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Health care practice in psychosocial institutions: effects of the capitalist mode of production. Assis, SP, Brasil. The mode of production of material goods is correlated to the mode of production of health and indicates the possible forms of subjectivation in a society, thus, the mode of production is related to the ways in which the social and psychic impasses materialize.
Conflicts of the class struggle produce contradictions, so it is crucial to note that the symptoms that trigger the crises come to enounce an objection to the social context in which they emerged. Based on institutional analysis, we find that mental health institutions in the context of the capitalist mode of production have served to manage these crises in order to dissuade them.
It is observed that despite the advances of Brazilian psychiatric reform, psychosocial establishments still serve social adaptation, producing alienated subjectivities and reproducing historical forms of domination-subordination, such as psychiatric hospitalization and medicalization of life and suffering. In the scope of Collective Mental Health CMH , there are several social representations and ways to understand psychological distress and the process of health production. According to Costa-Rosa , , from these social representations derive different modalities of mental health establishments, among them being the Psychosocial Care Center, Therapeutic Residences, etc.
The combinations between institutional establishments and means of work are numerous and constitute different ways of producing health.
At an institutional establishment there is always, explicitly or not, a theoretical-technical and ethical-political reference that directs the treatment practices, which we call a paradigm. Different ways of conceiving psychic impasses and, consequently, treating them, imply different productive results, which must be analyzed according to their ethico-political status Costa Rosa, , i. In this perspective, the conception of subject as well as health is dialectical and does not fall into the movement of producing HDPP objects.
The psychiatric reform Fleming, inaugurated a series of questions regarding the practices of the HDPP, above all, it brought to the fore an expanded knowledge about psychic suffering, criticizing hospitalization and medicalization, and inspiring the creation of psychosocial establishments within communities. However, despite these advancements, as described by Amarante , i. The way to produce health is correlated to the mode of production of the various material goods and indicates possible forms of existence, social relationship and subjectification in a society, therefore, they are directly related to the ways in which social issues materialize and are experienced at the level of psychological suffering and even physical disorders Shimoguiri, , Costa-Rosa, Through his craft, the individual was constituted as a generic being, i.
In general terms, we highlight some of the consequences of the CMP: the worker no longer owns the means of labor nor his production; with industrialization and technicalization, there was a brutal separation between knowing and doing; there arose the figure of the non-worker, the one who holds the necessary capital to buy the labor of another, and, finally, the invention of surplus value.
As a result of these changes, on the level of subjectivity, we have estrangement and alienation, the objectification of doing as loss and the appropriation as estrangement and alienation. Still in regards to estrangement and alienation in the CMP, we find that man is lowered to the condition of object, being himself a worker-commodity. This human misery has an inverse relationship to productive and creative power.
It is observed that goods lead people to the market, not the other way around: more than a speech without words, Marx enunciates a discourse without subjects. Shimoguiri, , p. In capitalism, labor ceased to have use value in order to become a value of exchange.
Moreover, because of this commodification, the aim became to achieve the greatest volume of production possible, at any price. There is a social bond fed by the circuits of productivity and consumption - a bond of economic and subjective expropriation. According to Shimoguiri , most of the theoretical-technical references of the Brazilian Psychiatric Reform BPR highlight social and labor market integration as important health indicators, bringing the idea of health closely connected to the capacity to develop functions that are economically productive, and hence, linked to capitalism.
From this perspective, re producing health, or in other words, promoting rehabilitation, is the same as seeking functionality and adaptation, re framing individuals into the logic of capitalism: production and consumption. However, the definitions of what health is can be problematized, and even modified, depending on the paradigm in question, on what is sought as a therapeutic and ethical effect. Thus, in this study we are interested in reflecting on the function of psychosocial care institutions in regards to the production of subjectivityhealth and in discussing the effects of an ontological and functionalist perspective of the human condition molded in the capitalist mode of production.
All economic and social formation encompasses divergent interests, so that conflicts between the dominant pole and the subordinate pole make up a set of opposing forces that produce crossings and impasses, which is commonly translated into psychological suffering.
In this way, social demand is related to the pulsations resulting from the conflicts of the class struggle that occur in the territory Costa-Rosa, , understanding it as being beyond the physical and geographical space, but further, into a space crossed by economic, political, sociocultural, ideological, and subjective factors.
