancient colony hospitals in which madness was retained and excluded from society. Thus, the Festival, in addition to bringing outsiders to know the history of the city, also broadens the knowledge of the population about the historical process and the mode through which the city copes with madness in the current days. (DSC1)

The approach of madness from its presence and production in the sociocultural space is one of the essential points of the Psychiatric Reform process. This process aims at implementing profound changes in the legal, political, assistential and, especially, in social values ​​and meanings around the madness and the insane subject⁵. Despite restrictions in dealing with the issue of madness, due to the stigma, the Festival might be an initiative of the municipality for assuming the title of Fools’ City with a diverse connotation of what is historically recognized.

In Brazil, the mental health care model for replacing the hospital-centered paradigm has emerged in a particular historical context¹. Accordingly, it becomes crucial having historical knowledge of practices and skills that supported the asylum-based paradigm so that we can implement new practices of mental health care in the psychosocial scope. Thus, it should be emphasized the relevance of the meaning of the Madness Festival as the possibility of historical rescue asserted by CAPS professionals.

The deinstitutionalization, proposed by the Psychiatric Reform, believes that the mentally ill patient should be treated in its real life conditions. For this purpose, the treatment ceases to be the exclusion in spaces of violence and social death to become the creation concrete possibilities of subjectivity and social interaction¹¹. According to this ideology, the changes should transcend the simple reorganization of the assistential model and achieve social practices and perceptions, intervening not only in the operation of services and vocational trainings, but also in the complex phenomenon of social representation about madness¹².

In our country, there is evidence of greater individual and social effectiveness of mentally ill patients treated in the community, when they are compared with those who received treatment with regime of deprivation of liberty^13-15. It is perceived in the Psychiatric Reform a set of political, social and cultural initiatives aimed at radically transforming the psychiatric care, health care policies, lives of countless individuals with mental disorders and the daily routines of many social practices¹⁶. Seen in these terms, it is perceived the representation found in the Madness Festival as a strategy of the deinstitutionalization process:

he Madness Festival is a relevant time to think about mentally ill patients, who were previously excluded and kept on the margins of society. In this sense, the event is a chance to share what we have done and make society aware that they can live together with other people, as well as being included and getting a decent life and other treatment options, without staying within a hospital environment. Thus, the Festival is also a time of social inclusion outside of CAPS and of a therapeutic residences. (DSC2).

The indication of the Madness Festival as a strategy of the deinstitutionalization warns us for an important deadlock of the called institutionalization of CAPS¹⁷, which can be found in several alternative services of mental health care network, such as in the therapeutic residential service. This stalemate (or risk) refers to the transformation of the substitute service in a chronic and permanent institutionalization, thereby reproducing the insane asylum, which everybody aims at escaping from¹⁸.

The deinstitutionalization is made possible by theoretical, political and ethical construction of community care networks associated to professionals willing to take care from the perspective of integrality, the establishment of bonds, the organization and enhancement of territorial resources and, especially, the guarantee of the rights of citizenship¹⁹. The Reform seeks to deconstruct the asylum-based reality beyond the fall, in the physical sense, the asylum walls, and the construction of new realities with epistemological, political and social basis, with sights to transform the culture of violence, discrimination and imprisonment of the madness¹⁸. In this case, the emphasis is not placed on the healing process, but rather on the project of the health invention and of social reproduction of the mentally ill patient with the use of collective spaces of conviviality²⁰. Therefore, health is understood as the production of life with uniqueness and circulation in the different spaces of sociability and solidarity. Thus, the Festival might be understood as a hybrid experience of deconstruction of the asylum-based reality and construction of life and health invention.

The set of ideas of the Psychiatric Reform as a process of cultural change determines goals and actions of contact between madness and society. This contact allows the participation of the individual in the culture. Thus, the feasibility of its interaction with the other members can instigate the transformation of relationship patterns between madness and society, thus stimulating the change itself²¹. In this case, we should understand the Madness Festival as a strategy of the deinstitutionalization process, in addition to being an anti-asylum expression.

