PSYCHOSOCI AL REHABI LI TATI ON I N MENTAL HEALTH CARE: STRATEGI ES UNDER
CONSTRUCTI ON
1Mar ia Alice Or nellas Per eir a2
Pereira MAO. Psychosocial rehabilit at ion in m ent al healt h care: st rat egies under const ruct ion. Rev Lat ino- am Enferm agem 2007 j ulho- agost o; 15( 4) : 658- 64.
Th is st u dy aim s t o iden t if y t h e r epr esen t at ion s abou t Psy ch osocial Reh abilit at ion by Men t al Healt h
professionals working in open services, and also t he difficult ies t hey have m et in t he process of t urning t he care
effect ive for t he populat ion. The st udy uses a qualit at ive m et hodology, collect ing dat a by m eans of sem ist ruct ured
int er v iew s w it h 15 subj ect s. The pr ofessionals ident ify t he r ehabilit at ion pr ocess as com plex , m eet ing sev er al
obst acles and r equir ing t heir dedicat ion and a flex ible at t it ude t o achiev e t he ex pect ed r esult s.
DESCRI PTORS: social suppor t ; m ent al healt h; concept for m at ion
REHABI LI TACI ÓN PSI COSOCI AL EN SALUD MENTAL: CONSTRUCCI ÓN DE ESTRATEGI AS
La finalidad de est e est udio es ident ificar las r epr esent aciones sobr e la r ehabilit ación psicosocial por
los profesionales de Salud Ment al que t rabaj an en servicios abiert os, y t am bién las dificult ades que han encont rado
en el pr oceso de h acer la at en ción ef icaz par a la población . El est u dio u t iliza u n a m et odología cu alit at iv a,
r ecogiendo dat os por m edio de las ent r ev ist as sem i- est r uct ur adas hechas con 15 per sonas. Los pr ofesionales
ident ifican el pr oceso de la r ehabilit ación com o com plej o, con v ar ios obst áculos, a r equer ir su esm er o y una
act it ud flex ible par a alcanzar los r esult ados pr ev ist os.
DESCRI PTORES: apoy o social; salud m ent al; for m ación de concept o
A REABI LI TAÇÃO PSI COSSOCI AL NO ATENDI MENTO EM SAÚDE MENTAL: ESTRATÉGI AS
EM CONSTRUÇÃO
Est e est udo t eve com o obj et ivos ident ificar as r epr esent ações elabor adas por pr ofissionais de ser viços
su b st it u t iv os acer ca d a r eab ilit ação p sicossocial, e as d if icu ld ad es p or eles en con t r ad as n a ef et iv ação d a
assist ên cia em Saú d e Men t al. Ad ot an d o ab or d ag em q u alit at iv a, a p esq u isa t ev e a p ar t icip ação d e q u in ze
suj eit os, que for am ouv idos at r av és da ent r ev ist a sem i- est r ut ur ada. I dent ificou- se que a r eabilit ação é v ist a
com o pr ocesso com plex o que enfr ent a obst áculos div er sos par a a concr et ização de seus obj et iv os, e que as
m udanças ocor r idas na assist ência solicit am , de cada pr ofissional, disponibilidade e flex ibilidade.