For the agency of the class struggle, each institution cuts out its referent of action from the social demand. An institutional establishment is defined by its function offer of medical, psychological care, education, etc.
In fact, given the indissociability between subjective constitution and social reality, collective health work goes beyond the psyche of individuals.
It is necessary to consider the subjective, economic, social, cultural and political factors that led the subjects experiencing symptoms and suffering to seek treatment Costa-Rosa, Before being translated into requests for treatment, the social demand goes through imaginary and ideological mediation to come to express itself in orders Lourau, , which are usually requests for help, and which is how they reaches institutional establishments.
The process of transforming demand into order depends on the impasses of subjectivation with which it deals and on how the establishment to which the orders are directed positions itself in the territory is directed. Considering that demand generates supply and supply also generates demand Costa-Rosa, , if the mode of production of the establishment is in tune with the capitalist mode of production, the orders will appear as requests for resolution to be obtained by pharmaceuticals, hospitalizations, among others.
They will be requests for healing, quick solutions and supplies. Starting from the hypothesis that the social and psychological impasses that trigger ruptures and crises bring with them a questioning, an objection to the familiary and social dominant instituted Costa-Rosa, , it is necessary to stress that institutional establishments fulfill a specific function of re producing historical forms of domination-subordination that ensure the relations of power that are exercised by the dominant social class over the subordinate class Baremblitt, At an institution there are two important movements: the instituted and the instituting.
The instituted corresponds to the hegemonic social relationships and the instituting is the set of forces capable of leading to social transformations. These movements are encompassed in the strategic process of hegemony Gramsci, cited by Costa-Rosa, The strategic process of hegemony is the mechanism in which one seeks to ensure the maintenance of the current social formation, to maintain inherently divergent dominant and subordinate interests in a state of equilibrium.
Due to the ideological and material preponderance of the dominant social pole, it generally maintains its interests to the detriment of the interests of the subordinate pole Costa-Rosa, Thus, it is evident that the instituted play an important historical role, because the created laws, the constituted norms or the habits, standards, are in force to regulate the social activities.
Therefore, it is important to know that social life - understood as the process in permanent transformation that must drive towards perfection and aim at greater happiness, greater achievement, greater health and greater creativity of all members - is only possible when. Baremblitt, , pp. No institution operates alone, there is interpenetration and interlinking that exists between all organizations, establishments, agents, among others Baremblitt, There are countless tools to re produce adaptation, correction and normalization, or, in other words, to maintain the instituted social dominant.
Based on this analytical level, we infer that health and care establishments are created to metabolize and obliterate the tensions that arise from the instituting pulsations, which were unsuccessful and exist by virtue of social requests for attenuation of the suffering, of reintegration of the individual in production, family and society.
Health care institutional establishments operate as State Ideological Apparatus SIA Althusser, , as they exist to manage human miseries and buffer the organic, psychological and social problems that arise as d effects of the Capitalist Mode of Production and its corollary, the HDPP.
It is clear that the aim of the State is to rehabilitate those who suffer, to reintegrate them socially to make them return to society, especially as workers, namely labor for capitalism. The ideological discourse of psychosocial rehabilitation veils the social tensions of the class struggle.
Costa-Rosa, , pp. In order to broaden its political-economic powers and at the same time maintain divergent interests in homeostasis, the capitalist mode of production overlaps some claims outside its ideology, for example, those made by Brazilian psychiatric reform.
But we cannot be naive, they are easily recovered tactical concessions, insofar as their existence is only meant to water down tensions and undermine the instituting movements, without ever firing criticisms that are radically contrary to the HDPP. Under this bias, we can understand the reasons why, in the Capitalist Mode of Production, it is possible and desired to harmoniously combine health and alienation, as if one were not exclusive to the other. Considerations about the overall picture of the Brazilian Psychiatric Reform and psychosocial care.
According to the guidelines of the Brazilian Ministry of Health Brasil, a, b , the treatment proposals from the BPR should be substitutive rather than complementary to the psychiatric hospital. Psychosocial care has emerged as a public policy of mental health care. In order to achieve this, it was necessary to expand traditional clinical practice so that there could be various types and levels of health care.
