Nineteenth-century state mental hospitals across New England and the United States are linked today with images of confinement, forced treatment, torture, abandonment, and family separation. This project does not directly challenge those associations. An ethnographic study in medical anthropology, this study is based on three years of fieldwork observations and qualitative interviews with neighbors, townspeople, former employees, and visitors to the open campus of a decommissioned state mental hospital in Massachusetts. Excavated from that hospital’s annual reports dating back to 1896 and gathered from local memories and storytelling, this projects considers the central place that work once held in the lives of psychiatric patients at Medfield State Hospital and the place that idleness holds for patients living within today’s institution of community care. Participants’ memories track the shifting perceptions and meanings of mental illness that resulted once “industrial therapy” programs were ended in state mental hospitals. This inquiry describes the ways that the loss of work changed psychiatric patients’ experiences of suffering, promoting the use of new chemical treatments, accelerating deinstitutionalization, and catalyzing new patterns nationally of service utilization and psychiatric disability. From participants’ memories and the author’s reflections on clinical practice as an independently licensed social worker (LICSW) in Massachusetts, this analysis uncovers the social functions of staying sick within contexts of unequal opportunity and joblessness. This study reveals the complicated and punishing work of surviving and helping people survive across de-industrialized landscapes as mental health practitioners assist the disenfranchised by recasting social suffering into psychiatric illness with treatment-induced embodiments that simultaneously help to manage poverty and perpetuate risk within disabilized citizens.

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In recent years, institutional theorists have been increasingly interested in institutional change, seeking to understand the contextual factors and agents responsible for alterations to existing institutional arrangements. Institutional theory’s historical focus on isomorphism has made it challenging to account for actors’ motivations to pursue change projects. It is generally believed, though, that agents are mobilized through exposure to multiple institutional logics. Recently, scholars have begun to recognize that competition among multiple logics may not quickly produce a ‘winning logic’; rather, such logics may co-exist for prolonged periods in a context of ‘institutional complexity’. The turn toward institutional complexity reveals that preoccupation with the ‘paradox of embedded agency’ has left the development of change projects themselves under-theorized: What happens when organizational actors must interpret puzzling institutional contexts and generate alternatives? In seeking to understand organizational actors’ efforts to cope with conflicting logics in a context of scientific uncertainty, this study aligns with this growing interest in institutional complexity. Drawing on concepts from sensemaking theory, this research illuminates how actors with divergent interests, enacting their organizational roles, cope with competing logics and interact around a change project that emerges as a result of their efforts at coping. It thus contributes to institutionalist understandings of institutional complexity and change and adds to an emerging body of research linking institutional theory and sensemaking. The empirical setting for this single-case study is the ‘sustainable seafood’ discourse that began in the early 1990s when the cod collapsed off North America’s eastern seaboard. Prolonged scientific uncertainty regarding the collapse made generation of preferred alternatives problematic; this resulted in lengthy sensemaking efforts by multiple stakeholder groups, drawing on different institutional logics to produce divergent and competing interpretations and action scripts. Tracing the evolution of this discourse through documents, observations, and interviews empirically reveals processes of interrelated sensemaking, and further, exposes sensegivers as bricoleurs who use institutional elements creatively to affect the sensemaking of others.

This thesis builds on the bachelor thesis Preparation of persons with intellectual disability for sheltered living, in which I dealt with three clients of a particular social service provider - Tereza, who were about to go into sheltered living or who lived there for a short time. Two of these clients and one new client of sheltered living were for the purpose of this thesis put under long time surveillance. The thesis is divided in two parts, theoretical and practical. Theoretical part deals in detail with an adult person with intellectual disability, family of such an adult, rights and quality of life of people with intellectual disability. Further, I deal with the process of deinstitutionalization. The practical part is dedicated to Tereza, a provider of social services, its sheltered living and three clients already mentioned. The aim of this study was to determine what for advantages and possibilities living in sheltered living has, eventually what restrictions it brings. By describing the specific situation I tried to show what life in sheltered living provides to these clients, if there are any problematic situations and as subsequently affect their current lives. Keywords: Adult with intellectual disability, quality of life, adult rights, deinstitutionalization, sheltered living,...