DESCRI TORES: apoio social; saúde m ent al; for m ação de conceit o
1 Paper extracted from Free Lectureship Thesis; 2 Adj unct Professor, Botucatu Medical School, Paulista State University “ Júlio de Mesquita Filho”, Brazil, e- m ail:
m alice@fm b.unesp.br
I NTRODUCTI ON
T
he t ransform at ion process psychiat ric care has been going t hrough in Brazil has led t o com plex structural changes, raising discussions about the need t o reorganize t he pract ice of professionals from t he m ult idisciplinary Ment al Healt h t eam , in view of t he new form s of care t hat are adopt ed. The creat ion of n ew ser v i ces af f i l i at ed w i t h m u n i ci p al an d st at e n e t w o r k s d i d n o t o n l y m e a n a n a l t e r n a t i v e t o hospit alizat ion, but also t he opening of possibilit ies for com m unit y w or k t ow ar ds r eint egr at ion int o t he social context, capable of giving a new individual and social m eaning to people affected by m ental disorders, as well as to their fam ilies.Cu r r e n t ca r e p r a ct i ce t e n d s t o f o l l o w r ecom m endat ions by t he Wor ld Healt h Or ganizat ion b y g r a n t i n g a n i n cr e a si n g l y sm a l l e r a m o u n t o f r esour ces t o psy chiat r ic hospit als, dislocat ing t hem t owards m ore elast ic and cont ext ualized com m unit y structures. Although the roles of each structure under const r uct ion, t her e is no doubt about t he need t o redirect the care m odels, in view of the im portance of returning respect to people with m ental disorders and reest ablishing t heir social bonds. This t ransform at ion m ovem ent entails conflicts and challenges, leading to an ot h er k n ow ledge t h at dem an ds flex ibilit y in t h e different t eam professionals’ act ions and roles.
I n this perspective, psychosocial rehabilitation is configur ed as a set of st r at egies t o incr ease t he p o ssi b i l i t i e s o f e x ch a n g e s, t h e v a l u a t i o n o f subj ect ivit ies, and t o pr ovide for cont r act ualit y and solidarity, thus m oving beyond the m ere im plantation of service net w orks.
As a st rat egy, r ehabilit at ion allow s for t he recovery of t he capacit y t o creat e m eaning, which is capable of reest ablishing t he exercise of cit izenship, creating bonds between the person needing care and t he care service. Hence, “ t he m ent al healt h service’s t ask is t o help t he person who at som e m om ent in h i s/ h e r l i f e l o st t h e a b i l i t y t o cr e a t e m e a n i n g , a cco m p a n y i n g h i m / h e r i n t h e r e co v e r y o f n o n pr ot ect ed but socially open spaces t o pr oduce new m eanings”( 1). This evidences the change from tutelage
t o cont ract relat ions, giving rise t o new pract ices at i n st i t u t i o n s t h a t a d o p t t h e p sy ch i a t r i c ca r e t ransform at ion process. Current proj ect s direct ed at t he psy chosocial r ehabilit at ion m odel hav e focused on four aspect s: housing, work, fam ily and creat ivit y ( r ecr eat ional/ ar t ist ic) .
The created spaces also contain concerns and doubts about how to deliver daily care, how to advance in order to actually deliver rehabilitating and m eaning-p r od u cin g car e. I t r eeaning-p r esen t s a ch allen g e t o t h e professionals, in t heir abilit y t o est ablish bonds and be r ecept iv e t o t he ot her. I t becom es essent ial for t he act or s in psy chiat r ic car e t r ansfor m at ion t o be m ore ethically com m itted to the care and to their own desir e, and t o cont inuously ask t hem selv es: “ What am I doing here?”, reconst ruct ing t heir answer each day and thus configuring a dynam ic com ing and going of represented practices( 2). This m akes us reflect that
t h e e x ch a n g e o f e x p e r i e n ce s a n d sh a r i n g o f k n ow led g e can lead t o a b r oad er u n d er st an d in g , facilit at ing rehabilit at ing int ervent ions.
I n v i e w o f t h e Me n t a l He a l t h ca r e t ransform at ion process, t his st udy aim ed t o ident ify t he r epr esent at ions pr ofessionals fr om subst it ut iv e services elaborat e about psychosocial rehabilit at ion, and t he difficult ies t hey face t o apply new pract ices.
METHODOLOGY
This r esear ch fit s int o t he pr em ises of t he qualitative research m ethod, where we work with the m eaning an individual or a certain group attributes to r elev ant phenom ena. Qualit at iv e r esear ch uses t he nat ural environm ent as a direct source of dat a, and t he researcher as it s m ain inst rum ent( 3).
We developed the study at two open services in the region of Ribeirão Preto - SP: the Day Hospital of the University of São Paulo at Ribeirão Preto Medical School Hospit al das Clínicas, and t he Ribeirão Pret o Psy chosocial Car e Nucleus ( NAPS/ RP) .
y o u co n si d e r i m p o r t a n t f o r p sy ch o so ci a l rehabilitationto occur? c) What are the difficulties faced in t his process?