The psychosocial devices, due to their non-hospital character and refusal of the biomedical and symptomatological model Brazil, , must ensure that Collective Mental Health demand management moves in the opposite direction to asylum institutionalization Amarante, In addition to the regional hospital, which had beds and psychiatric emergency rooms, there were four more fully functioning psychiatric hospitals in the region.
In , it was estimated that this group was approximately people Cayres et al. Based on this very small reduction, we presuppose the ineffectiveness of dis hospitalization and deinstitutionalization strategies, since the reduction in the number of dwellers was mainly due to deaths. It was noticed that the activity and number of psychiatric hospitals, instead of having decreased, following the paths of the BPR, increased, with the inauguration of the pole of intensive care in mental health.
During the six years between the two censuses, no mental hospital inpatient was discharged following improvement, and other subjects who arrived for a brief hospitalization period became permanent residents.
We emphasize that, not infrequently, the PCC were mentors of referrals for hospitalization, hospital teams complained that the PCC asked for beds, but did not accompany the subjects during hospitalization, so the discharges were not viable because there were no proposals for treatment in the community, nor were there individuals to pick up the subjects from the hospital. In this way, given the long period of stay at the facility, they became residents, with no hope for social reintegration.
In , there were 86 hospitalizations in psychiatric hospitals and religious therapeutic communities. As characteristics of the HDPP, there are vigilance, moral treatment, punishment, custody and interdiction. In this regard, it should be emphasized that the permanent resident status of most of the patients in psychiatric hospitals was not necessarily justified by situations of crises resulting from intense psychological suffering.
On the contrary, from this standpoint, all of them were eligible for treatment in the community, at most, it would be necessary to build some therapeutic places to meet the more complex demands.
Social and family conditions were still crucial determinants to keeping these patients at the asylum. Often we witness hospitalizations induced in the name of social hygiene, especially when it comes to street people using crack and other drugs. The somewhat Manichean solution was their exclusion from public spaces, regardless of their wishes, the causes of inequalities, and the socioeconomic problems closely associated with their modes of subjectification, or at least the achievements of the BPR and its efforts for deinstitutionalization.
Often, admissions of people using alcohol and other drugs give the implicit notion that this is a crime-prone population. So demands for social assistance and health care are conducted as public safety cases, and from this policing and exclusionary perspective, policies that induce repressive actions and violations of human rights are disseminated.
These actions, if not analyzed in detail, can be considered to be effective practices, since they promise resolving measures. In this sense, treatment proposals follow, in a veiled manner, the pattern of the Middle Ages by maintaining its character by social cleansing.
The ethics of guardianship prevails as guiding human relations and possible treatment experiences. The hospitalizations that we analyzed used the social vulnerability in which the subjects existed as a justification, so as to attenuate the historical issues of social inequalities through medical and psychiatric treatments.
The National Secretariat for Drug Policy has produced a report on drug addiction treatment, whose goal is the supposed cure of the disease, i. For example, a thirteen-year-old boy was placed in compulsory detention for marijuana use, not so much for the use of the drug itself, but based on the belief that the adolescent would soon commit offenses. What is most out of tune in this case is that this young man was homeless excluded from school and without any basic guaranteed rights, however, the drug use was presented as a priority intervention , as if it did not refer at all to the socio-family context.
Hospitalization and the medicalization of psychological distress are still quite accepted and requested, even within the institutional settings of the PSCN. In addition to the architectural asylums, we currently have the figure of the chemical asylum as a major expression of the advances in the chemical-pharmaceutical industry and the medicalization and psychopathologization of life.
If psychosocial establishments work in the service of social adaptation, we emphasize that a critical analysis is needed on the social production of health and on the effects of the CMP on the subjectification processes.
In addition, it is necessary to think of a critical practice in the CMH, one that considers its ethical-political effects. In this sense, Costa-Rosa highlights the role they play as fundamental parts of the Strategic Process of Hegemony EPH , since they can both guarantee re production of dominant social relations within their practices and produce new intersubjective relationsships, and thus impart a different movement to the EPH, a paradigmatic transition, in favor of the subordinate pole.
Althusser, L. Rio de Janeiro, RJ: Graal. Amarante, P. Rio de Janeiro, RJ: Fiocruz. Arendt, H. Baremblitt, G. Barros, S. LOAS anotada.
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