As we saw earlier, the Psychiatric Reform is defined from technical-assistential, epistemological, legal-political and sociocultural dimensions. Thus, as it was born from the claim of citizenship for the mentally ill patients, the reform in question breaks down into a broad and diverse scope of practice and skills¹³. As a result, the anti-asylum movement takes on characteristics of networks with different and fractals foci of activity. Among the foci, there are health, culture, justice, social security, arts and generation of employment and income that, quintessentially, are intersectoral¹¹. In accordance, the Festival of Madness is understood as an anti-asylum expression:

The Madness Festival is an event that drives the tourism and the culture of the city by means of a varied artistic programming. It is a special time of celebration of the Psychiatric Reform of Barbacema, with exposure of the users' production, discussion on health issues - mental disorder and psychiatric treatment. (DSC3).

The sociocultural dimension expands knowledge about madness by push it away from the exclusive field of the psychiatry. In this dimension, the madness wins the open field of trials and ends up influencing society, main by conquering space in the media and using socially valued resources of expression¹⁶. Accordingly, it is realized the tourist-cultural and academic-cultural function of the Madness Festival.

The anti-asylum movement aims not only the extinction of asylums, since it is known that the relationships with the mentally ill patients can remain excluding and asylum-based out of the psychiatric hospital. In this case, broad social change is needed to rescue the respect for the subjectivity, besides providing the possibility of expression of differences, peculiarities and personal assets. Therefore, it is necessary to change the cultural standard with warranty of social heterogeneity and might can be seized through the discourse that reflects the anti-asylum expression of the Madness Festival.
The anti-asylum movement is not restricted to the technical or assistential change of the madness, but primarily seeks to ensure its inclusion and warranty of its citizenship. In Brazil, the celebrations of the National Day of the Anti-Asylum Struggle, celebrated on May 18^th, make clear the inclusion of the madness and the radicalization of change of the way of caring for those formerly excluded from the world of rights and of citizenship. Accordingly, Psychiatric Reform presents itself as an ethical, political and cultural issue, which goes beyond the technical coverage and, therefore, advocates more sensitive modes of taking care¹¹.

The Psychiatric Reform gradually advances from innovations restricted to the psychiatric care to achieve a complex social process, which aims at transforming social relationships with the madness and, consequently, with the diversity and the differences⁴. Thus, the interviewees identify the Madness Festival as reflect of the paradigm shift:

The Madness Festival opens space to discuss new paradigms, demystification of madness and deconstruction of the old model in which the patient was trapped in the psychiatric hospital. It also allows the society to discover that mentally ill patients are human beings as anyone else, because many of them still do not accept the madness and think they are dangerous. (DSC4).

Strategically, Psychiatric Reforms aiming at transforming the social imaginary in relation to the madness makes use of the proper devices of art and culture. At the national level, we can found the public policy Crazy for Diversity, which is developed by the Brazilian Ministry of Culture, giving visibility to the productions of people bearers of mental disorders¹⁶. Thus, the editions of the Festival are in regional level. In this vein, it is an event that reflects a paradigm shift through art and culture.

In Brazil, experiences for deconstructing asylums and constructing substitutive care networks demonstrate the possibilities of overcoming the traditional model. These transformations have abandoned the restricted therapeutic field, which is an interest of health care professionals, to engage society in a more broad manner¹.

CONCLUSION

According to the perspective of CAPS professionals, the meanings of the Madness Festival are four: the representations of historical event, strategy of the deinstitutionalization process, anti-asylum expression and reflection of a paradigm shift. Such meanings are pretty relevant, since it is known that the Psychiatric Reform makes fundamental the historical knowledge of practices and skills that supported the asylum-based paradigm so that new practices in mental health care might be constituted in the psychosocial scope. It is also relevant to mention the significance of the event as an expression of the experiences of deconstruction of the asylum-based reality, as well as life and health invention, which are characteristics of the deinstitutionalization process. Finally, the change in the cultural standard with warranty of social heterogeneity from the transformation of relationships between society the madness and, consequently, with the diversity and the differences.