Based on “ floating attention”( 4), the transcribed
t ext s w ere read several t im es t o have cont act w it h t he collect ed m at er ial. The next phase consist ed of
Them at ic Analysis, which is part of the first phase of t he Discour se Analy sis( 5) process. Five t hem es were obtained from this phase. I n this article, which is part of the research, we will present the them es Aut onom y
and Social I nser t ion.
RESULTS AND DI SCUSSI ON
I n t he narrat ives, psychosocial rehabilit at ion appear s associat ed w it h t he idea of aut onom y, and refers to the conception of the patient as a person to be con sider ed in h is/ h er in div idu alit y, valu in g t h e occurred changes as conquest s:
... before he cam e and went back hom e, he was t here
inside t he room , isolat ed, wit hout t aking care of him self, he didn’t
leave t he room for anyt hing, and now, t he m ere fact t hat he’s
act ive, t hat he com es t o t he H.D. and goes back, I t hink t hat ’s
rehabilit at ion.
Considering the person in his/ her individuality, a sso ci a t e d w i t h t h e ch a n g e s o ccu r r e d i n t h e professional him - / herself who perform s this reflection, values t he pr ogr ess t owar ds aut onom y, addr essing aspect s of daily life.
... I used t o im agine t hat rehabilit at ion would be t o put
t he person in a college ( ...) t oday, I underst and t hat rehabilit at ion
are sm all t hings which we have t o value ( ...) like t aking a bat h,
self- care, cut t ing one’s hair, shaving, cut t ing one’s nails.
We observe from t he report t hat aut onom y is a concept t he professional should elaborat e:
Som et im es t he professionals t hem selves help t o t urn
people chronically ill. I t hink t hat what is m issing is t he act ual
t herapeut ic proj ect , aim ed at aut onom y.
Au t on om y is also r elat ed w it h t h e idea of in depen den ce:
... it is when he m anages t o be m ore independent , I
t hink it varies according t o t his person’s degree of dependence,
degree of illness.
A m or e elabor at e con cept ion of au t on om y r e f e r s t o t h e p a t i e n t ’ s e n g a g e m e n t i n a se l f -or ganizat ion pr ocess:
... it m eans t he person having cont rol over t hings and
being able t o act ually do som et hing for his own life.
... I t hink t hat t he individual’s com prehension of t he
cure m echanism is not lim it ed t o t he physician, psychologist or
nurse, but allows him t o have ot her possibilit ies wit hin his abilit y.
Anot her sim pler concept ion only focuses on social insert ion:
... our goal is t o gradually bring him back t o social life
or as closely as possible t o t he basic condit ion he had before.
The diversificat ion of t he professional’s look and the dislocation of his/ her attention from the focus on the disease stim ulate im portant discoveries in care, allow in g b r oad er p er sp ect iv es t o t h e p at ien t an d facilit at ing his/ her readiness for daily life.
Autonom y is a condition for people to create st an d ar d s, or d er s f or lif e it self, accor d in g t o t h e sit uat ions t hat have t o be coped wit h. Occasionally, there is a wrong understanding of the relations am ong aut onom y, self- sufficiency and independence. We are all dependent to som e extent, but people with m ental disorders excessively depend on few relat ions/ t hings, a n d t h i s l i m i t e d si t u a t i o n ca n d e cr e a se t h e i r aut onom y( 6).
I n t his cont ext , t he exchange relat ions, wit h broad dim ensions, const it ut e a link t hat out lines t he rehabilit at ion process, cont inuing t he different levels o f co n t r act u al i t y, w h et h er af f ect i v e, m at er i al o r sy m bolic. To t he ex t ent t hat people incr ease t heir ex ch a n g e p o w er, t h ei r co n t r a ct u a l p o w er g r o w s p r op or t ion ally an d can ex t en d t o au t on om y as a condition the patient acquires through his participation in t he rehabilit at ing process it self.
