Social Science contributions to the understanding of psychiatric care have highlighted the passage from person to patient as being crucial to the moral career of the mentally ill. In this article another moment relevant to a discussion on illness and social identity is investigated, namely the passage from patient to clinical case. Socio-anthropological fieldwork was conducted between 2007 and 2010 with users of a care network after release from psychological internment, their relatives and neighbors. It highlighted not only the administrative categories that professionals in the network used to designate patients, but also those given by other villagers. Some villagers are considered doidos (“loonies”) without having been admitted as “patients” to the local inpatient facility. Others are “users”, registered at an outpatient service; or “clients”, when they are frequent users. Some are called bonequeiros (“troublemakers”), “nervous”, or barulhentos (“noisy crackpots”) because of their behavior in public. Finally, by becoming the object of comments by people on the street, they also become “cases,” which are eventually discussed at the mental care facilities, thus becoming “clinical cases.” Mental disorders are as relevant to the management of a stigmatized social identity as surnames and nicknames.
Social identity; Mental health; Stigma; Family; Community
According to Goffman, a crucial moment in the moral career of the mental patient is the act of internment in an asylum, because of the transition from being a person to being a patient and the sharp reduction in free adult status implicit in this transition11 Goffman E. Manicômios, prisões e conventos. São Paulo: Editora Perspectiva; 1996.. He also highlighted the action of the recording of degrading facts by the management team, the preparation of the case history impacting the intern’s exercise of civil rights, the loss of privacy being one of the most acute effects. Thus, not only the moment of the transition from person to patient but also that from patient to case can be a relevant event for understanding this moral career. For Foucault, it is precisely the documentary techniques, such as a medical examination, that turn an individual into a case22 Foucault M. Vigiar epunir: nascimento da prisão. Petrópolis: Vozes; 1987.. Based on these and other theoretical, conceptual and methodological contributions of the humanities to the field of mental health, I considered it important to understand the moral career of those released from psychiatric internment by the delineation of another type of transition: from patient to story.
Some studies in the mental health field have worked with cases specifically in order to develop their theoretical ideas33 Goldberg J. Cotidiano e Instituição: revendo o tratamento de pessoas com transtorno mental em instituição pública [tese]. São Paulo: Faculdade de Medicina; 1998., although it is possible to find investigations on the transition from person to patient44 Mantilla M. De persona a paciente: las prácticas y los sa-beres psiquiátricos y psicoanalíticos en un hospital de la ciudad de Buenos Aires [tesis]. Buenos Aires: Conicet; 2010.. There are situations in which patients became legal cases, such as illustrated by the Custodio Serrão case at the turn of the nineteenth to the twentieth century55 Carrara S. Crime e Loucura: o surgimento do manicômio judiciário na passagem do século. Rio de Janeiro, São Paulo: EDUERJ, EDUSP; 1998., differing from the health cases previously cited. Increasingly common are studies on the protagonist role of66 Costa D, Paulon, S. Participação Social e protagonismo em saúde mental: a insurgência de um coletivo. Saude em Debate 2012; 36(95):572-582. the users of Psychosocial Care Centers (PCC), some of whom even became anti-asylum activists during their later lives77 Soalheiro N. Da experiência subjetiva à prática política: a visão do usuário sobre si, sua condição, seus direitos [dissertação]. Rio de Janeiro: Fiocruz; 2003. and others who took on specific cultural identities, such as that of the artist88 Reinheimer P. Tô maluco, mas tô em obra: a trajetória do artista moderno e as representações da loucura. Rev Ciencias Sociais 2010; 41(1):48-66.. In addition, many former interns of asylums have lived as residents99 Pereira R. De volta para casa: a vida nas residências terapêuticas e o trabalho dos cuidadores em Barbacena-MG [dissertação]. Niterói: UFF; 2008. in Residential Therapeutic Services (RTS), although some of them remain abandoned in Brazilian asylums1010 Arbex D. Holocausto brasileiro. São Paulo: Geração Editorial; 2013.
