Abstract

In the light of new challenges posed to processes of deinstitutionalization by Brazil’s mental health reform, this study explores the production of existential territories in the city by recording the experiences of users of a psychosocial care center in São Paulo. Using methods based on social cartography, including the creation of affective maps and accompanying participants on routes around the city, it was possible to understand how participants weave multiplicities of living territories and networks throughout their itineraries, breaking free from places instituted by the asylum logic and cementing the principles of deinstitutionalization in the micropolitics of their everyday lives. During this process, the participants’experiences stimulated reflections on the kind of cities we want to build, collectively reinventing urban territories, making them more sensitive and permeable to instituting forces and creating new ways of living together and producing differences. At the same time, they stimulate reflection on how these singular experiences of the city can be incorporated into and enhance the therapeutic itineraries of clinical practices based on the “logic of territory”.

Key words:
Mental health; Deinstitutionalization; Mental health services; Cities; Public health

Introduction

Historically, the experience of madness, like other deviations from constructed normality, has involved long periods of isolation - spatial as well as social and symbolic¹. By defining madness as “mental illness” - a specialty of psychiatry and idea that became hegemonic in the 19th century - psychiatric diagnosis was able to deny a subject’s right to freedom. In the context of perverse modern methods of “treating” madness based on psychiatric knowledge, so-called “mad” people were admitted to asylums - “desertified and desertifying territories” - and subjected to numerous violations of human rights².

The legal right to care in liberty is a recent collective triumph of the anti-asylum movement. Brazil’s mental health reform has made great strides, such as the creation of psychosocial care centers (PSCCs) as substitute mental health services in the 1980s and Law 10216/2001, which “deals with the protection and rights of people with mental disorders and reorients the mental health care model”³. New questions have arisen from these achievements relating to the process of deinstitutionalization of madness. PSCCs and other measures face the daily challenge of upholding these rights, constituting “day outpatient care services operating according to the logic territory”⁴4 Brasil. Portaria nº 336 de 19 de fevereiro de 2002. Estabelece CAPS I, CAPS II, CAPS III, CAPSi II e CAPS ad II. Diário Oficial da União. 2002 fev..

Deinstitutionalization is therefore a broader challenge than dehospitalization and the rejection of the asylum as a total institution and physical space. The asylum logic and culture prevails in the institution of madness like an “arsenal of knowledge, truths, norms and instituted places about and for madness and the mad”⁵5 Paulon SM, Trepte R, Neves R. Todo dia se faz tudo sempre igual...? Recortes da desinstitucionalização da loucura Brasil-Itália. Mnemosine 2013; 9(2):180-198., cutting across the whole social fabric. In the symbolic dimension of territory, promoting the effective implementation of Brazil’s mental health reform becomes more complex, since outside the walls of the asylum the city continues to erect symbolic walls when it comes to ways of relating to madness¹1 Saffiotti A. Atenção em saúde mental a partir da noção de território: uma reflexão sobre os Centros de Atenção Psicossocial [tese]. São Paulo: Universidade de São Paulo; 2017..

This study, focusing on dimension territory-madness-deinstitutionalization, was conducted in São Paulo, Latin America’s biggest city and grand example of large urban centers as megamachines producing subjectivities and full of contradictions. In these centers, “both territory and place are schizophrenic, because on the one hand they embrace the vectors of globalization, that establish themselves to impose their new order, and, on the other, a contra-order is produced within [these centers], because there is an accelerated production of the poor, excluded and marginalized”⁶6 Santos M. Por uma outra globalização (do pensamento único à consciência universal). Rio de Janeiro: Record; 2001. (p. 114).

According to Félix Guattari⁷7 Guattari F. A restauração da cidade subjetiva. In: Caosmose: um novo paradigma estético. Rio de Janeiro: Editora 34; 1992. p. 169-178., in this constituent tension there is a clash between the State form, which represents the vectors of totalization, homogenization and stratification of differences, and city form, where vectors of dispersions and fluxes of singularities are played out. In the city form, the power of heterogenesis persists, giving rise to the concept of subjective city, which prompts us to think of the city as a plural territory in which multiple singular cities coexist from the point of view of each of its inhabitants⁸8 Paulon SM. Quando a cidade "escuta vozes": o que a democracia tem a aprender com a loucura. Interface 2017; 21(63):775-786..