I t i s e v i d e n t t h a t t h e p r o f e ssi o n a l ’ s involvem ent , com m it m ent and part icipat ion are very v aluable and also facilit at ing aspect s for people in m ent al suffering t o be able t o reconst ruct and t ake up again their own road. However, this road without a predeterm ined destiny will follow the course the walker can/ want s t o walk, wit h t he professional act ing as a cat alyzing elem ent and as an im port ant reference in subj ect iv e cour ses.
The narratives presented rehabilitation in the sense of social insertion in com bination with the idea of belonging, and of m ovem ent that brings som ething t h at w as sleepin g. I n t h e au t h or it y of t h e asy lu m appar at us, im bued w it h t he subj ect - obj ect r elat ion, procedures are st andardized, depersonalizing people, in a silent cycle that leads to chronified states for the pat ien t , in st it u t ion an d pr of ession als. Th e idea of recovery appears connect ed wit h insert ion:
... it m eans reconstructing som ething that was lost inside
the hospital (...) we can try to prom ote spaces for the person to take
up his things again, including the ability to participate.
The bond wit h com panies is good, we don’t have t hat
part nership here and it ’s very difficult for m ore severe cases of
pat ient s t o go back t o work.
Hen ce, t h e n ot ion of r est it u t in g lost par t s appears connected with the possibility that the patient can r ecov er for him self; “ only w hat em er ges fr om each bein g’s cor e can be ex per ien ced as r eal. An apparently norm al life can be m aintained on the basis of t he f alse self, w hile t he indiv idual is st ill absent from him self, excluded from life itself. I t is interesting to observe that the false self is actually a dissociative defense t hat pr ot ect s t he t r ue self, w hile t he lat t er rem ains hidden”( 7). What is hidden inside the hospital
and configur ed by t he sy m pt om s of psy chosis can lead t o t he r et r eat pr ocess of ex ist ence it self. The reconst ruct ion of what seem ed lost direct ly depends on t he bonds creat ed around t he person, as well as on t he professionals’ sensit ivit y t o unknown codes.
Alt hough t he subj ect s seem t o have brought rehabilitation, insertion and context as interdependent fact ors, disbelief appears in t he possibilit y t hat a set o f p r o ce d u r e s o r st r a t e g i e s e x i st w h i ch a r e in t er con n ect ed w it h t h e ex p an sion of in t er act iv e net works t hat prom ot e real exchanges:
... it m eans being able to insert the person in his context,
I work m ore wit h t he t erm insert ion t han wit h rehabilit at ion,
because rehabilit at ion depart s from t he prem ise of int egrat ing
all aspect s of t he person, and t hat is oft en not possible.
Th e su bj ect ’s n ar r at iv e con t r ast s w it h t h e t heoret ical prem ises of hum an conduct , wit h respect to the m eaning of conduct in a specific situation that is experienced( 8). The obj ect’s quality is relational and
derives from t he relat ions and condit ions each obj ect is in at every m om ent .
A f r e q u e n t co n ce p t i o n o f p sy ch o so ci a l rehabilit at ion ident ifies it as a com plex pr ocess:
... it involves m any fact ors, wit hin a t ransform at ive
m ent al healt h policy and it aim s t o lead t he person back t o life.
The com plexit y of psychosocial rehabilit at ion su g g e st s t h e e x i st e n ce o f co n t r a d i ct i o n s, i n d e t e r m i n a t i o n s, p r o b a b i l i t i e s, d i f f i cu l t i e s a n d connections that contast with the sim plifying thinking:
I see it as quit e a broad, com plex proces, quit e difficult
t o define it s range, where it st art s, because t here are so m any
and big variables we see t hat are int erconnect ed wit h t he illness
pr ocess.
... it is com plex... it covers a look, at t ent ion for t he
review of social roles. The relat ives and t he pat ient ’s place in
societ y is a place t hat favors disease or healt h.