Thus, according to Goffman’s theory, some individuals may experience the change from person to patient when admitted to a psychiatric hospital, and the patients admitted there can come to be considered as cases by the management team. However, there are other possible consequences of what the author calls the moral career of the mental patient, also involving status, rights and privacy: the legal case, user, activist, artist, resident and abandoned. The legal case illustrates an extreme level of loss of privacy, when the pain reaches the newspapers1111 Vianna A. Introdução: fazendo e desfazendo inquietudes no mundo dos direitos. In: Vianna A, organizadora, O fazer e o desfazer dos direitos: experiências etnográficas sobre política, administração e moralidades. Rio de Janeiro: E-Papers; 2013.. The abandoned exemplifies a sharp reduction in the opportunities to exercise rights, further hindering the act of coming and going, already constantly curtailed for psychiatric patients, including them in the areas of social abandonment in which a social death is articulated with a pharmaceutical life1212 Biehl J. Vita: life in a zone of social abandonment. Los Angeles: University of California Press; 2005.. The user and the resident apparently maintain the status of free adult, albeit with varying degrees of dependence on relatives, health professionals and/or institutions. The activist and the artist seem to gain more than they lose in status, obtaining prestige at least among mental health professionals.
Certain psychiatric patients became famous in a given locality and came to symbolize the values of a people, such as those which the citizens of Trinidad called ‘Mother Earth’1313 Littlewood R. Pathology and Identity: the work of Mother Earth in Trinidad. New York: Cambridge University Press; 1993.. Some people, at a time when there were no mental asylums in Brazil, were known to passersby and chroniclers of the city of Rio de Janeiro, as “mad” because of their behavior in public such as the ‘Dock-side Philosopher’1414 Engel M. Delírios da Razão: médicos, hospícios e loucos no Rio de Janeiro (1830-1930). Rio de Janeiro: Fiocruz; 2006.. In addition, other people who did not become psychiatric patients could be thought of as “loonies” in a given locality and receive nicknames because of this “fame”, such as the ‘loony from Monsanto’ in the State of Pernambuco1515 Marques A. Intrigas e questões: vingança de família no sertão nordestino. Rio de Janeiro: Relumé-Dumará; 2005.. When I use the term “story” I am referring to people who were psychiatric patients are now are ex-interns having been discharged from psychiatric internment, not to the people who were never interned nor to those that were and remain there. Among those ex-interns, I refer to those that are known and recognized in public by the residents of a given locality, not those who are the subject of discussion and record only among members of the management team of a psychiatric institution: to the stories and not to the cases, therefore. Thus, the term “story” points to a possible consequence of the moral career of an ex-intern, that is, of acquiring a certain reputation among the citizens, of being publicly known by others and not just their relatives, neighbors and mental health professionals, being the subject of comments, gossip and rumors in a given locality.
Later on I will pursue at greater length this category of being a native which emerged in the course of field work carried out in a health care network (network) of a given municipality (city), explaining why it became to be considered an analytical category. So far I have only tried to explain the choice of the object of this research, the transition from patient to story - rather than that from person to patient or from patient to case - in the moral career of ex-interns of psychiatric institutions - and not of someone mentally ill or still interned. In my view this transition has more to do with a gain in publicity than a loss of privacy, more of a rise than a decline in status, unlike the moral career of the mentally ill person described by Goffman.
Regarding the exercise of rights, the enactment of Law 10.216, of April 6, 20011616 Brasil. Lei 10.216, de 6 de abril de 2001. Dispõe sobre a proteção e os direitos das pessoas portadoras de transtornos mentais e redireciona o modelo assistencial em saúde mental. Diário Oficial da União 2001; 9 abr., known as the Anti-Asylum Law, led to a major change in national psychiatric care since internment came to be considered a secondary therapeutic procedure - “it will only be recommended when the extra-internment resources prove to be insufficient “- and it was even prohibited in some cases
“ prohibited... in institutions with characteristics of asylums.” Additionally, the Anti-Asylum Law also contributed to a change in the term used to refer to those who had been previously designated “alienated” - Decree 1,132 of December 22, 19031717 Brasil. Decreto 1.132, de 22 de dezembro de 1903. Realiza a assistência a alienados. Diário Oficial da União 1903; 23 dez. - or even “psychopaths” - Decree 24,559, of July 3, 19341818 Brasil. Decreto 24.559, de 3 de julho de 1934. Dispõe sôbre a profilaxia mental, a assistência e proteção á pessôa e aos bens dos psicopatas, a fiscalização dos serviços psiquiátricos e dá outras providências. Diário Oficial da União 1934; 14 jul. - and also “mentally ill”
Decree 3,138 of March 24, 19411919 Brasil. Decreto 3.138, de 24 de março de 1941. Dispõe sobre a prestação de assistência médica, pelos Institutos e Caixas de Aposentadoria e Pensões, dos doentes mentais que forem seus segurados ou associados. Diário Oficial da União 1941; 31 dez. - and who, from then onwards, were referred to as “a person with a mental disorder.”