Thus, the Madness Festival is characterized as an expression of the sociocultural dimension of the Psychiatric Reform, where the cultural resources are raised up with purposes of social reinsertion and allow the review of excluding and stigmatizing values ​​and beliefs in a dynamic, unusual and playfully way.

REFERENCES

1. Devera D, Costa-Rosa A. Marcos históricos da reforma psiquiátrica brasileira: transformações na legislação, na ideologia e na práxis. Rev Psic UNESP. 2007; 6, 60-79.

2. Fassheber VB, Vidal CEL Da tutela à autonomia: narrativas e construções do cotidiano em uma residência terapêutica. Psicol Ciênc Prof. 2007; 27:194-207.

3. Desviat M. A reforma psiquiátrica. Rio de Janeiro (RJ): Editora FIOCRUZ; 2002.

4. Amarante PDC. Saúde mental e atenção psicossocial. Rio de Janeiro: Editora FIOCRUZ; 2008.

5. Passos ICF. Cartografia da publicação brasileira em saúde mental: 1980-1996. Psic: Teor e Pesq. 2003; 19:231-40.

6. Lefèvre F, Lefèvre AMC. O discurso do sujeito coletivo: um novo enfoque em pesquisa qualitativa (desdobramentos). Caxias do Sul (RS): EDUCS; 2003.

7. Vidal CEL, Bandeira M, Gontijo ED. Reforma psiquiátrica e serviços residenciais terapêuticos. J Bras Psiquiatr. 2008; 57:70-9.

8. Magro Filho JB. A tradição da loucura. Belo Horizonte (MG): COOPMED; 1992.

9. Esteves B, Carvalho RB. Bárbaras cenas. Ciência Hoje. 1999; 26(156):50-3.

10. Amarante PDC. Loucura, cultura e subjetividade: conceitos e estratégias, percursos e atores da reforma psiquiátrica brasileira. In: Fleury S. Saúde e democracia: a luta do CEBES. São Paulo: Lemos Editorial; 1997. p. 163-85.

11. Pitta AMF. Um balanço da reforma psiquiátrica brasileira: instituições, atores e políticas. Ciênc saúde colet. 2011; 16:4579-89.

12. Coelho M. A dimensão sociocultural da reforma psiquiátrica e a companhia experimental Mudança. Saúde em Debate. 2008; 32(78): 92-8.

13. Tenório F. A reforma psiquiátrica brasileira, da década de 1980 aos dias atuais: história e conceito. Hist cienc saude-Manguinhos. 2002; 9(1):25-59.

14. Wetzel C, Kantorski L. Avaliação de serviços em saúde mental no contexto da reforma psiquiátrica. Texto contexto-enferm. 2004; 13:593-98.

15. Surjus L, Togni S, Onoko R. A avaliação dos usuários sobre os centros de atenção psicossocial (CAPS) de Campinas, SP. Rev latinoam psicopatol fundam. 2011; 14:122-33.

16. Amarante PDC, Rangel M. A liberdade é terapêutica: reinventando vidas na reforma psiquiátrica. Rev Eletr Com Inf Inov. Saúde. 2009; 3(4):10-6.

17. Barros RB. Reforma psiquiátrica brasileira: resistências e capturas em tempos neoliberais. In: Conselho Federal de Psicologia. Loucura, ética e política: escritos militantes. São Paulo: Casa do Psicólogo; 2003. p.196-206.

18. Amorim AKMA, Dimenstein M. Desinstitucionalização em saúde mental e práticas de cuidado no contexto do serviço residencial terapêutico. Ciênc saúde colet. 2009; 14:195-204.

19. Dutra VFD, Rocha RM. O processo de desinstitucionalização psiquiátrica: subsídios para o cuidado integral. Rev enferm UERJ. 2011; 19:386-91.

20. Rotelli F, Leonardis O, Mauri D. Desinstitucionalização. São Paulo: Hucitec; 2001.