Contemporary mental health practices in Brazil
Despite the neglect of cultural diversity there has been, since the 1980s, an ongoing problem-atization and concern with the mental distress of the popular classes. The debate around the social and cultural differences between professionals and service users basically orbited around the notion of the ‘nervoso’. Doença dos nemos was considered the most common cultural idiom of distress among Brazilian lower classes. It emphasized social and cultural dimensions of mental suffering (Duarte 1988).
As an illustration of doença de nervos, 22 interviews were conducted by a psychologist in a primary care facility in Natal, a big city in Northeast Brazil with Maria, a 38-year-old married woman and housewife with a specific complaint of doença de nervos. Her anxieties were associated to her financial situation and the existential insecurity. During the first interviews the professional notices a diffuse condition and Marias attempt to clarify her feelings. “When 1 go to sleep, I feel that thing shaking, I shudder ...”, and she continues,“! just know that I was falling asleep (...) and I wake up because of this tremble that I feel, (...) and 1 get a lethargy (Jeseira) in my head, I can’t even explain it” (Traverso-Yépez and Medeiros 2004: 98).
Doença de nervos is precisely characterized by the multiplicity of symptoms, which brings different sensations that disturb and interfere in Mary’s daily routine. When Mary started to speak freely about her suffering her narrative evolved from focusing on symptoms multiplicity to an attention to family relationships, domestic and everyday life. The dialogical process generated narratives in which suffering was progressively associated to the social and structural limitations of her life-context. Although they are structural problems of difficult solution it is important to emphasize the importance of this dialogical practice, in which the participant can be actively involved in producing changes in her daily life. This case study ratifies the considerations of doença de nervos as a complex problem, which brings significant suffering to the complainant in a context of profound socio-structural constraints.
Brazilian scholars argue that the expression of mental distress as located in the body and articulated through the idiom of the doença de nervos defied professionals’ assumptions that located suffering within the individual subject, at the level of her feelings, desires and thoughts. Professionals frequently assumed that popular classes shared the same world view, had the same representations of health, disease and personhood. As a consequence, social problems tended to be psychologized, leaving aside the sociocultural, historical and political determinants of their behavior (Lima and Oliveira Nunes 2006).
We would like in the last part of this section to describe briefly two experiences of intercultural competence and sensitization which take into account the diversity of symbolic and therapeutic systems, as well as conceptions of mental suffering: the role of the community health workers (ACS, agentes coinunitdrios de saúde) and the Community Therapy (CT, terapia coinunitaria or terapia comunitaria integration). They are experiences of primary mental health care that valorize local culture and favor the constitution and strengthening of local support networks.
Community health workers
Community health workers (ACS) have a leading role within the Family Health Strategy (ESF, Estrategia Saúde da Familia), the primary health care model adopted by SUS (Brasil 2012).The ACS should enable the interaction between ESF teams and communities and must live in the territory they assist. They carry out regular home visits, monitor health indicators, and develop health promotion and disease prevention, mainly through educational practices.
Community health workers assume the role of mediators between local cultural idioms and lifestyles and biomedical knowledge. This role makes the ACS a social actor who mobilizes contradictions and at the same time establishes a deep dialogue between these two worldviews. (Lara, Brito, and Rezende 2012).
ACS know personally everyone they care for personally, where and how they live, and which are their major health complaints. Through home visits and health education groups, ACS draw on their knowledge of the cultural idioms, customs and local or private beliefs of the community to facilitate the communication with health professionals. That guidance often demands some form of translation between biomedical and popular worldviews (Lara, Brito, and Rezende 2012). ACS therefore exhibit important intercultural competence that turns them indispensable actors to effectively engage with patients’ and communities’ cultural backgrounds, values and beliefs. However, this mediation role also leads to situations in which upholding this dual identity brings uncertainty and difficulties. On the one hand, ACS have incorporated into their practice principles and strategic tools in line with the psychiatric reform and the expansion of mental health in primary care. On the other hand, community workers have major difficulties in dealing with mental health issues. They show prejudice regarding mental disorders and, although they recognize the importance of working with patients and their families, they do not feel prepared to provide adequate care (Waidman, Costa, and Paiano 2012).
Community therapy
Brazilian Community Therapy (CT) or was initiated in the 1990s by psychiatrist Adalberto Barreto in Fortaleza, Northeastern Brazil. Its theoretical basis is rooted in systemic theory, communication theory, Paulo Freire’s pedagogy, cultural anthropology' and resilience theories (Barreto 2005).
Each Community Therapy session — also called roda — consists of six phases: welcoming, selecting a theme, contextualization, problematization, closing and appreciation. Every stage has a specific progression and sequence of actions, leading participants to observe themselves through accounts of personal experiences (Barreto, 2005). After the welcoming, in which the rules of CT are explained and some jokes or engaging exercises are introduced, one topic is chosen through a vote among the possible issues raised by the participants. During the contextualizing step, the person who proposed the topic is invited to give more details about her situation and feelings.
Problematization starts with the CT therapist’s key question addressed to the group for discussion. Everyone may become aware of the many possible outcomes and solutions, promoting resilience and self-esteem. The closing ritual and appreciation phases will consolidate links between participants and highlight what they have learnt from the group. The evaluation enables the facilitators to have a critical view on the session and collect data for further research. (Barreto 2005).
It is important to highlight that CT is a social intervention addressed to the community that has demonstrated efficacy in mental health promotion within primary mental health care, and helps mental health professionals to grasp the emotional conflicts within individuals, families and community. It constitutes a privileged space to convey social support, strengthen emotional bonds, consolidate social networks, diminish social exclusion and stigma and enhance individual and group resilience (Rocha et al. 2013).
As an illustration, 14 CAPS users with severe mental disorders and 8 relatives participated in weekly CT sessions, which took place in a CAPS in Joao Pessoa, Northeast of Brazil. Among the main problems related by the users were family conflicts, abandonment, rejection, stigma, financial difficulties and low self-esteem resulting in lack of motivation and social withdrawal. The participation in CT sessions was very important since it positively influenced the individual selfperception. One participant states,“Here I feel important, because people listen to me and respect me when 1 have something to speak” (Ferreira Filha and Carvalho 2010: 237). CT contributes to the social inclusion of participants, improving family and affective relationships and reducing stigma. Asked if the CT changed their life, a participant observed,“therapy helped me to get rid of my shame, because I learned from others that I should be not ashamed of my illness” (Ibid. 238).
Mental, physical and spiritual balance is achieved through a systemic approach, that draws on the participants’ beliefs and cultural values. The experience of developing CT in CAPS produced good therapeutic outcomes after two years of its introduction. Participants consider CT a cozy space, where everyone shares her feelings and which values the individual history and cultural identity, restoring self-esteem and self-confidence.
Respect for cultural diversity and the multiplicity of contexts and local knowledges and practices are therefore among the main features of CT. It valorizes the cultural heritage of Indigenous, African, Oriental and European ancestors. Moreover, CT mobilizes local cultural resources which contribute to its success, attracting people to take part in the roda and disinhibiting participants to express their suffering. Those resources strengthen community and social bonds and help participants to resignify their suffering. Music and traditional sayings are CTs fundamental tools to embrace pain, stimulate resilience and to provide a feeling of belonging and inclusion in the community (Oliveira and Ferreira Filha 2011).