The adoption of the term “user” by the mental health services marked the change between the Workers Movement of Mental Health (WMMH) and the National Anti-Asylum Movement (NAAM) in the late 1980s, becoming one of the segments of this movement, together with relatives and mental health professionals2020 Amarante P. Loucos pela Vida: a trajetória da reforma psiquiátrica no Brasil. Rio de Janeiro: Fiocruz; 1995.. In 2009, furthermore, the User’s March to Brasilia for Anti-Asylum Psychiatric Reform, led to the IVth - and final - National Conference on Mental Health in 2010. The terminologies adopted in the mental health field have been the subject of political debates and theoretical investment. This debate has relied on contributions from the fields of ethics and epistemology for addressing the stigma, the so-called “insane offenders” being referred to increasingly as “adults with mental disorders in conflict with the law”2121 Brasil. Ministério Público Federal. Parecer sobre Medidas de Segurança e Hospitais de Custódia e Tratamento Psiquiátrico sob a perspectiva da Lei 10.216 / 2001. Brasília: PFDC, MPF; 2011., for example.
Two dimensions of the socio-historical process of psychiatric reform were very relevant to the anti-asylum cause, the legal-political and the epistemological2020 Amarante P. Loucos pela Vida: a trajetória da reforma psiquiátrica no Brasil. Rio de Janeiro: Fiocruz; 1995., which resulted in the change of the nomenclature to use the expression of people with a mental disorders that had been established by law. However, the stigmatized identity of the mentally-ill person2222 Goffman E. Estigma: a manipulação da identidade deteriorada. São Paulo: Brasiliense; 1990. was not always viewed in isolation to the specific sociocultural contexts. A recent study, for example, highlighted the stigmatization of certain PCC users due to its association with a particular religious cult2323 Nunes M, Torrenté, M. Estigma e violências no trato com a loucura: narrativas de centros de atenção psicossocial, Bahia e Sergipe. Rev Saude Publica 2009; 43(Supl.1):101-108., not necessarily because of its psychiatric diagnosis. In my research, carried out in a city health service network, there were situations in which the the fact of belonging to a given family or neighborhood dominated the religious aspect of the stigmatization process.
A person who was an ex-intern of a psychiatric institution and who had experienced the transition from patient to story in his moral career could be treated as “schizophrenic” by the network health professionals and seen as a “loony” by the city’s residents. Such person could also be referred to as a “troublemaker” for causing trouble in the city’s shops, both by mental health professionals and residents. The person could even be called a “moorhen” on account of belonging to a certain family and/or locality, where the those with a given surname were dubbed in this way because they were considered to “talk too much” by neighbors, sometimes even to be “noisy”. Thus, during the field work that will be presented below, I witnessed situations and heard reports of occasions in which not only having a mental disorder but also having certain surnames and nicknames contributed to the construction of stereotypes in relation to ex-interns of psychiatric institutions.
Identity is an important issue in the field of public health, both that of users2424 Nóbrega J. Identidade surda e intervenções em saúde na perspectiva de uma comunidade usuária de língua de sinais. Cien Saude Colet 2012; 17(3): 671-679. and of2525 Bachilli R, Scavassa, A, Spiri, W. A identidade do agente comunitário de saúde. Cien Saude Colet 2008; 13(1):51-60. health service professionals. By studying the transition from patient to story in the moral career of ex-interns of psychiatric institutions, my objective was to investigate the relationship between illness and social identity in this particular socio-cultural context, addressing as well the socio-cultural dimension of the socio-historical process of Brazilian psychiatric reform.
The reference material that supports this text was, in part, extracted from a doctoral thesis in social anthropology, and the research project was funded by the CNPq and approved by the Committee for Research Ethics, based on the use of Agreements of Informed and Free Consent. This was research “with” and not “on” human beings2626 Oliveira L. Pesquisa em versus Pesquisa com Seres Humanos. In: Victora C, Oliven RG, Maciel ME, Oro AP, organizadores. Antropologia e Ética: o debate atual no Brasil. Niterói, Porto Alegre: EDUFF, ABA; 2005. p. 33-44., especially as concerned the ex-interns of psychiatric institutions, to the extent that they became partners and not just informants during the fieldwork. The fieldwork was conducted within a city health services network, and in order to preserve the identity of the health professionals, family members and health service users, as well as the city’s residents, details will not be provided on them, only such data as necessary to contextualize the situations observed and the interviews carried out.