These numerous subjective cities are formed from singular fluxes of connection in which each subject weaves their own existential territories: “spaces built from material and affective elements from the surrounding environment, which, expressively appropriated and mediated, end up constituting places to live”⁹9 Lima EMFA, Yasui S. Territórios e sentidos: espaço, cultura, subjetividade e cuidado na atenção psicossocial. Saude Debate [periódico na internet]. 2014 [acessado 2020 out 29]. 38(102):593-606. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext &pid=S0103-11042014000300593&lng=en.
http://www.scielo.br/scielo.php?script=s... (p. 599). The possibility of inhabiting the city as a territory of social and affective exchanges unfolds in these spaces, weaving living networks that are capable of sustaining existence.

Through the mediation of heterogeneous components, each subject etches out contours and meanings, constituting centers of territorializing significance⁹9 Lima EMFA, Yasui S. Territórios e sentidos: espaço, cultura, subjetividade e cuidado na atenção psicossocial. Saude Debate [periódico na internet]. 2014 [acessado 2020 out 29]. 38(102):593-606. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext &pid=S0103-11042014000300593&lng=en.
http://www.scielo.br/scielo.php?script=s... and building unique dwellings in their existential territories, like nests that sustain and embrace life, protecting it from chaos. These nests harbor the possibility of taking new flights that will come to reconfigure their unique rhizomatic networks, which are made processual and changeable by a “desire for wings”¹⁰10 Pelbart PP. A nau do tempo-rei: sete ensaios sobre o tempo da loucura. Rio de Janeiro: Imago; 1993. (p. 122), each subject constituting a nomad and protagonist of their weave.

The right to care in liberty for subjects who are considered mad raises the possibility of the right to the city as a right to this construction. However, the continued imposition of abandonment, stigma and various types of inequalities by the city in the face of the experience of madness stands in the way of the realization of this right. This violence brings the threat of new chronicities, reactivating illnesses in which the experience of “deterritorialization” leads to “reterritorialization” in very rigid or closed territories, or deterritorialization itself becomes the subject’s long-term home¹⁰10 Pelbart PP. A nau do tempo-rei: sete ensaios sobre o tempo da loucura. Rio de Janeiro: Imago; 1993..^.

According to Pande and Amarante¹¹11 Pande MNR, Amarante P. Desafios para os Centros de Atenção Psicossocial como serviços substitutivos: a nova cronicidade em questão. Cien Saude Colet 2011; 16(4):2067-2076., there is a risk of creating a relationship of dependency between mental health services and service users, renewing the asylum logic, centered on the knowledge of health professionals, in rigid closed health facilities circuits, thus continuing to suppress the possibilities of broader exchanges and free movement. By closing these networks, our health institutions also become “chronified”. In the same manner, chronification also makes our cities sick, as they harden into fluxes of homogenization, closing up to encounters with otherness.

In light of the challenge of deinstitutionalization, faced simultaneously by subjects, health services and cities, this study explores territory as “a relational space pulsing with life”⁹9 Lima EMFA, Yasui S. Territórios e sentidos: espaço, cultura, subjetividade e cuidado na atenção psicossocial. Saude Debate [periódico na internet]. 2014 [acessado 2020 out 29]. 38(102):593-606. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext &pid=S0103-11042014000300593&lng=en.
http://www.scielo.br/scielo.php?script=s... (p. 598) from the perspective of mental health service users living in this space. The study aims to allow their city itineraries to appear in and broaden the therapeutic itineraries of clinical practices based on a “logic of the territory”, and experiment in which ways they can bring movement to the debate about the right to the cities that we want to build.

Methodology

The data were “gathered”¹²12 Passos E, Kastrup V. Sobre a validação da pesquisa cartográfica: acesso à experiência, consistência e produção de efeitos. Fractal Rev Psicol 2013; 25(2):391-413. - understood as the act of producing worlds, as opposed to data “collection”, which extracts information from a prior and static world - between October and December 2018 in a PSCC in the center of São Paulo. The study protocol was approved by the research ethics committee at the Institute of Psychology, University of São Paulo (CEP-IPUSP). The study participants are users of a PSCC where the researcher works as a psychologist and is undertaking a post-graduate course as part of a professional development program (São Paulo State Department of Health).