Th e com p lex it y in d icat ed in t h e su b j ect s’ nar r at iv es r em inds us of t he r ange of int er act ions bet ween t he part s, which int erfere and const ruct t he dynam ic whole, which is never exhausted nor reduced to the sum of the elem ents. The specifity of each part, in cont act wit h ot hers, is m odified, and t he whole is also m odified:
. . . t h e r e a r e m a n y d i f f e r e n t f a ct o r s, b u t I se e
rehabilitation as a net, each one depending on the other to construct
som et hing.
The exist ence it self of t his “ net ” brought by the subj ect suggests life and this im plies dependences, con t r adict ion s an d am bigu it ies t h at lead t o a n ew u n d e r st a n d i n g o f a n d i n t e r w e a v i n g b e t w e e n ph en om en a.
Variables and cont radict ions brought by t he suj ect s, fam ilies and t he pat ient ’s posit ion in societ y were m ent ioned as fact ors t hat influence t he healt h/ disease process. Thus, significant reference borders are extended to the larger social group. They are not l i m i t e d t o t h e f a m i l y, b u t i n cl u d e t h e se t o f i n t e r p e r so n a l b o n d s, co n si d e r i n g cu l t u r e , w o r k , f r i e n d s, a n d u n d e r st a n d i n g t h e i m p o r t a n ce o f professionals m et abolizing t his social view as well.
... t he com plexit y of rehabilit at ion work dem ands very
high invest m ent s in t he developm ent of t reat m ent professionals
and in t he developm ent of t reat m ent m et hodologies.
t hat em er ges in discour se is t he im por t ance of t he contest am ong various activity lines in the construction of a new care, which does not allow the suprem acy of one single knowledge:
A g ood t eam , p r eci sel y b ecau se t h e f act or s ar e
div er sified, w hich w ill im ply effor t s by sev er al pr ofessionals
from different areas, working j oint ly.
Team work is im port ant , it is fundam ent al for t he t eam
t o be com pet ent for a needs diagnosis.
... som et im es t he professionals’ sign m arks different
roles, on t he packing label, but t he cont ent is not different , you
open it and t hey all sm ell t he sam e, appear t he sam e so, t hen, t he
psychosocial rehabilit at ion process is already im paired because
t hey have diferent iat ed knowledge and com pet ences, t hey are
not capable of reaching different iat ed diagnoses and even less of
different iat ed t herapeut ic planning.
Alt hough t he narrat ives consider t he t eam ’s im por t an ce, t h ey dem on st r at e con cer n s abou t t h e product derived from its perform ance which, according to the subj ects, m ay not be capable of apprehending p e o p l e ’ s a ct u a l n e e d s. Th i s su g g e st s t h a t t h e pr ocedu r es car r ied ou t by t h e w h ole t eam can n ot always offer t he benefit s of sat isfied needs. I n ot her w or ds, t h e pr odu ct ion of act ion s does n ot alw ay s con t ain t h e ex pect ed dy n am ics bet w een iden t ified needs and int ervent ions t hat m ake life possible.
Delim it ing r oles is quit e difficult in Ment al Healt h, rem inding t hat , specifically in t his area, good t eam r elat ion s ar e essen t ial( 9 ). How ev er, t h e n on
st rict ness, t he flexibilizat ion of roles, respect ing each m em b er ’s p r of ession al t r ain in g an d t h e d y n am ic f l u e n cy o f o p e n se r v i ce s’ d a i l y ca r e r e q u e st com pet ence, account abilit y and com m it m ent t o t he present ed dem and. The t ype of service and t he care t eam ’s organizat ion are variables t hat det erm ine t he evolut ion of t he disease process and t he efficacy of t h e in t er v en t ion s, w h ich ar e gu ided by t h e bon ds est ablished in welcom ing and solidarit y( 1).
Th e co n ce r n w i t h d e v e l o p i n g i m p r o v e d devices that are capable of dealing with the range of each patient’s requests is very present in the subj ects’ discou r se:
A good t eam is im port ant , what happens is t hat , oft en,
t he service t urns int o a vacat ion colony, a t hing like t hat , because
it ’s a prot ect ed space, som et im es t he pat ient get s bet t er because
prot ect ion does good, but t he pat ient ’s act ual needs are not at all
perceived. This leads t o a m ore superficial approach because
t here is som e im provem ent , but t hat is followed by a rapid relapse.