The fieldwork was initiated following a news item about the city’s health service network, sent to me and to all the other participants of the internet virtual group called “In defense of reform” in 2006. The group brings together activists in the psychiatric reform movement throughout Brazil and consists basically of three segments: users, relatives and mental health service professionals. In addition to beg a health professional in a different health care network in a different municipality in Brazil, at the time I received the news item, I was a relative of residents of the city mentioned. Furthermore, this relative was a user of the health network in this city. Through the contacts with the health professional who had sent the news item and my relative who was a user of the network, I performed field work in that city between 2007 and 2010, during which time I was there for a total of 5 months although not in succession.
The health service network was composed of: A PCC, a PCCad (including alcohol and drugs, a RTS, a psychiatric ward in a general hospital (PH), an outpatient facility with special services and nearly 30 primary health units (PHUs) in which approximately 50 family health teams (FHTs) operated. The PCC had more than 20 employees, most of them being female and with university degrees, including nurses, social workers, occupational therapists, educational psychologists, psychologists, technical nursing staff, psychiatrists and administrative staff. These employees attended approximately five thousand users, the vast majority of which lived in the city, which had a total population of almost 200 thousand. The PCC held a weekly team meeting and the network underwent a process of clinical-institutional supervision monthly.
With the exception of the PCCad, I observed participants in all the network’s premises, during consultations, team meetings, clinical-institutional supervisions; I also made observations outside of the health services premises in the company of their professionals - on home visits - and without them - in the homes of users and their relatives, as well as in the squares and other public spaces of the city, both with them and the other residents of the city. Except for the RST residents, I interviewed professionals, users of health services and their relatives (in the health service premises and also in their homes), as well as some of the city’s residents who had no relations with the health services. During the course of the fieldwork I talked informally with 30 PCC users, while they were waiting for their appointments, of whom 10 had been indicated by the team and/or by my relative who was also a user of the service.
Furthermore, some city residents interviewed were also users, relatives and health network professionals. In addition, some city residents were not only residents but also born there. Sometimes these residents belonged to well-known families in the region - not only in the city - by their surname. It was in this social and institutional context that I heard the term “story.” I was interviewing a health network professional who had not been born in the city, when he recommended that I interview a colleague who was a resident and a native of the city, in order to know more about the daily lives of the ex-interns of psychiatric institutions. According to this health professional his colleague used to speak of the “stories” behind the “clinical cases” at the weekly PCC team meeting. That is, his colleague - a health network professional, and a resident and native of the city - knew the stories of the lives of the users and not just their clinical and institutional records, because he was immersed in a social network different from the health services network: one formed by the city residents, particularly those belonging to a certain local family.
This social network emerged in the 2000s, following the closure of the city’s nursing home in the 1990s, and which had begun its operations during the 1970s. The nursing home was closed after a legal case involving one of its patients, that is, the legal case contributed to the nursing home being closed and to the emergence of the health service network, in which the city’s residents could be treated as “clinical cases” by the PCCs.
In the nineteenth century a philanthropic hospital had already been created in the city, but this did not have a psychiatric ward. Relatives of the current mayor owned the nursing home, while relatives of the former mayor were in charge of the philanthropic hospital. The owners of the nursing home had a surname that resulted in them being given the nickname “miliquita” among the city’s residents, being considered “nervous” and “workers”, while those in charge of the philanthropic hospital bore a surname which resulted in them being given the nickname “moorhen”, due to their being considered to “talk too much” and even to be “noisy” in group situations, as mentioned above.