Tools from cartographic investigation were used, a method that is suitable for accompanying processes and gaining in-depth insight into experiences and existential territories¹³13 Passos E, Barros RB. A cartografia como método de pesquisa-intervenção. In: Passos E, Kastrup V, Escossia L, organizadores. Pistas do Método da Cartografia: Pesquisa-Intervenção e Produção de Subjetividade. Porto Alegre: Sulina; 2015. p. 17-31.^,1414 Alvarez J, Passos E. Cartografar é habitar um território existencial. In: Passos E, Kastrup V, Escossia L, organizadores. Pistas do Método da Cartografia: Pesquisa-Intervenção e Produção de Subjetividade. Porto Alegre: Sulina; 2015. p. 131-149.. This method also provides a framework of ethical, aesthetic and political principles that cut across the methodological tools, such as the importance of attentive dedication, readiness and emotional openness to the experience¹⁵15 Rolnik S. Cartografia Sentimental: Transformações contemporâneas do desejo. São Paulo: Estação Liberdade; 1989.. The PSCC users’ city itineraries and existential territories were experienced and registered, exploring how their unique experiences contribute to processes of deinstitutionalization of madness and the construction of the cities we want.

Three individuals were invited to participate using the following criteria: attends the PSCC at least three times a week; has a disabled person’s travel pass, which provides free travel on municipal public transport, thus ensuring that study participation did not incur costs; affiliation - defined by the National Primary Care Policy as the “construction of a relationship of affection and trust between the user and health worker […]”¹⁶16 Brasil. Ministério da Saúde (MS). Política Nacional de Atenção Básica. Brasília: MS; 2012. (p. 21) - between the participant and researcher as a PSCC member of staff; and signed an informed consent form.

We conducted semi-structured interviews¹⁷17 Renault L, Passos E, Silva A. Da entrevista de explicitação à entrevista na pesquisa cartográfica. In: Amador FS, Barros MEB, Fonseca TMG, organizadores. Clínicas do Trabalho e Paradigma Estético. Porto Alegre: UFRGS; 2016. p. 61-77., recorded using affective maps of the city¹⁸18 Augusto DM, Feitosa MZS, Bomfim ZAC. A utilização dos mapas afetivos como possibilidade de leitura do território no CRAS. Est Inter em Psicol 2016; 7(1):145-158. drawn by each participant on A2 sheet of paper. The trigger questions explored which places the participants visited on a daily basis, points of reference in the city, and places of memories, relations and affects, which were accessed and updated throughout the course of the interview. We also investigated itineraries, routes and wanderings between the places mentioned, encouraging the participants to record these items on the map.

At the end of the interview, the researcher asked each participant if she could accompany them on a route of their choice, chosen based on its importance in their everyday routine. Images of the participants’ itineraries were also created on a map of the city using Google’s My Maps, showing the approximate location of the participants’ addresses to protect their privacy. Notes of the meetings were also made by the researcher in a field diary.

The participants’ names were replaced by fictitious names chosen by the participants. Street and personal names were also excluded from the maps so as not to expose the participants’ identities.

Results

Marcos

Marcos, 59, is white, tall and friendly, constantly greeting other PSCC regulars in the corridors. He has used the service since he moved to São Paulo 10 years ago, being referred to the PSCC from his home town. He attends the center almost every day and can generally be found in the garden close to the coffee table. He also attends the assemblies held at the PSCC and museum visits organized as part of arts workshops. The first thing he draws on the map is the route from his house to the PSCC (Figure 1). The drawing then spreads out in all directions, showing several places and routes and Marcos worries that “they might not fit on the sheet” (Marcos’ own words).

Since moving from T., a town in the state of São Paulo with less than 50,000 inhabitants, he has been sharing an apartment in the city center with his brother, helping to pay the rent with his monthly income of a minimum wage from a disability support pension. He says he really likes São Paulo, which he describes as “a big megalopolis with everything”, but he refers to the town where he was born as “my town” (Marcos’ own words). He visits his home town once a year, staying with relatives, and records the journey on his map: São Paulo exit, represented by buildings; the bus on the road; and arriving at T., depicted by tall trees, the church in the main square, and himself walking open-armed towards the church.

Most of the records are concentrated in the city center, close to Marcos’ home. Ibirapuera Park, further away from his circuit, appears as a space that he does not go to regularly, but contains important memories of a picnic he went on with PSCC users and staff. He also mentions that he walks the streets a lot by himself when he is happy - when he is not feeling well he goes to the PSCC. Marcos’ walks play a central role in his everyday life and are planned and follow a routine. Every day he chooses a predefined route, whose streets and distances he describes unhesitatingly in exact detail.

