ORIGINAL ARTICLE

 

Concepts and prejudices on mental disorders: a necessary debate

 

Conceptos y preconceptos sobre trastornos mentales: un detalle necesario

 

 

Maria Rosilene Cândido^I; Edina Araújo Rodrigues Oliveira^II; Claudete Ferreira de Souza Monteiro^III; José Ronildo da Costa^IV; Geórgia Salanne Rodrigues Benício^V; Flora Lia Leal da Costa^VI

^IDoctoral student, Universidade Federal da Paraíba, João Pessoa, PB, Brazil. Professor, Universidade Federal de Campina Grande, Campina Grande, PB, Brazil
^IIMaster’s student, Universidade Federal do Piauí, Teresina, PI, Brazil. Assistent Professor, Universidade Federal do Piauí, Teresina, PI, Brazil
^IIIPhD, Adjunct Professor, Universidade Federal do Piauí, Teresina, PI, Brazil
^IVRN
^VUndergraduate student in Nursing, Universidade Federal do Piauí, Teresina, PI, Brazil
^VIRN

Correspondence

 

 

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ABSTRACT

Mental disorders have gained Brazilian’s media space for discussion and, currently, there is a lot being said on the subject. This paper has dealt with a group of professionals’ concepts of a higher education institution on mental disorder, in order to verify the existing stigma and to produce debates on its reduction.  This is a qualitative, action research study, developed with eighteen technical-administrative professionals of a public institution of higher education in Piauí, in 2009. The declarations revealed no clear definition of mental disorder. We have verified that the connection between prejudice and psychological distress remains within society, requiring that the subject continue to be discussed in social groups.

Descriptors: Mental Health; Knowledge; Cognition Disorders; Concept Formation.

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RESUMEN

Los trastornos mentales ganaron escena de discusión en medios de comunicación de Brasil y, actualmente, mucho se tiene oído hablar sobre el tema. El presente trabajo trató de las concepciones de un grupo de servidores de una institución de enseñanza superiora sobre trastorno mental, a fin de verificar el estigma existente y suscitar debates en torno a su reducción. Estudio cualitativo, del tipo investigación-acción, fue desarrollado con dieciocho servidores técnico-administrativos de una institución pública de enseñanza superiora de Piauí, en el año de 2009. Las declaraciones evidenciaron no haber definición clara sobre trastorno mental. Se verificó que la relación entre preconcepto y sufrimiento psíquico permanece embutida en la sociedad, requiriendo que el tema continúe a ser discutido en los grupos sociales.

Descriptores: Salud Mental; Conocimiento; Transtornos del Conocimiento; Formación de Concepto.

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Introduction

All through history of madness people with mental disorders were considered ‘dangerous’, ‘sick’, ‘abnormal’ or ‘special’. These concepts were and still are attributed to these people, which contribute to the production of ambiguous thoughts about this subject. Contrary from the fifteenth to nineteenth centuries, in which the madness concept went from natural to pathological ⁽¹⁾, debates in the twentieth first century discuss nodular hinder issues for the need for social/cultural reinterpretation, under the approach of the new object: the person with disorder and instead of the illness and the mentally ill person.

During the history of madness ⁽²⁾, it is noted that the society has used different names regarding this phenomenon, according to the needs and interests of members of the ruling classes, when the terms "madness" and "insanity" had different connotations over the years. Besides the changes in their meanings, there were also changes in the practice of health care for those who attended the psychiatric institution, the hospital and, later, mental hospital.

Insanity, which was initially considered a human nature phenomenon, would later take over the role of causing harm to the society by those affected by it. The insane (crazy people) were dangerous beings, aggressive, so they were put into cells and enchained by health professionals, under the pretext that the isolation itself had the healing power ⁽³⁾.

In Brazil, with countless deaths occurring in these psychiatric institutions, and considering useless this type of practice towards the insane treatment, the mental health professionals have organized themselves through intense mobilization in several Brazilian cities. This movement, known as the Movement of Mental Health Professionals led to a very complex process called Psychiatric Reform ⁽⁴⁾ and with the enactment of Law No. 10216, April 6, 2001, which redirects the mental health model ⁽⁵⁾.

Because of this recent law, the direction towards a new way of thinking and dealing with the process of psychological distress in Brazil stimulates widespread debate, discussions and disclosures in favor of the participation of those involved and the society in their democratic institutions, so it can be monitored and administered by the population ⁽⁶⁾.