Miliquita is the name of a type of ant, and is a symbol of work for the city’s residents. It is a small red ant, whose sting burns, and it gave rise to the nickname given to those who hold a given family surname in the city; I will denominate them here as the Silva family. Moorhen is the name of a bird that frequents a certain river on the outskirts of the city. It makes a lot noise and it was this custom that, by analogy, led to this nickname being attributed to the city residents with another family surname, which I will denominate here as Batista. The people linked to these families and/ or these places are called by these nicknames in a jocular manner and in public. Although this nickname was essentially pejorative, it could also be used to honor a city resident, since he could either be considered “nervous” and “noisy” or a “worker” and “talking too much”. In addition, there were other nicknames attributed to other surnames, such that the nickname could be used to designate a person even though he did not belong to this or that family or locality, simply being sufficient to be in a group discussion situation and behave in a way that the others considered to be characteristic of the “noisy” moorhen or the “nervous” miliquitas. So it was something of a contextual not a substantial order.
This terminology used to refer to the behavior of the city’s residents was present even within the health service, being used even by professionals during consultations. For example, when two doctors were discussing a case in a certain primary health unit (UBS), one of them suggested a diagnosis of “bipolar disorder” for one of the users being attended, while the other retorted saying the user was a “moorhen”, both because of her habit of talking too much and also because her surname was Batista. The doctors and the user were residents and natives of the city, one of which, in a playful manner, went on to designate the other in a jocular manner due to his nickname given to his surname, neither Batista nor Silva.
In this way, one could note the preeminence of the language of the nervous person2727 Duarte L. Da vida nervosa nas classes trabalhadoras urbanas. Rio de Janeiro: Zahar Editores; 1986. in this specific socio-cultural context, reflecting Duarte’s contribution concerning people accused of being mentally ill among the urban working classes. Moreover, the jocular relations and satirical sanctions that Nogueira noted among the inmates of a sanatorium for patients with pulmonary tuberculosis2828 Nogueira O. Vozes de Campos do Jordão: experiências sociais e psíquicas do tuberculoso pulmonar no estado de São Paulo. Rio de Janeiro: Editora Fiocruz; 2009 were present among the city residents in the context of my fieldwork, pointing to the relevance of the nicknames given to those with a particular surname in this city. Not to mention the domestic moral attributes and institutional nicknames mentioned by Biehl in his study of medical institutions, the homes of families and the neighborhoods in the city1515 Marques A. Intrigas e questões: vingança de família no sertão nordestino. Rio de Janeiro: Relumé-Dumará; 2005., making me think of the moral attributes and public nicknames among the city’s residents: “nervous” but also “noisy”.
The term “story” was used by a mental health professional to refer to information about the PCC user that circulated among the city’s residents, as opposed to those that circulated only among the network professionals, the “clinical cases” or simply “cases”. I have generalized this term for every and any ex-intern of the city’s deactivated nursing home that later became notorious, acquired a reputation, became known and recognized in public by the residents. Thus, I changed this category of being a native into an analytical category in order to investigate the transition from patient to story in the moral career of the ex-interns of psychiatric institutions, as distinct from the transition from patient to case.
The moral careers of only three of the ten users interviewed will be presented and discussed in this text, since they together provide for the understanding of the specificity of the transition from patient to story: José, Gerson and João are fictitious names. These three PCC users contributed to the understanding of the different moments in the moral career of an ex-intern of a psychiatric institution: “user” because he was enrolled in the PCC; “customer” due to his frequenting the PCC; “clinical case” due to being reviewed by health professionals in the PCC team meetings and/or the network clinical-institutional supervision process; “stories” because they were the subject of comments among the city’s residents. It should be remembered that this moral career is permeated by a singular relationship between illness and social identity, mediated by nicknames and surnames and not just by psychiatric diagnoses, since the city’s residents can be considered “loonies” even without being “patients” of the nursing home, or even “troublemakers”, as we will see below.
Results and discussion
The city’s nursing home, established during the 1970s, functioned with approximately 60 beds in the final years of its existence. The city was only a village in the eighteenth century, and then became more prominent in the nineteenth century due to the planting of cotton and the start of the leather trade, but it was only in the twentieth century that it became famous in the region mainly on account of the nursing home. I realized this when I took a trip through the region in the company of a health network professional and visited my relatives in one of the municipalities during a weekend.
In my relatives’ house, during the afternoon snack, and in the company of the health network professional, his teacher colleague, my uncles and cousins, one of the neighbors recognized the health network professional network as his therapist. When my uncles started to joke with this neighbor, referring to the fact of her being a PCC user, she replied that one of my cousins was also a “loony” for having been born in the city of the nursing home and not in the municipality of the region. The mocking tone and the fun-like mood, rather than any feeling of embarrassment, continued during this collective conversation, until my uncles started to “joke about” this cousin as well.