The following description of the route to the shopping mall is an example: he leaves the PSCC every Tuesday and Thursday after coffee is served at 10am. After applying sunscreen and going to the bathroom, he walks to the shopping mall. He goes into the mall and looks in the store windows until it is time to go back for lunch, which is served in the PSCC canteen at midday. He organizes his routine around the center’s routine activities. The center’s schedule and group activities make time a factor that helps him locate himself and feel a sense of belonging in the spaces he frequents, creating boundaries and territories.

It is the route to the shopping mall that Marcos chooses to take with the researcher. Although he has been going to the mall for years and mentions that he especially likes this route because he can marvel at the stores, it is during the accompanied visit that he makes what he says is his first purchase in this space: a pair of flip-flops. Marcos’ relation with territories of consumption are a central part of his experience, revealing contradictions in ways of accessing circuits of financial exchange, as shown by the following extract from the field diary:

He calls me over to a Rolex watch and jewelry store, pointing out the number of digits of the prices. […] I comment on the danger of being mugged wearing such expensive items, to which Marcos replies ‘these people only drive, they don’t walk on the street like us’. I ask him what he would do if he was really rich: I think I’d have a Rolex, hire a private shrink and stop going to the PSCC. Surprised with his answer, I mention that various psychiatrists who work at the PSCC also have private clinics and ask him why he would choose to pay for a service that he can get free on the SUS. Laughing, he says that the psychiatrists at the PSCC are good and he would like to hire his current doctor privately […].

Grilo

Grilo is a tall, thin 47-year-old man. He likes to wear smart clothes because he says that being “well dressed” is important to “give a good impression” (Grilo’s own words), avoiding negative prejudgments that says he receives because he is black, poor and has no fixed abode. Grilo has been living on the streets for the last four years, since family conflict led him to leave the place he calls “my home I miss”, which he draws on the map (Figure 2). He sleeps in temporary homeless shelters in the center of São Paulo, reserving a place on a daily basis.

Grilo works at the Benedito’s Stop Solidarity Economy and Culture Bazaar, which promotes social inclusion through employment and culture. Based on a schedule defined on a weekly basis by the workers, he works an average of three days a week. He is organized and completes his tasks with assiduity, earning between 120 and R$200 a week, which is his only source of income. He also participates in “Trecho 2.8”, a creative and communications project linked to the Benedito’s Stop Solidarity Economy and Culture Bazaar (shown on his map) that targets vulnerable persons¹⁹19 Trecho 2.8. O Projeto. [acessado 2018 nov 15]. Disponível em: http://www.trecho2ponto8.com/sobre.
http://www.trecho2ponto8.com/sobre... .

Grilo goes to the PSCC mainly when he is not working at the bazaar/project. He has a friendly relationship with the service users and staff, is a member of the football team and sings rock and punk songs at the parties. He is a fan of rock and punk music, which is why he goes to other towns in São Paulo (shown on his map) to go to “good rock bars” with friends. The PSCC is the last place he draws, mentioning that it is a place he can go to when he is feeling sad.

Other things he does when he feels sad include: walking the streets by himself, visiting the bazaar, and going to the football stadium in Barra Funda, where he meets friends to watch games from outside the ground without buying a ticket. He complains about lack of money and mentions other places he goes to that offer free leisure: “bars in Mooca, forró at the MASP (São Paulo Museum of Art) on Sundays, Avenida Paulista when it’s closed and open to pedestrians” (Grilo’s own words). He begins his map with the daily route to work, starting with public transport and ending at the Bazar/Trecho 2.8. It is the route between the PSCC and these spaces that Grilo chooses to take the researcher on.

The visit shows just how important these spaces are from an affection point of view for Grilo, who calls all the people in these places his friends. At the Bazaar, he shows the researcher around and introduces her to the other workers, recounting his experiences in the place. Then takes the researcher to the Trecho 2.8 offices. On the day of the visit, six members of the project team were discussing a script for a radio soap opera.

The main character of the soap opera is a dog that runs away from its owner “because she wants to boss him around all the time” (Grilo’s own words). While on the run, the dog dodges danger, avoiding being run over by a car or being caught by the stray dog truck. Helped by a friendly bird, he comes to a square where he finds the “good old man”, whose lines are written and acted out by Grilo. This character, who is homeless, like many of the people in the project, feels sorry for the dog and invites it to live with him in the square so they can keep each other company, an invitation that the dog happily accepts.