From this angle, it is expected that the knowledge spaces of production, especially university environments, are raising debates around this issue, seeking ways to solve it, with actions that involve not only the communities which students and teachers attend during practices derived from the area of ​​health curricula, but also within the academic environment, with students, teachers and professionals, considering that, where there is interpersonal relationships, it is necessary to rethink concepts, values ​and practices.

However, often, what we see are educational projects aimed at the public outside the university, whose strategies and resources could also be applied to employees of higher education institutions, so that they could become health multipliers. Thus, studies that could verify conceptions and bias about the matter with this audience, could serve as a basis so the interventions in this direction could be effected, which justifies this study.

With this understanding and in order to promote discussion so constant reflections could occur to reduce prejudice against people affected by mental disorder, the present study sought to uncover the stigma present in discourses of a group of professional in an institution of higher education about mental disorder, what they know about the institutions that provide mental health care in Brazil and the possibilities considered by them to reduce this stigma.

 

Materials and Methods

In order to achieve the proposed objective in this study, we have chosen the qualitative method, which explores the subjective understandings of people, enabling us to capture very specific issues, such as meanings, beliefs, values ​​and attitudes (7) from the individual phenomenon understanding, making the link with the social context, both researched as the researcher, as the central concern of the qualitative method is not the phenomenon itself, but what it means to subjects (8).

Under these aspects, this research has presented as focuses the meanings attributed by the participants regarding mental disorder and the ways in which they express their beliefs and taboos, thus, being part of the field of social phenomena for considering the existence of a system of representations coming from symbolic systems that exert power relations in the mental health field, leading to formation of meanings and several behaviors according to the intensity they influence humankind.

In this study it was used the action research method, because it is a simultaneous process of research and action, through which the individuals involved (researchers and researched) discuss the problems looking to find proactive solutions that transform reality ⁽⁹⁾, in this case, solutions to the stigma problem surrounding the mental disorder patients. This strategy, consisting of twelve steps, allows occurring knowledge and collective problem solving from the facts observed in the social context of the problem ⁽¹⁰⁾. In this paper there are presented only the results obtained in Phase 1 (exploratory phase).

The target population of the study included technical-administrative professionals, invited from several sectors of the Campus Senador Helvídio Nunes de Barros (Picos Campus) of the Federal University of Piauí, selected from a list provided by the Human Resources Department (HR), so that all sectors could be represented. It was part of the study eighteen professionals who were actively working when the invitation was made and that accepted, spontaneously, to participate in the study, whose execution was the first activity of the project Therapeutic Interventions in Mental Health: a proposal for stigma reduction, funded by the Scientific and Technological Development (process No. 5752012008-8/CNPq).

It was prepared a questionnaire with open questions applied during the first group meeting, at which there were present the proposals and project objectives to be developed, as well as the ethical and legal aspects involved. The meeting took place in April 2009, on the Nursing laboratory at Picos Campus, and the questionnaires were available after reading and the individual’s signature of the informed consent of each one of them.

The questions that guided the exploratory phase of this action research were: What is your understanding of mental health and mental disorder? What mental health services do you know? What are the differences between them? Have you ever visited a mental health institution? How did you feel at the time? What is the role of the University regarding stigma reduction? What could you do to reduce society’s prejudice towards the individual with psychological distress?

This study was submitted and was approved by the Ethics Committee of the Federal University of Piauí, CAAE 0022.0.045.000-09.

 

Results and Discussion

The professional group was composed from various sectors of the Campus, whose activities involve, in addition to contact with colleagues, the attendance of teachers and students. Thus, among the 18 technical-administrative professionals who accepted to participate, seven were from laboratories; four were from administrative sectors; three were from courses departments; two from library and two from security of the Campus. The participants’ age group ranged from 23 to 59 years, mean of 36.3 years, 10 males and eight females. Regarding the level of education, eight had completed college, eight completed high school and two had not finished high school.

In order to obtain a situational diagnosis about the background of the participants on issues related to mental health, there were some questions, resulting in five thematic categories, shown below. It is understood that these categories reflect symbolic marks of a reality that is still being built with the evolution of mental health in the country, providing a new reading on the history of madness through the ages, an aspect often highlighted in the participants’ speeches.

Abnormality, escape of society ethical concepts, psychological change

Among the different ways to express their point of views about mental disorders, the participants have considered them as an abnormal phenomenon, not a part of the ethical standards of social behavior: It is a mess of thoughts, a behavioral inconsistency, behaviors and reactions beyond the standards (S1); It is something that makes the human being act abnormally before the other; it is a organic dysfunction generated by external factors (environment), or inherent to the person (hereditary), escape from the ethical concepts of a society (S2); It is a psychic alteration that makes the person out of reality, without discernment between right and wrong (S3); Is a human exceptionalism, depending on the level, this person can live in society, but there is severe mental disorders that are immediately identified and these have to undergo a treatment (S4); It is any brain alteration causing strange behavior to a person, or behave differently than normal standard (S6); It is some issues involving the mind, the soul [...] (S8).