When the son of some resident in the region was born in this city, it was said jokingly that he was a “loony” or “had problems”. So, being a “patient” of the nursing home in this city or even a PCC “user” was not a condition to be considered a “loony” among the residents of the region, just being a native of that city was enough. However, among the city’s residents, someone was designated as a “loony” or “grease burner” only after having been a “patient” of the nursing home or, eventually, having been a “user” of the PCC too.
Unlike the nursing home, situated on the outskirts of the city, the PCC was located in one of the city’s central squares, giving greater visibility to its patrons. However, while only a few of the city’s residents were patients of the nursing home, many of them were users of the PCC, which had enrolled more than 2% of the city’s residents (5 thousand of the 200 thousand residents), including José, Gerson and João.
Although José had never been a patient at the nursing home, he had been committed to a PH. He was a resident and native of the city, having attended the only two private psychiatric clinics in the city up until the year 2000. He attended the PCC during the field work, where he was diagnosed in a medical consultation as having a bipolar disorder. This user of the health network, and ex-intern of a psychiatric institution, began showing signs of having “mental problems” when he was about 17 years old, and living with his parents and siblings. He remained in psychosocial care in the area during the period of fieldwork, between 2007 and 2010, without ever having gone through a single period of internment.
José spoke about his process of inclusion as a PCC user, his agreement to participate in occupational therapy activities (crafts, music, rides) from the beginning, and which had been instrumental in keeping him in this establishment. From the moment he attended regular individual and group activities at the PCC he became defined as a “customer” and not just a “user” by the health professionals. He gave up going to one these activities after having a strong reaction to the gaze of the passersby when he played guitar in public in the company of other PCC users. From being discreditable he had become discredited2222 Goffman E. Estigma: a manipulação da identidade deteriorada. São Paulo: Brasiliense; 1990., making it clear to the other inhabitants of the city that he could also be considered a “loony”, although in the region the mere fact he was born in this city already put him under this risk, and within the PCC he was considered a “customer” in a “social rehabilitation” process.
José made a distinction between himself and the other users based on the degree of ability in carrying out certain tasks, not dangerous ones - as in the case of many residents - or chronic ones
- as for some professionals. Only one other “customer” became his companion for walking in the city streets: Gerson. He remembered the times when he received this “colleague” in his house and was received by him too, noting that the other had made him a sandwich, as if emphasizing the skills of being a “friend”.
Gerson was older than José and lived with his father in an apartment, after having lived in his own home with his wife and children, having been the owner of a “shop” in the city. He told me in an interview that he had been interned in other States in Brazil, as a way of referring to the fact of having been a patient in psychiatric hospitals so many times that he had forgotten exactly how many, and had been interned in both the city’s nursing home and the HP, of which a few times in the latter during the period of fieldwork. He knew the PCC professionals from encounters outside the network premises, such as during his participation in political parties and campaigns, and had made both friends and enemies in these situations: one of the PCC professionals accompanied him at rallies, and he maintained friendly relations with him; on the other hand he approached one of the PCC professionals at a party and tried to seduce her. When this failed he began to offend her, so much so that the episode was included in the agenda for the PCC team meeting and also in the network supervision process.
Thus, this former patient of the nursing home and the HP, a user and a customer of the PCC, also came to be seen as a “clinical case” by the PCC health professionals, because of both the “trouble” with one of them in addition to other episodes where he had repeatedly threatened the public order: a resident filed a complaint with the police against him for attempted rape. The health professionals were alarmed by both events and thought about referring him to a hospital for custody and psychiatric treatment during one of the supervisions. However the final decision was to keep him in psychosocial care and help him so that he could defend himself in the legal process as in the case of any other citizen. On this occasion, his diagnosis was the subject of debate, and switched between a “personality disorder” - as the PCC team saw him - and a “mood disorder” - as the supervisor suggested he should be described.