At the end of the interview, Grilo says that “São Paulo is a fascinating city”, writing “SP Fascinating” at the top of the sheet as a title. His fascination with the city, which he describes as “a beautiful city, with beautiful people, cold and drizzle”, also has its contradictions, as shown in the script of the radio soap opera, which complexifies the concept of liberty. As a result of abandonment and the lack of work, a fixed address and a family support network, Grilo, like the character in the soap opera, also moves intensely between the offerings and inequalities of the central area of the city and the encounters that this provides him. In these wanderings over the years he has built himself a network of territories and relations in a city center in which he says he feels very welcome, and where he moves around with safety, fluidity and the autonomy of who belongs.

Carolina

Carolina is 46, black and originally from Senhor do Bonfim, Bahia. She moved to São Paulo with her family when she was 18, and has never felt like going back to visit her hometown. She has children, but neither has custody nor is allowed to visit them, “because I wasn’t able to look after them” (Carolina’s own words). Some of her children are in care and others were adopted. Without a source of income, she wanders around town mainly in search of social assistance, such as her visits to the Penaforte Mendes Day Center and Canteen, drawn on her map (Figure 3), where she receives meals and clothing donations.

Carolina has faced various forms of precarious living conditions and irregular accommodation in “favelas, pensions and hostels” (Carolina’s own words), resulting in a permanent state of transience. She is currently living in a building occupied by 60 families from a local housing movement. She joined the movement in search of housing, recommended by an ex-colleague from a recycling cooperative that she worked in some years ago. The movement - which involves daily meetings that she says feel like a burden sometimes - is also an opportunity to experience community and active political mobilization against inequality.

Married for 20 years, Carolina says that her husband accompanies her almost everywhere, justifying this with his displeasure with the looks she gets from men in the street. The only time she goes out by herself is her morning visits to the PSCC - her husband comes to meet her and walk her home when she leaves - and to buy cigarettes for her husband. She mentions spaces that she likes but stopped going to five years ago because of her husband, such as a park (Parque da Juventude) and friend’s house. Not having seen her friend (P.) since she stopped going to visit her, she stays in touch by cellphone, making the phone a tool for circulating affects in territories beyond the restricted domestic territory.

The Solo Sagrado (sacred ground), a religious park in the south of the city, is another place on the map that is outside this circuit, described as a territory of memories of precious social and affective exchanges. She has only been to the park once, 10 years ago, with a group of women that she was part of, with whom she “was able to share life and problems” (Carolina’s own words). The PSCC also appears to be a territory that provides possibilities of sharing, which is why she drew it in “green for hope”, as the following excerpt from the field diary illustrates:

Carolina repeatedly states that “São Paulo is a mother”, a maternal figure that welcomes and cares for everyone: “It’s marvelous, it has everything. Here I get given clothes in the Penaforte; in Bahia I would be wearing clothes with holes in them. There’s work, life is better […] It’s the best city” (Carolina’s own words). Her remarks express gratitude for the possibilities of survival that she finds in the city, while at the same time confirming her vulnerability, due to the restricted access she has to these offerings. They therefore reveal that the city she describes as “maternal” strays from this hegemonic and insufficient ideal of motherhood - just like Carolina’s own story, which is alive with contradictions in an experience of motherhood crisscrossed by large burdens of guilt and yearning.

Carolina chose the route to take the researcher on: from the PSCC to her home. She was enthusiastic about the researcher visiting her home, although “there’s no stove to make a coffee” (Carolina’s own words). The visit was cancelled, however, due to a concern expressed repeatedly by C.: she was afraid of bothering her husband, who would have to accompany them. This could have a disruptive effect on her relationship and life, which could have had ethical implications for the study.

Discussion

Each of the three participants were aged over 40, did not have formal employment and had a monthly income of up to a minimum wage. Two were in a highly vulnerable housing situation. The lack of a family support network and treatment for long-term mental health problems, the typical profile of PSCC users, mean that these individuals are exposed to high levels of psychosocial vulnerability. The effects of racism can also be observed²⁰20 Machado K. O racismo em três séculos de escravidão. EPSJV/Fiocruz; [acessado 2020 out 19]. 2018 Maio 11. Disponível em: http://www.epsjv.fiocruz.br/noticias/reportagem/o-racismo-em-tres-seculos-de-escravidao.
http://www.epsjv.fiocruz.br/noticias/rep... , with the two most vulnerable participants being black. The itineraries of the only female participant are directly restricted by her spouse. Issues of gender, race and social inequality are therefore present in these existences and remind us that it is impossible to think of madness without considering these determinants.

