Território e crise em saúde mental: contribuições de Milton Santos e Itinerários de mulheres com experiência de internação psiquiátrica

Abstract

Psychosocial Care in the territory faces heightened challenges in the face of mental health crisis scenes that involve psychiatric hospitalization. Although the brazilian Psychiatric Reform proposes shifting the center of care from the hospital to the territory, short- and medium-stay admissions to beds in general hospitals remain, within the Psychosocial Care Network (RAPS), a point of attention for crisis care. Research has indicated an emptying of the debate on territory in mental health, both in academic production and in public policies concerning care in the territory. Against this backdrop, this dissertation has the general objective of discussing the concept of territory in the literature on Psychosocial Care and the meanings attributed by two adult women, service users of the Psychosocial Care Network (RAPS), to their experiences of care during crisis, in psychiatric hospitalization, and in the return home. Three specific objectives were defined: (1) to map uses of the concept of territory in Brazilian scientific production on mental health; (2) to understand attention to mental health crisis based on the experience of compulsory psychiatric hospitalization; and (3) to analyze the support network in the territory after discharge from psychiatric hospitalization among adult women. The dissertation comprises three articles. The first, “Territory: mental health and the contributions of Milton Santos’s living geography to psychosocial care,” maps the uses of the concept of territory in Brazilian scientific production on mental health. Eleven articles published between 2019 and 2023 were analyzed, retrieved from Scientific Electronic Library Online (SciELO) Brazil and from the Regional Portal of the Virtual Health Library (BVS), highlighting five ways the concept is mobilized: (a) the concreteness of places; (b) an element for understanding singularities; (c) the space and contextualization of CAPS (Psychosocial Care Centers); (d) a resource for care actions distinct from the biomedical model; and (e) a strategy for comprehensive care. The second and third articles draw on 14 months of fieldwork inspired by qualitative epistemology and González Rey’s constructive-interpretive analysis, which understands knowledge construction as the production of subjective senses emerging in dialogical interaction with active involvement of researcher and participant. Case studies were conducted from a service-user-as-guide perspective, incorporating the Therapeutic Itinerary (IT) as an analytic tool for the search for care. Two adult women participated following psychiatric admission to a hospital bed, with semi-structured interviews conducted with both service users and their key informants (professionals from the hospital, from CAPS, and family members), alongside the production of a field diary. The first participant, Rosa, is a white woman, 34 years old, with completed elementary schooling, mother of two adolescents, born in a city in Brazil’s Northeast, in her first hospitalization. The second participant, Amélia, also a white woman, 45 years old, with incomplete higher education, had lived since her marriage with her husband and son (24 years old) in a house provided by her mother, located in the same territory where she built her life history. Thematic analysis was conducted on materials produced in the field phase using González Rey’s concept of indicators. The second article, “Crisis and the experience of a woman following compulsory psychiatric hospitalization,” seeks to understand attention to mental health crisis through Rosa’s case, whose hospitalization was compulsory. Two analytical categories stood out: (A) crisis as a limit-situation, marking the complex density of psychological suffering as well as fragilities and ruptures in bonds; and (B) disarticulation of care in the territory, reflecting institutional barriers in networked care. These categories revealed CAPS as distant from care in the territory, with barriers that limited network action. The third article, “Reencountering the territory after discharge from psychiatric hospitalization and the role of the support network in the life production of service users,” analyzes the support network in the territory after discharge, based on the two case studies (Rosa and Amélia). Rosa’s history shows negotiations of care in sustaining the territory’s support network and was organized into the themes: (A) housing and migration; (B) caring and being cared for in the exercise of motherhood; and (C) family of origin, neighborhood, and work. Amélia’s history points to ambivalences of informal support and the weave of belonging in the territory, with themes: (A) housing and work involving the maternal family; and (B) resuming routine and bonds after hospitalization. In Rosa’s case, a scene of violence marked the limits of care in CAPS, even in the subsequent history, designated as a limit-situation. In this conjunction, formal support within psychosocial care also took on a punitive sense by acting to suspend circulation in the territory, as occurred with compulsory psychiatric hospitalization. Amélia, whose trajectory in RAPS was longer than Rosa’s, experienced hospitalization likewise as a suspension, in her case of family tensions, given that her bond with CAPS was exhausted. Thus, hospitalization emerges as a resource in the absence of institutional strategies for intermediate care between tensions lived in the territory and hospital admission. Both cases demonstrate how service users’ histories with health services directly influence their search for care. Mental health care is therefore not realized solely by the formal availability of services in the territory; it is constructed, above all, in the relations and subjective senses produced along service users’ trajectories. Care in the territory requires teams to recognize the asymmetries and tensions that traverse the everyday life of services as constitutive elements of care.