These speeches illustrate how ingrained is the idea that a person with a mental disorder is on a condition of human abnormality, putting the person in a position of danger, disability and social transgression of moral norms. There are also differences of understanding of what is mental disorder. Among the participants there are those who associate mental disorder to any behavior that puts people out of reality, into a clear vision that most people see them.

It is well known that mental disorder has biological, psychological and social causes and it need specialized care, but also family and social support. However, the process of social reintegration is a very difficult task, because there is also the connotation that someone with disorder is unable, abnormal, a transgressor of social norms and, therefore, deserves isolation from society ⁽¹¹⁾.

The positivist concept of "mental illness", "abnormal", "exceptionality" reflects a historical conception of madness, transcribed in literature that address the issue ^(1-4), requiring that attitudes are taken to its redefinition as the meanings attributed by the participants can express the conservative view of many people who have not yet been asked about it, but that may be exerting, in everyday life, the prejudice contained in their minds.

Difficulties in distinguishing partial hospitalization and psychiatric institution

Although seeing the person with mental disorder as someone who is outside the standards accepted by society and should receive specific treatment, the researched group expressed knowledge about the traditional models of mental health care in the country. 

Although there are three types of health care services in the city of study (Partial hospitalization, Psychosocial-alcohol care center, drugs and psychiatric beds in general hospitals), the participants reported only to the partial hospitalization in their speeches, mentioning also the traditional psychiatric institution, located in the capital  of the state (Teresina), which is reference in assistance of severe cases; these institutions have been compared by the participants, who pointed out similarities and differences between them: In partial hospitalization there is no hospitalization properly, but there is hospitalization in a psychiatric institution. (S1); I do not know the difference... (S3); I think it’s the same thing. (S9);Partial hospitalization should be a kind of psychiatric institution and the psychiatric institution is a place to treat people with mental disorder (S10); Partial hospitalization is a treatment center for the mentally ill, the psychiatric institution is an isolation place of the mentally ill in society (S4); The psychiatric institutions turn the crazy people even crazier (S6); The partial hospitalization and the psychiatric institution  withdraws people from society (S11).

It appears that, despite all the efforts coming from Brazilian Psychiatric Reform in transforming existing care models and proposes new forms of assistance to people with mental disorder, the participants had difficulties in pointing out the differences between these institutions, and sometimes, considering the institutions similar regarding the type of care provided, calling them asylums.

Such difficulties may be the result of intense transformation process proposed by ministerial laws and regulations, an ongoing process that emerged from the constant struggle of mental health professionals, through a way of care that has been consolidating the paradigm change from ‘disease-cure’ for ‘existence-suffering’ ⁽¹²⁾.

On the other hand, the participants’ speeches also can led us to assume that, although there has been a change in the existing care models in Brazil, many services have remained the same, professionals with conservative, positivist graduation, whose disease is the focus of attention, rather than the individual who suffers from it, resulting in traditional health practices in new and existing institutions. Perhaps this is the reason for the synonym used between partial hospitalization and psychiatric institution.

In the socio-historical context of mental health, the psychiatric institution is reflected by the greater manifestation of exclusion, control and violence against humans in psychological distress. Its structure hides the physical and symbolic violence imposed by the forms of psychiatric therapy with drugs, repressive, segregating, saving the society to live with a human with this obvious distress ⁽¹³⁾. It is, therefore, of extreme importance that projects and actions for the dissemination of information are increasingly performed, so that people know how it was before and what still remains within the Brazilian mental health.

Another point emphasized in the speeches was about how they felt when they visited psychiatric institutions. They have reported considered unsuitable for therapeutic purposes, because they realized that there are other ways to foster care in a more humanist way, this finding was obtained when the subjects were discussing visits to mental health, if they had gone to these places and how they understood their roles: Initially I was shock, followed by fear and doubt that I still have: what causes a person to be like that? (S1); I felt a bit sad because of the way they were treated, but otherwise, I found interesting the fact that certain disorders seem to activate or develop specific skills (S3); The reaction was involuntary, even when you see people you knew had a good heath, and when you see the person sick, it is surprising (S8); I did not bother me because I have not noticed anything, I was under the influence of medication (S10).