During the fieldwork, with the exception of Gerson, none of the 10 users I interviewed was admitted to the HP or to any other psychiatric internment institution. Similarly to Gerson, José had spent some time at the HP, but only on one occasion. Differently from Gerson, during the fieldwork, José was mot treated as a “clinical case” during the PCC team meeting nor in the network supervision, thus not becoming a subject of discussion among the establishment’s professionals. As a result, José was certainly a network user and seen as a “customer” by the PCC professionals such that he participated in the weekly activities of occupational therapy, while Gerson was a regular patient of the HP, user and client of the PCC and, which should be emphasized here, also a “clinical case” for the network by virtue of being the subject of discussion at both the PCC team meeting and the network supervision, having previously been a “patient” of the nursing home. Although thousands of city residents were enrolled at the PCC and therefore could be considered “users” of it, hundreds of them frequented the premises and dozens of them were called “customers” by the health professionals, few of them having been “patients” of the nursing home. Being considered a “clinical case” in the network, and not being just a PCC user or customer, made the person the subject of regular reviews by the PCC team members, though not necessarily among the city’s residents.
This “clinical case” in the PCC considered himself to be someone very involved “in politics,” saying this with pride: “I’ve always campaigned for the Silvas...”. Gerson was not viewed as a “loony” by most residents. Unlike Gerson, José had no involvement in political activity nor did he participate in “parties”, staying at home most of the time. José was a user who attended monthly medical consultations and was a PCC “customer” going to weekly therapy group meetings, at which time he played guitar in the square in the company of his colleagues, with a fear of being labeled as a “loony”. Unlike Gerson and José, João was pointed out on the street as being a “loony”.
João had been admitted to the nursing home as had Gerson, though, unlike Gerson and José, he had never been in the HP. Also differently from Gerson and José he had been a user of an UBS before being forwarded to the PCC, while in the former he had been diagnosed as “epileptic” in the latter he was considered “schizophrenic”. In this transition from one network establishment to another, he was a clinical case that was discussed at the PCC team meeting. João went to the PCC almost every day and was referred to as a “customer” by the professionals, not as a “user”. João was older than Gerson and lived with his mother, like José, in a house lent by a brother-in-law. He used to listen to “loony jokes” at home, which amused him greatly, but he complained of the fact of being “called a loony in the street”, something that really bothered him. That is, he was annoyed and amused at the same time with the use of the expression “loony”, since he was seen in this way by the city residents while at the same time he enjoyed the openly derogatory comments about people who were viewed in this way.
“There I stood out!” João told me during one of these visits, after having shown me a tape recording of a radio program in which he was mentioned by the respondent, his brother. Listening to tapes and CDs, amusing himself with live recordings of comedy shows - the “the loony jokes” - and many different types of music - especially “forró” - was João’s most common activity when he was at home. The interview with his brother took place because of the following occurrence: a bar in which João and his mother worked had been robbed and João’s brother, the bar owner, was telling how the robbery had taken place on his business premises that had the same name as João’s nickname.
João used these and other expressions - such as “enhance” - to refer also to some activities he carried out as a “client” of the PCC: the therapeutic group, at which he rarely failed to appear; the Association for Users, Relatives and Friends of the PCC, through which he had became an activist in the anti-asylum cause, even giving lectures at the university on the subject; the distribution of the PCC newspaper on the streets, an activity he carried out voluntarily and without receiving any compensation, although he had been offered a monetary amount.
When he spoke about the times that he had lectured and distributed newspapers, João also used the expression “There I stood out”, although in this last case there were situations where someone called him “loony”. Thus, João often said “I enhance” or “I stood out” to refer to moments when he was publicly acknowledged, in activities where he acquired visibility in the city. His nickname came, he said, from the fact of holding in his hands a “puppet” that “honked”, when he was behind the counter at the bar, in order to deal with customers who annoyed him. When he felt “bitten” or felt “pricked” by someone, he pressed the puppet and made the sound of a car horn echo around the establishment. Possibly, he also was aggressive with the customers who, he said, “fight over a glass of rum [cachaça]” and tried to cheat him when it was time to pay the bill.
However, his nickname also had another use and meaning in the region where this ex-intern of a psychiatric institution lived. While he was among his relatives, I heard them say several times that a certain resident was a “troublemaker”, something that could either be seen as a compliment or a criticism. I heard it so often that I asked them what it meant: “puppeteer” meant a “party-goer”, but also someone who “causes trouble” and “gets into fights,” someone who likes to party and have fun, and “put a puppet in” is an expression used to refer both to causing trouble as well as organizing parties. After this I checked in the dictionaries distributed to tourists and found the expression “put a puppet in” exclusively defined as causing trouble, thus making “puppeteer” a synonym for “troublemaker”. João kept the bar’s business card on him, and showed it to me during one of my visits to his home. He liked to be called by its nickname and was proud of the fact that his brother had used it to name his bar.