[pt] Este trabalho discute a implantação do Programa Nacional de Atenção Comunitária Integrada a Usuários de Álcool e Outras Drogas visando pensar criticamente a concepção de clínica para dependentes de drogas que surge no movimento da Reforma Psiquiátrica Brasileira. Privilegiando princípios subjacentes à legislação e aos principais desenvolvimentos teóricos no campo da saúde mental no Brasil, são tecidas considerações acerca do modelo adotado na assistência a usuários ou dependentes de drogas. Tendo em vista o tradicional modelo privado e organicista da assistência ao dependente de drogas, o Centro de Atenção Psicossocial para Álcool e outras drogas (Caps ad) surge como possibilidade promissora de por em andamento, na clínica voltada a essa clientela, processos como de desterritorialização subjetiva e de desinstitucionalização. Após contextualizar historicamente o problema, foi realizado um mapeamento da assistência nesse campo e analisados os impasses encontrados na criação de uma rede efetiva de cuidados, caracterizada pela transdisciplinaridade e interinstitucionalidade. Ao final, foi aventada a proposta de transformação da clínica instituída em clínica territorial. / [en] This work discusses the implementation of the National Program for Community Attention to Users of Alcohol and Others Drugs. It has the intent of reviewing the concept of the Clinics to treat drug addicts within the reform of the Brazilian Psychiatry. The model adopted to assist drug users and addicts is discussed, considering the principles of the Brazilian legislation and the important theoretical developments in the field of mental health. Considering the traditional institutionalized model to provide assistance to drug addicts, the Center for Psychosocial Attention for Alcohol and Others Drugs seems to be as a plausible proposal to enhance the processes to address the removal of the subjective territoriality and the deinstitutionalization for the treatment of this clientele. After putting the issue at its historical context, we mapped the assistance provide in this field and we evaluated the issues impairing the creation of a effective mental health care network, which should be characterized by being cross disciplinary and intra institutionalized. At the end a proposal to transform the institutionalized health care into a territorial health care was made.

Este estudo elegeu para objeto de investigação o fazer, o saber e o saber-fazer de quinze agentes de enfermagem de nível médio que desenvolvem atividades assistenciais no Centro de Atenção Psicossocial II Prof. Luís da Rocha Cerqueira, sede do Programa de Integração Docente Assistencial em Saúde Mental da Secretaria de Estado da Saúde e Universidade de São Paulo. A escolha das agentes deu-se mediante a crença de que o grupo protagoniza a ação e o trabalho da enfermagem em saúde mental no campo psicossocial porque é quem prevalentemente oferece ação de saúde mental no cenário de estudo. Esta pesquisa utilizou a Oficina de Trabalho como procedimento metodológico para a captação, análise e reconstrução do fazer e do saber das agentes de enfermagem. A construção compartilhada do conhecimento indicou duas dimensões da produção de produtos de saúde. Na primeira dimensão as agentes de enfermagem de nível médio produzem e oferecem ação de saúde mental mediatizada pelo fazer impregnado de saber alinhado ao campo psicossocial do coletivo institucional e compartilham a autoria da ação de forma subalternizada ao agente com formação de nível superior. A segunda dimensão do fazer agrega significado à ação de saúde e permite a apropriação da autoria da produção de produtos de saúde, configurando o trabalho da enfermagem: o cuidado em si de enfermagem em saúde mental. Os resultados indicam ainda uma prevalência de produção e oferta de produtos de saúde que atinge o usuário individual, no interior da instituição, indicando a necessidade institucional de buscar aprofundamento e coerência aos pressupostos do campo psicossocial no que tange à articulação do serviço com o território, à inclusão de ação de saúde para familiares e à ampliação da produção de produtos na esfera da vertente crítica da reabilitação psicossocial. A Oficina de Trabalho revela-se um instrumento potente para a particular aquisição de consciência crítica quando amplia o repertório teórico das pesquisadas, eleva o relato de experiência para o patamar do saber construído coletivamente e promove a mudança objetiva da posição das agentes de enfermagem no cenário do poder institucional. / The object of this study was the to do, the knowledge and the how to do of the fifteen medium level nursing agents who perform assistance activities in the Center of Psychosocial Attention II, Prof. Luis da Rocha Cerqueira, home office of the Program of Academic Assistance Integration in Mental Health of the State Health Secretary and University of São Paulo. The agent choice was performed according to the belief that the group performs the action and the nursing work in mental health in the psychosocial field because this is the individual who predominantly offers action in mental health in the study environment. This research used the Work Shop as a methodological procedure to achieve, analyze and reconstruct the to do and the knowledge of the nursing agents. The shared construction of the knowledge showed two dimensions to produce health products. In the first dimension, the medium-level nursing agents produce and offer intermediated mental health action by the do impregnate of knowledge aligned to the psychosocial field of the institutional collective and share the authorship in a subordinated way to the academic agent. The second dimension of the to do adds meaning to health action and allows the appropriation of the authorship of the production of health products, determining the nursing work: the care itself of nursing in mental health. The results showed a prevalence of production and offering of health products which reaches the individual user, within the institution thus indicating the institutional need of search for deepening and coherence of purposes in the psychosocial field regarding articulation of the service with the territory, inclusion of action of health action for relatives and to expand the production of products in the critical sphere of the psychosocial rehabilitation. The Workshop showed to be a strong instrument to specifically acquire critical consciousness when expanding the theoretical repertory of the investigated, raising the experience report up to the level of the knowledge collectively constructed and to promoting an objective change of the nursing agent’s position in the institutional power environment.