All participants were engaged in the study and showed keen interest and dedication. After the invitations, they constantly asked how the research was progressing and about the quality and usefulness of their contributions, taking ownership of the role of co-researchers. These results, which illustrate the inseparability of understanding and reaffirming in the cartographic method¹²12 Passos E, Kastrup V. Sobre a validação da pesquisa cartográfica: acesso à experiência, consistência e produção de efeitos. Fractal Rev Psicol 2013; 25(2):391-413., demonstrate how the very act of researching together can set in motion existences by recognizing the importance of each subject’s narratives about themselves, their life and the city they inhabit.

With regard to the routes in the streets and the agreements made with the researcher for the realization of the study, the participants were imbued with the sense of responsibility of a host in their own territories. In this regard, as health professionals, the generosity of these subjects reminds us of the importance of letting ourselves be guided, keeping in pace with and following the paths of those we are accompanying and tracing the lines that are projected from the path together. Creating unique affective maps showed itself to be a powerful tool, recovering the untamed multiplicity of the territory where countless subjective cities cohabit, in contrast to traditional maps, which homogenize and control urban fluxes.

Figure 4 above, shows the participants’ itinerary network on traditional maps of the city and state of São Paulo. The results show that the streets are the setting of agency in this production, harboring the possibilities of dispersions and fluxes of singularities and constituting new planes of subjectivation as spaces of encounters and composition between otherness, where cities become plateaus - zones of continuous intensity- in which territories are woven²¹21 Deleuze G, Guattari F. Mil Platôs. Capitalismo e Esquizofrenia. Rio de Janeiro: Editora 34; 1980..

Public spaces are a central part of the participants’ maps, showing themselves to be important offerings, especially for those in financial difficulty. Strengthening the habitability of these spaces, turning them into real collective territories that promote sociability, free movement, coexistence and the production of differences, rejuvenates the city and enables the constitution of rich, shared and single dwellings, expanding networks of spaces and relationships in which it is possible to live.

The results also show that vectors of violence, marginalization and the stratification of difference persist simultaneously with these multiplicities in São Paulo. Considering the contradictions of our big cities - which, as the participants’ accounts show, offer everything, but not for all - strengthening deinstitutionalization also means investing in the collective construction of reinventions of urban territory, making it more sensitive and permeable to instituting forces, producing discontinuities in its rigid forms:

The logic of global capitalism, which give precedence to economic growth as a synonym of development, compartmentalizes the city into spaces of production and reproduction of work force and the streets are mere passages. However, keeping pace with the human time of subjective cities and their itineraries invites us to decelerate this logic, and imagine territories guided by the pace of our individual and collective stories. The concept of right to the city is no longer understood merely as access to public, State-offered facilities and services, but rather becomes underpinned by the protagonism of its inhabitants: the right to the city as open infrastructure, to be disputed and transformed by what we collectively defend.

In this construction, the process of deinstitutionalization itself proves to be a deterritorializing experience for the city, stemming from an inevitable coexistence with deviant subjectivities, previously confined to asylums and today inhabiting new territories and social roles at each new day. As a creative and disruptive force and experience of radical otherness, madness confronts the city with the need to question its own imprisoning prescriptions. “Maddening” cities, believing in its power of heterogenesis, and reinventing ourselves in new ways of living with differences, is a civilizing gain for all:

The investigation of existential territories at the micro-political level reveals “the places where existences pierce institutional walls […] the place of the processes of encounters and shifts in power relations”²²22 Merhy EE, Gomes MPC, Silva E, Santos MFL, Cruz KT, Franco TB. Redes Vivas: multiplicidades girando as existências, sinais da rua. Implicações para a produção do cuidado e a produção do conhecimento em saúde. Divulg Saude Debate 2014; (52):153-164. (p. 148). When it comes to the city, deinstitutionalization is cemented in the richness of these living networks of existential connections in which social and affective exchanges take place. These networks, woven in the everyday lives of these subjects outside the walls of health services, continually challenge and transgress asylumesque concepts of processes of institutionalization and chronification, which snare the subjects with the label of illness, exclusion and marginalization.

