Theses defended

Para lá dos Silenciamentos. Sofrimento mental, integralidade e (im)possibilidades de uma ecologia de cuidados

Cláudia Nogueira

Public Defence date
January 25, 2024
Doctoral Programme
Pedro Hespanha
Despite political orientations defending a community-based and multidisciplinary model of mental health care, the Portuguese public model remains markedly biomedical and hospital-centric, concentrating its responses, almost exclusively, on psychiatric diagnosis, psychotropic drugs and hospital services. The present study starts from the recognition of the unequivocal urgency of moving towards a new model of care aimed at mental suffering; a model that, breaking with the silencing and reductionism produced by the hegemonic biomedical model, is led by the ethical-political ideal of integrality and promotion of effective citizenship in care.

Based on the theorical assertion that the pursuit of integrality in the field of mental health only becomes possible through the construction of an ecology of care - i.e., recognizing the presence of different epistemologies/practices of care and promoting a dialogue between them -, the general objective of this work is to contribute to expanding the field of possibilities for action, making visible "voices", conceptions, practices, rationalities and forms of care which were (and continue to be) subalternized or even delegitimized (as valid therapeutic agents) because of the biomedical/scientific hegemony. More specifically, the research aimed to know - at the level of public mental health services - the existing conditions for the construction of this (new) ecological/integral model of care, identifying either the favorable conditions (i.e., "signs of hope") or unfavorable conditions (i.e., obstacles). The aim was also to analyse to what extent people transcend the responses of public biomedical services, mobilizing (alternatively or simultaneously) "other" epistemologies/practices, outside the National Health Service. The methodological strategy combined qualitative techniques: in-depth interviews and ethnographic research.

As an object of study, the thesis privileged the analysis of experiences lived by a group of men and women (with psychiatric diagnoses), whose trajectories pass, at a given moment, through public mental health services (hospital services and Community Mental Health Team). In addition, the research also analyses (through an ethnographic study) the context of care provided by one of the rare Community Mental Health Teams operating in Portugal. It was decided to study this context because it represents (within the scope of the Action Plan for the Restructuring of Mental Health Services) the most innovative political proposal, which, theoretically, provides greater conditions for hope of breaking with the biomedical model/hospital-centric currently hegemonic.

In a general anticipation of some of the main results of the research, it should be noted that it suggests the prevalence of multiple obstacles to the construction of an ecological/integral model of care; these obstacles are mainly related to the maintenance of high level of biomedical power and the supremacy of hospital logics in public health services (including community services).

When analyzing in depth the context of a Community Mental Health Team, it was verified, as a counter-hegemonic element led by professionals, a high spirit of commitment to a holistic vision and the ethics of care - a fact which leads us to envision a horizon of hope and possibilities for transformation towards the construction of an ecological/integral model of care. However, paradoxically, it was noted how much a strong dependence on the hospital/biomedical model is reflected in its functioning, due to the way it imposes reductionist logics that deprive them to respond holistically to people's (multidimensional) needs.

Narratives of people who sought other care responses outside the National Health Service were also analysed - people who went through "heavy" processes of biomedicalization and psychiatric hospitalization. In this context, a set of "other" epistemologies/practices emerged with great propriety and vigour, revealing emancipatory results that contradict the idea that the "true" responses to mental suffering lie exclusively at the level of scientific/biomedical rationality. Looking at the narratives, one can clearly see the density of possibilities and potentialities of care existing within the scope of this epistemological diversity (e.g., Art Therapy, Yoga, Naturopathy, Peer Support Group, Hypnotherapy, Spiritual/Energetic practices in a Spiritist Center), which confirms the enormous importance of building an ecology of care in the field of health care.

Keywords: Mental Suffering; Integrality; Ecology of Care; Epistemological Diversity in Health; Community Mental Health Team