The speeches evoke reflections on the images seen or experienced by these people, some of them was surprised by the appearance and behavior of the person being visited, while others, seeking to identify something positive on the hospitalization.

Being a psychiatric hospital traditional, appointed by the participants who reported having met a mental health institution, it is understood how much is still needed, within the Psychiatric Reform, the deconstruction of the symbolic power of this institution, as the participants reported having experienced surprising scenes, people acting differently than usual and the use of chemical restraint as therapy.

The Psychiatric Reform Movement and the National Anti-Asylum Movement had major contribution in the change process of mental health in Brazil, by denouncing inhumane and anti-therapeutic practices in psychiatric hospitals, for example, asylums. These two movements were truly sentinels in the identification and reporting movements which suppressed the rights and autonomy of people with mental disorders, emerging transformation that is being consolidated at present in Brazil, not only in existing institutions, but also in their professionals ⁽¹⁴⁾.

The stigma rises by discrimination, by lack of information and by fear

Participants also discussed about the prejudice against people affected by mental disorder and express, clearly, that the source of bias is due to misinformation, ignorance, generating the image and stereotype of dangerousness and aggressiveness. This fact generates fear and repulsion of people: What does not fit the standards dictated by society is always discriminated, not only the mentally ill, but many others (S1); Society, in general, sees the mentally ill with a stereotypical perspective (S3); There are sorely missed information, knowledge of which is to be mentally ill... (S5); Fear of aggression of some people with mental disorders; the population is afraid of them... (S6); The mentally ill may cause a difficult situation, as there are surprising cases ... (S7); The biggest prejudice is ignorance; we all think we know what this disease is, and we discriminate those who we believe are sick, without even really knowing what they have, we do not help them at all, only isolate them (S9).

Although they talk as if they were other people, the participants refer to people with mental disorder as ‘mentally ill’. This denomination, itself, generates stigma, separation and fear brought over the centuries. However, it was also understood that new denominations are still ongoing and will gradually changing, in a rapid search of a word or phrase that may reduce this prejudice, which starts by changing the name that most people know to those who suffer from mental disorders.

Among the different ways of expressing the stigma, the participants speak of lack of information. For them knowledge is also a way of inclusion. Information on mental health is considered a necessity, both for lay people and for professionals, and basis for behavior change in relation to people with mental disorder.

There was also fear in the speeches, justified by the close relationship between aggressiveness and mental disorder. In fact, in the representation of the "crazy" person wandering the streets there is a social expression of danger that comes from the unpredictable and violent behavior, homogenizing "mad" as an expression of madness and danger ⁽¹⁵⁾.

To be changes in traditional scenarios of mental health care, it is necessary, first, to understand the basis of prejudice, and who are its contributors, whether they are managers or lay society. A proof of this was the realization of the Fourth National Conference on Mental Health, held in Brasilia, in 2010, which brought together various social spheres, rulers of several Brazilian states and foreign authorities, all of them aiming at expand efforts in consolidating the Psychiatric Reform, from the viewpoint that the problems of mental health should be envisioned as public health problems, and therefore, intersectional articulated ⁽¹⁶⁾.

A proposal to stigma reduction

The madness stigma in the West is transcribed in literary productions, emphasizing that it started in the eighteenth century, on the occasion of its pathologization, which was named mental illness, adding, with this new denomination, the power of psychiatric knowledge, practice with medicine, monitoring and isolation ⁽¹⁷⁾.

Considering the stigma understanding with mental disorder patient sine qua non to bring change of thoughts and attitudes and, therefore, are feasible measures to reduce it, it is necessary to identify strategies that can be reached from the local community and have the processing power in the conduct of these people in order to expand the opportunities for debate and minimize discriminatory attitudes.

Given these considerations, it was discussed with the professionals what they would do to change the existing prejudice against people with mental disorder in the city if they had governmental power to change it. The speeches were ambiguous: sometimes pointing to actions to prejudice reduction; sometimes emphasizing the separation between the person with mental disorder and society, reinforcing the exclusionary aspect still in force in the country: Well, I would promote awareness campaigns and would support institutions that work with these people (S1); I would seek greater interaction between society and mentally ill so they could change the conception of mentally ill... (S3); For the society, I would improve health, education, urbanization... for the mentally ill, I would build clinics (S4); In favor of society, I would perform campaigns to meet these adults and homeless children. In favor of the mentally ill, a hospital or home that could assist these patients... (S5); I would change education, because it is the basis of everything and would prepare us better to face the difficulties with much more naturally (S7); I would try disclose as much as possible about this disease and its forms, because information is one of the main weapons in the fight for society inclusion (S8).