The professional’s possibility of having a plural look increases his/ her com pet ence and responsibilit y
t o d e l i v e r ca r e t h a t a i m s t o cr e a t e su b j e ct i v e m eanings, rediscovering resources according t o ech p e r so n ’ s t i m e a n d l i m i t . I t a l so e v i d e n ce s t h e im port ance of t he professional developing condit ions to bear the m ental suffering of the other person before him / her, and t o organize his/ her own experience.
Op e n se r v i ce s n e e d t o ch a r a ct e r i ze t hem selv es as places w her e people ar e w elcom ed, but not w her e t hey can r em ain( 10). This t hink ing is
direct ly relat ed wit h t he condit ions t he professionals develop t o underst and t he subj ect ive experiences of suffering and, consequently, develop interventions that act ually at t end t o t he pat ient ’s real needs.
Th e su b j e ct s r e v e a l t h e i m p o r t a n ce o f knowledge diversit y in care:
. . . t h er e is a n eed f or d ist in ct , sp ecif ic t ech n ical
com p et en ces, a sp ecif ic w or k m et h od t o d ev elop d if f er en t
Rehabilit at ion plans.
I n t h e con t ex t of cl assi f y i n g h eal t h car e technologies, it is considered that those based on the exist ence of bonds, welcom ing and t he prom ot ion of autonom y do not belong to any professional’s specific or st rict area, but const it ut e t he base for everyone’s act ion s, t h r ou gh t h e m ediat ion of k n ow ledge t h at co n st r u ct s e f f e ct i v e i n t e r v e n t i o n st r a t e g i e s( 1 1 ).
How ev er, t he pr ox im it y w it h m ent al suffer ing as a r e su l t o f t h e m e n t a l d i so r d e r p r o v o k e s t h e professional’s search for devices or internal resources, which are often felt as difficult to live with.
... t he t eam has one of t he m ost difficult t asks, which
is t o bring t he pat ient close t o t he service, because one cannot
t reat from a dist ance. The t reat m ent depends on t he bond, you
have t o t reat from nearby. This requires a lot of t raining and also
help. I n general, t his is not part of t he realit y of people working
in m ent al healt h.
This nar r at ive not only r eveals a com plaint about t he lack of care for t hose who care, but also d em on st r at es t h e d if f icu lt y t o d eal w it h ab st r act quest ions, be consist ent , est ablish bonds and adopt the person him -/ herself as the m ain work instrum ent. I f the object of care is the hum an being, the practice of this care is connected with reflections and revisions of t h e car e deliv er er s’ liv es, w h ich dem an ds t h at p r o f essi o n a l s p er cei v e t h e i r o w n f ee l i n g s a n d continuously expand the possibilities to cope with them . This presupposes that the object’s qualities are always relational; thus, the em ergent is situational and derives from a field(8). This thinking helps us to reflect on the
CONCLUSI ONS
The professionals from t he m ult idisciplinary Me n t a l He a l t h t e a m r e p r e se n t p sy ch o so ci a l rehabilitation as a com plex process of developing t he aut onom y of pat ient s w it h m ent al disor der s, m ak ing
possible t heir social inser t ion and t he abandonm ent
of a u n ilat er al v iew of sy m pt om s. For psy chosocial rehabilitation to occur, the professionals consider that it is im p or t an t t o elab or at e t h er ap eu t ic p lan n in g together with a com petent team , which diagnoses the patients’ needs, provides them with further inform ation an d a bet t er t r eat m en t , t ak in g in t o accou n t each p at ien t ’s p ot en t ialit ies in st ead of f ocu sin g on t h e lim it at ions ent ailed by t he m ent al illness.