Esta é uma pesquisa qualitativa cujo objeto de estudo são as necessidades de saúde da perspectiva de usuários de um serviço comunitário de saúde mental. A finalidade do estudo é contribuir para o fortalecimento da Reforma Psiquiátrica brasileira, propondo o conceito de necessidades de saúde como um instrumento para orientação da organização dos serviços e dos processos de trabalho em saúde mental. Os objetivos da pesquisa são identificar o entendimento dos usuários do serviço sobre suas necessidades de saúde, verificar se são satisfeitas pelo serviço e sistematizar as compreensões dos usuários de forma a contribuir para a organização das práticas no serviço. O cenário de estudo é o Centro de Atenção Psicossocial Itaim Bibi da Secretaria Municipal de Saúde de São Paulo que opera um projeto terapêutico baseado nos pressupostos da Reforma Psiquiátrica. Participaram deste estudo cinco usuários-trabalhadores do Projeto de Geração de Trabalho e Renda O Bar BibiTanTã, resultado da Cooperação Técnica entre o CAPS Itaim Bibi, a Área Temática de Enfermagem em Saúde Mental da Escola de Enfermagem da Universidade de São Paulo e a Associação Franco Basaglia. Os dados empíricos foram coletados por meio de entrevista semi-estruturada e analisados segundo a técnica de análise de enunciação. Os resultados apontam contradição com relação à satisfação das necessidades de saúde dos usuários. A análise das entrevistas demonstra que o serviço desenvolve projetos e ações que respondem às necessidades propriamente humanas e às necessidades alienadas de parte dos usuários, entretanto, na fala dos sujeitos, não está claro se a ação do serviço é voltada explicitamente para a apreensão e satisfação das necessidades, pois enquanto algumas são satisfeitas, outras parecem não encontrar espaço para serem expressas. Ressaltamos a importância dos projetos de geração de renda, baseados a lógica da Economia Solidária, pela diferença que faz na vida dos usuários-trabalhadores e, principalmente, por ser um importante instrumento para a efetivação da Reforma Psiquiátrica / This is a qualitative research whose object of study are the health necessities of users’ perspectives in a mental health communitarian service. The purpose of this study is to contribute to the strengthening of the Brazilian Psychiatric Reform, introducing the health necessities concept as an instrument for the directions of mental health work processes and services’ organization. The research objectives are the identification of the service user understandings about their health necessities, the verification of their performance by the service and the classification of users comprehensions in order to help the practice’s organization in the service. The scenery of study is the Psychosocial Care Center in Itaim Bibi (CAPS) of the Health Department in the City of São Paulo which performs a therapeutic project based on the pretext of the Psychiatric Reform. Five user-workers from the Income and Work Creation Project O Bar BibiTantã participated on this study as a result of the Technical Cooperation among the CAPS Itaim Bibi, the Nursing Thematic Area in Mental Health of the Nursing School from Universidade de São Paulo and the Franco Basaglia Association. The empiric data were gathered through semi-structured interview and they were analyzed according to the enunciation analysis technique. The results show a contradiction related to the satisfaction of user’s health necessities. The interview analysis demonstrates that the service develops projects and actions that supply the human’s proper necessities and some user’s private necessities as well, however it is not clear in their talk if the service action is turned directly to the apprehension and performance of these necessities because while some are performed others seem to find no place to be expressed. We emphasize the importance of Income Creation Projects based on the logic of Assisting Economy because of the difference they make in the user-worker’s lives and mainly for being an important instrument for the accomplishment of the Psychiatric Reform