Although some speeches also point to a context of overvaluation of the pathology and development of places for treatment, the attitudes expressed by the participants are directed to a promising psychiatric deinstitutionalization, which the primary path would be information and dissemination in large-scale, what mental disorder is and how people can live with the subjects in psychological distress. Such observations are essential so that people can better define, look and understand the phenomenon of mental disorder, extending it beyond the pathology ⁽¹⁸⁾.

The speeches are mixed between creating specialized spaces, but without a clear definition of what they consider ‘specialized’ and a more human conscience, passing by the reflection of education, knowledge and inclusion. It is observed that although the steps of psychiatric reform are still under construction and even more when it is about seeking new changes in these hinterland scenarios, these study participants envision that there is a need to look at these people with humanitarian feelings and offer them an improved quality of care.

Understanding that society is the supreme institution that can assign everyday life in its greater meaning, providing a space for the full expression of freedom ⁽¹⁹⁾, understand that everyone can contribute to reducing stigma is a fundamental requirement to positive attitudes towards the minimization of prejudice.

The role of the University regarding stigma reduction

During the discussions there were also commented issues related to the role of the university as a trainer field made of excellence professionals, on prejudice reduction in the mental health field: It is open knowledge, i.e., lead us to a new mentality to all, beginning with the employees, it is certain that students are closely inspired by the teachers and technical of the universities (S1); Through projects that address the issue, such as this one (S2); Showing the community that these people can live in society without any danger. This would happen through seminars, mini-courses and coexistence meetings (S4); Development of groups to give lectures in schools and institutions, and create a foundation for this purpose (S8); To continue to develop projects like this. The university, as a teaching institution, research and extension, has an obligation to develop social inclusion projects (S11).

Although the participants have pointed out that the university could play in reducing prejudice against mental disorder patients, they did not dare to do such intersection regarding their positions in the same institution, directing the responsibility change only to teachers and students, but not for them. The participants did not perceive themselves as part of the university group and, therefore, also able to promote actions and implement projects for stigma reduction, whether in academic environment, whether in social groups of which they are part.

However, the speeches show, very clearly, the actions that must be performed to stigma reduction that persists in relation to mental disorder and those affected by it. It is known that when integrating groups of people in seminars, workshops and other ways of discussion and information, the results are considered encouraging in the change process for which they are proposed. Thus, the participants understand the importance of these meetings and evaluate through their speeches which would be relevant actions in the process of change when it comes to mental disorder, stigma and social inclusion.

It is important to mention that, alone, the formal educational institutions, even if this task is assigned only to teachers and students, are not able to transform the perceptions formed in the mental health field, or deconstruct prejudices that are ingrained in them, although it is understood that the concepts that educators have on this subject will be the basis to support teaching related and, thus, to promote the necessary awareness to their students to stigma reduction ⁽²⁰⁾.

Furthermore, it is understood, also, that higher education is not yet fully adapted to the Brazilian mental health policy, a situation that often confronts the literature texts studied in the classroom and practical experiences arising from professionals and available mental health services ⁽²¹⁾. It follows a centered formation in excess of content, in the abstraction of the discussions, in detriment of specificities and challenges that still exist in the institutions that assist clients in psychological distress.

 

Final Consideration

The stigma that emerges in the scenarios of this century still adopts the terms ill and mental illness as inseparable labels as to the condition of exclusion and abnormality, even when the collective voice comes from social groups with higher educational level, for example, professionals of higher education institutions. 

It is necessary to understand that large and permanent debates on mental health are essential to reduce the prejudice against the person with psychological distress, which must occur in all society segments, encompassing from the less educated to those from production of knowledge, since knowledge is premised on access to information.

Breaking cultural barriers around mental health through multipliers corresponds to expectations as to stigma reduction, since it is not thought nor passed on standard formulas, but offer up opportunities for social actors to construct their own conceptions about the perception of "mad" as a self-existent being. This requires that the issue continues to be discussed in different social groups and that projects/actions for prejudice reduction are able to transform traditional/conservative concepts in a new paradigm of mental health.

 

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Correspondence
Maria Rosilene Cândido Moreira
Universidade Federal de Campina Grande
Rua Sérgio Moreira de Figueiredo, s/n
Casas Populares
Cajazeiras, PB, Brasil
E-mail: rosilenecmoreira@gmail.com

Received: Oct. 30^th 2010
Accepted: Jan. 25^th 2013