Am ong t he difficult ies and challenges faced t o pu t psy ch osocial r eh abilit at ion in pr act ice, t h e pr of ession als’ lack of appr opr iat e pr epar at ion w as m entioned, in com bination with a m ental health policy t hat induces t he pat ient ’s dependence, and wit h t he com plexity of the work ( involving the patients’ fam ilies and part nerships wit h social agent s) , difficult ies t hat are aggravat ed by prej udices, st igm as and pat ient s’ pr evious social exclusion pr ocesses.
The r esult s of t his st udy suggest t hat t he transform ation process of psychiatric care is ongoing, pr oducing r esult s at t he ser v ices w her e it is being im plantes. Despite difficulties in its im plantat ion, it is observed t hat m any of t he professionals we list ened t o have creat ed awareness of t he new focus t hat is ad op t ed . Th r ou g h t h eir d iscou r se, som e of t h em evidence a syst em ic concept ion of t he hum an being wit h m ent al disorder and his/ her social environm ent , t h u s a p p r o a ch i n g t h e p r o p o sa l f o r a sy st e m i c under st anding of healt h. Just lik e sy st em ic fact or s i n f l u e n ce t h e v u l n e r a b i l i t i e s t h a t cr e a t e a n d / o r aggr avat e t he disor der, t hr ough t he t eam ’s act ion, t hey can also be r edim ensioned, pr ov iding ser v ice users wit h new rehabilit at ion alt ernat ives.
Th e t h eo r et i ca l r ef er en ce f r a m ew o r k s o f psychosocial rehabilitation are based on concepts like
aut onom y, socializat ion, cit izenship and cont ract ualit y.
Th e su b j ect s’ d iscou r se d em on st r at es t h at t h ese fr am ew or k s hav e been par t ially assim ilat ed, w hich m a k e s u s q u e st i o n w h e t h e r t h e se t h e o r e t i ca l det erm inat ions, alt hough necessary, are sufficient t o guide the transform ation process? Would the subj ect ive aspect s not have to be considered as well, for exam ple h o w t h e u se r s a sse ss t h e se r v i ce s i n t e r m s o f im provem ent s in qualit y of life t hey provide?
The context in which psychosocial rehabilitation occur s is poly sem ic, in v iew of t he plur alit y of t he subj ect s involved, which dem ands adequat e form s of action. Finding unique possibilities for each person, in the different situations in their lives, constantly dem ands a l o o k a n d l i st e n i n g t h a t a ck n o w l e d g e t h e se subj ect iv it ies. Thus, t he pr ox im it y w it h t he per son suffering the experience of a m ental disorder confronts sev er a l i n t er p r et a t i v e p o ssi b i l i t i es, q u est i o n s com pet ences, r equir es t he pr ofessional’s sensit iv it y and understanding that m ental suffering cannot be seen as som et hing t o be elim inat ed or fought against , but ca n l e a d t o t h e r e d i sco v e r y o f t h e r e a l , o f t h e underst anding of t he pat ient ’s em ot ional experience.
I t is relevant for professionals to be aware of the historicity of m adness, its whole evolution, as well a s i t s t r a n sf o r m a t i o n p r o ce ss t h a t g r a d u a l l y d e t e r m i n e s t h e d e l i v e r e d ca r e . Th i s h e l p s t o u n d er st an d t h e r u pt u r es occu r r ed t h r ou g h ou t t h e evolut ion and in t he acknow ledgem ent of m adness’ so ci a l p r o d u ct i o n , e v i d e n ci n g t h e ch a l l e n g e s, cont radict ions and t he im port ance of open services. Thus, each per son is r equest ed t o t ak e up his/ her responsibilit y in t he scenario of changes t owards an u n k n o w n a n d n o t p r e d e t e r m i n e d f u t u r e . Th e professional, social, supportive, affective com m itm ent, aim ed at im proving everyt hing t hat surrounds us, is n e e d e d i n t h e d a i l y co n st r u ct i o n o f b o n d s, t ransform at ions, hope and t he cont inuous prom ot ion of life. Perhaps t hat is how we can always m aint ain t he creat ive light burning and t he current desire for const ant sear ches.
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