Thus, this PCC client who had already been a UBS user and a clinical case for discussion at the team meeting, and a patient at the nursing home, who was identified as a “loony” in the city’s streets and had received a nickname related to the expression “troublemaker” due to his unusual behavior at the establishment where he worked, both because of the fright he gave the customers by honking his horn or with his aggressive behavior and fighting. In this transition from patient to story, João became one of the symbols of the anti-asylum cause, at the same time he gave his nickname to his brother’s bar.
João helped me enter the world of the city’s nicknames, moral categories that were being established and sometimes competing with the administrative categories such as “patient”, “user”, “customer” and “clinical case”, as well as the scientific categories of “epilepsy” and “schizophrenia”. A link between having a mental disorder and a having a nickname was being built up in this way until another element appeared in conversations with this ex-intern: having a given surname.
João’s grandfather was from the Neves family. One of the city’s streets had been named after him, a fact that was published in a newspaper when he passed away. João spoke of his grandfather, father of his mother, with pride, differently from the view of his mother. According to her, her brother-in-law, whose surname was “Batista”, was a “moorhen”. When asked about this nickname, she explained the reason for her grudge against her father: João’s mother thought that the Batistas “talked too much”, the Silvas were “all gossipers” and the Neves were “all ignorant” According to her, the origin of João’s “problem” lay in this “ignorance” because he and his father had “fought” many times and, after the last conflict, João left his house to go to the nursing home. She then separated from João’s father and went to live in her father’s house. She ended by saying that João was both “Neves” and “Silva.” João defended himself from this stereotyping based on an association between behavioral traits, surnames and nicknames, by saying that his mother liked to “chat”, but was then accused by his mother of being a “snitch”.
So, participating in the daily life of João’s home and the city in which he lived led me to note that some of the city’s “loonies” were in fact rather famous, receiving nicknames, they were intrinsically linked to the value system of behaviors of the residents of the State: anyone who caused a lot of trouble on the street could be considered a “half-loony”, although causing trouble itself - “put a puppet in” - was not considered to be reprehensible per se. Thus, João was a patient in the nursing home and was more than just a “user” of the PCC, being considered a “customer” during the period of fieldwork, and prior to this he was a “clinical case” discussed by health professionals at the team meeting, he disliked being called a “loony” in the street and enjoyed having fun with “loony’s jokes” at home. If José was not mentioned at the PCC team meetings - just a “customer” and more than a “user” - and Gerson was and quite often - making him a “clinical case” - then João, besides being a “customer” for the professionals, was a matter of discussion among the city’s residents, although not an subject of concern on the part of PCC team: he was a “story” and not a “clinical case”.
Duarte’s classical study2727 Duarte L. Da vida nervosa nas classes trabalhadoras urbanas. Rio de Janeiro: Zahar Editores; 1986. on illness and social identity presented a framework under which the various accusations of mental illness among the urban popular classes could be understood: at one extreme of a continuum, qualified as positive, those accused of having lived a spiritual experience; at the other, seen as negative, those being made a spectacle of; among them, people considered to be possessed, going through a nervous breakdown or being insane. This framework is based on the greater or lesser degree of responsibility and consciousness attributed to the accused, those possessed being considered less aware of their actions than the bad, the insane being seen as less responsible for their actions than those having a nervous breakdown.
Based on the study of the transition between patient and story in the moral career of former psychiatric patient, who bore surnames and nicknames that counted as much as having a mental disorder in the management of his stigmatized social identity, I noticed a peculiar relationship between illness and social identity. Basically, the ex-interns of the city’s nursing home had three distinct destinations: a legal case of justice which led to the closure of the city’s nursing home, a clinical case for discussion at PCC meetings and a story that joined the anti-asylum cause.
Other possible outcomes for the moral career of ex-interns of psychiatric institutions were created as a result of the anti-asylum movement, those of the activist and the artist demonstrating that people interned in asylums do not necessarily face only a horizon of declining status. I believe that this was also the case of the stories presented here, in which the levels of publicity and visibility were more relevant to understanding the relationship between illness and social identity than the levels of consciousness and responsibility.
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- Publication in this collection
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09 Dec 2013