With regard to our health institutions, which operate either as “institutional networks, […] referring patients, creating rules and disciplining the lives of users; and on the other, singular, rhizomatic networks, built around their protagonism […]”²³23 Carvalho MN, Franco TB. Cartografia dos caminhos de um usuário de serviços de saúde mental: produção de si e da cidade para desinstitucionalizar. Physis 2015; 25(3):863-884. (p. 873), as analyzers of the ethical and political aspects of clinical practice in services like PSCCs, this type of investigation enables us to explore whether or not sharing, belonging, and strengthening of autonomy exist in these spaces, as opposed to asylums, which are places of zero sharing²⁴24 Saraceno B. Libertando Identidades. Da reabilitação psicossocial à cidadania possível. Belo Horizonte: Te Corá Editora; 1999.. In the participants’ narratives, the PSCC appears as an important place that promotes and produces health and life. Within the context of the city, the participants regard the PSCC as a home amongst various homes, each one making use of it in different ways. From this perspective, the PSCC becomes a nest, providing a supportive and welcoming environment for the subjects with their contradictions, without confronting them as crossroads and enabling them to live encounters with others.

The tension between institutional networks and the multiplicities that their users construct and live in their territories calls on us to make health institutions more and more permeable to “life outside”²⁵25 Yasui S. A produção do cuidado no território: "há tanta vida lá fora". Textos de apoio do Ministério da Saúde. Brasília: Ministério da Saúde; 2011., accompanying and supporting users in taking flight. In their multiple existences outside the “walls of the service”, these subjects carry “a living ensemble of strategies, new modalities, ways of creating meaning, producing other networks, other existential territories”²²22 Merhy EE, Gomes MPC, Silva E, Santos MFL, Cruz KT, Franco TB. Redes Vivas: multiplicidades girando as existências, sinais da rua. Implicações para a produção do cuidado e a produção do conhecimento em saúde. Divulg Saude Debate 2014; (52):153-164. (p. 23), which often remain unknown or underutilized by institutional projects.

Final considerations

The methodological tools enabled the study to delve together with the participants into part of the process of production of multiple existences in their city itineraries. The results reveal the richness of being together in territories where the participants are not assigned the label of mad, delirious, slow, chronified, as they are often described in the gaze of the health team responsible for their care; and where they are not restricted to occupying inferior or dangerous positions, due to the stigma of madness, racism or poverty. They move around these territories in many other roles.

In the face of the history of confinement and isolation of madness, while the realization of the right to care in liberty and the right to the city continues to be in process, the living experiences of the participants remind us that that which is instituted is only a fragment of reality - a broad field of possibilities that emerge and establish themselves in a history of struggles, which we are also part of. In the micropolitics of the everyday, in weaving the multiplicities of the territories and networks throughout the course of their itineraries, these subjects are cementing the principles of deinstitutionalization.

Given the contradictions of our health institutions - which unfold in the hardening of these institutions and the possibility of services being constituted as collective territories of the city, guaranteeing these rights - it is important to promote an alliance with service users, supporting them as protagonists of their own existence and care plans. New studies, experiences and practices are needed that promote the movement of health institutions together with users around the city, broadening the therapeutic itineraries of clinical practices based on the logic of territory.

It is also important that the experiences of these subjects inform the transformation of our cities and development of new urban policies that ensure the construction of truly democratic cities with new ways of living together and producing differences. Amidst the clashes and tensions that arise from these contradictions, forming part of the complex field where life is played out, the everyday wisdom of the “multipliCities” - multiple cities and multiple modes of existing, getting around and being - of so-called mad subjects show themselves to be potential antidotes for “chroniCities” - the chronification and hardening of cities and ways of existing - which sicken individual, collective and institutional existences.

Thus, overcoming the isolation that has been historically imposed on the experience of madness - strengthening deinstitutionalization and bolstering the principles of Brazil’s mental health reform - calls on to infect subjects, institutions and cities with a “desire for wings”, implying the construction of territories woven with the raw material of encounters and relations, where life becomes more livable for all. To this end, it is necessary to let ourselves be guided and impregnated with the power of these multipliCities, which ask for passage, pestering and polinating²⁶26 Pelbart PP. Da Polinização em Filosofia. In: O avesso do niilismo: cartografias do esgotamento. São Paulo: N-1 Edições; 2013. p. 371-387. with a gust of wind - or at least the desire to breathe.

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