Abstract

Introduction

Violence involves social, historical, and cultural factors which constitute singular experiences and context transforms. It consists of multiple dimensions which express themselves more or less explicitly, such as the use of force, or as practices of embarrassment or racism, which are less visible. It may involve conflicts of authority, dispute over power, desire for dominion, possession and annihilation of the other, which cannot be understood as an external phenomenon or force but one which is always relational¹1 Minayo MCS. Um fenômeno de causalidade complexa. In: Minayo MCS. Violência e saúde [Internet]. Rio de Janeiro: Fiocruz; 2006 [citado 23 Abr 2021]. p. 12-23. Disponível em: https://static.scielo.org/scielobooks/y9sxc/pdf/minayo-9788575413807.pdf
https://static.scielo.org/scielobooks/y9... .

Violence brings a great emotional burden to those who commit, suffer, and watch it. It is diluted in the social tessitura and public and private relations, always surrounded by moral judgment. It may or may not be approved or considered lawful or unlawful, depending on the society, period, and interests involved¹1 Minayo MCS. Um fenômeno de causalidade complexa. In: Minayo MCS. Violência e saúde [Internet]. Rio de Janeiro: Fiocruz; 2006 [citado 23 Abr 2021]. p. 12-23. Disponível em: https://static.scielo.org/scielobooks/y9sxc/pdf/minayo-9788575413807.pdf
https://static.scielo.org/scielobooks/y9... .

One of the forms with which violence expresses itself is in people’s relationships with institutions and provision of services, such as health care and social and public security, called institutional violence²2 Antoni C, Munhós AAR. As violências institucional e estrutural vivenciadas por moradoras de rua. Psicol Estud. 2016; 21(4):641-651.. Homeless people in an important situation of social vulnerability, often suffer institutional violence and are usually blamed, even if they are victims³3 Silva MLB, Bousfield ABS, Giacomozzi AI, Leandro M. Atribuições de causalidade à violência para pessoas em situação de rua. Estud Interdiscip Psicol. 2020; 11(2):17-39..

In this perspective, we point out, among others, a study with homeless women in Porto Alegre which found that institutional violence, particularly that carried out by public institution workers, has an important relation with the increase in suffering and worsening of vulnerabilities in those lives²2 Antoni C, Munhós AAR. As violências institucional e estrutural vivenciadas por moradoras de rua. Psicol Estud. 2016; 21(4):641-651..

A literature review on research on the homeless pointed out that most North American studies are based on an individualizing perspective, whereas Latin American research stem, to a large extent, from the need of analyses encompassing the multiple dimensions of life⁴4 Mendes KT, Ronzani TM, Paiva FS. População em situação de rua, vulnerabilidades e drogas: uma revisão sistemática. Psicol Soc. 2019; 31:e169056. Doi: https://doi.org/10.1590/1807-0310/2019v31169056.
https://doi.org/10.1590/1807-0310/2019v3... . The authors emphasize that more participative methodologies contribute more widely to the further development of the theme, enabling research to articulate social dynamics and life trajectory aspects.

This study dialogues with a more comprehensive and participatory epistemological perspective and is the result of one of its authors’ doctoral research project. It aims to reflect on the production of care with the homeless in a Psychosocial Care Center Alcohol and Other Drugs (CAPSad) in Salvador, Bahia State, Brazil, from the violence which occurred in this service. This study refrains from interpreting these situations or explain their genesis as if there was a meaning to be seen, rather aiming to understand their production a little more and “bring to light the elements which make up the set”⁵5 Lourau R. Objeto e método da análise institucional. In: Altoé S, organizador. René Lourau: analista institucional em tempo integral. São Paulo: Hucitec; 2004. p. 66-86. (p. 70) of this phenomenon, creating new meanings for these experiences⁶6 Rolnik S. Cartografia sentimental: transformações contemporâneas do desejo. 2a ed. Porto Alegre: Sulina, UFRGS; 2011..

Methods

The research which originated this study used a qualitative and cartographic methodology⁶6 Rolnik S. Cartografia sentimental: transformações contemporâneas do desejo. 2a ed. Porto Alegre: Sulina, UFRGS; 2011. which involved producing a field and data in direct relation with users and workers of this service. The main instrument for collecting empirical material were cartographic diaries⁷7 EPS em Movimento. O Diário Cartográfico [Internet]. 2014 [citado 31 Jan 2020]. Disponível em: http://eps.otics.org/material/entrada-apresentacao/arquivos-em-pdf/diario-cartografico
http://eps.otics.org/material/entrada-ap... which were restored⁸8 Lourau R. René Lourau na UERJ: análise institucional e práticas de pesquisa. Rio de Janeiro: UERJ; 1993. as narratives of situations (or scenes) in monthly meetings with the team of this service between July and December 2019.

Producing the cartographic diaries takes place “inside”⁹9 Slomp Junior H, Merhy EE, Rocha M, Baduy RS, Seixas CT, Bortoletto MSS, et al. Contribuições para uma política de escritura em saúde. Athenea Digital. 2020; 20(3):e2617. Doi: https://doi.org/10.5565/rev/athenea.2617.
https://doi.org/10.5565/rev/athenea.2617... the experience of the field of research. A place to record experiences and encounters, producing multiple outputs (affections and meanings) for these inputs⁷7 EPS em Movimento. O Diário Cartográfico [Internet]. 2014 [citado 31 Jan 2020]. Disponível em: http://eps.otics.org/material/entrada-apresentacao/arquivos-em-pdf/diario-cartografico
http://eps.otics.org/material/entrada-ap... . From this perspective, we emphasize that

Seeking other visibilities and sayabilities from an institutionalist theoretical framework⁸8 Lourau R. René Lourau na UERJ: análise institucional e práticas de pesquisa. Rio de Janeiro: UERJ; 1993.^,1010 Guizardi FL, Lopes R, Cunha MLS. Contribuições do movimento institucionalista para o estudo de políticas públicas de saúde. In: Mattos RA, Baptista TWF, organizadores. Caminhos para análise das políticas de saúde. Porto Alegre: Rede Unida; 2015. p. 319-346., we took violence in the service as an analyzer of care to the homeless¹⁰10 Guizardi FL, Lopes R, Cunha MLS. Contribuições do movimento institucionalista para o estudo de políticas públicas de saúde. In: Mattos RA, Baptista TWF, organizadores. Caminhos para análise das políticas de saúde. Porto Alegre: Rede Unida; 2015. p. 319-346.. Analyzers are “those events which may […] more forcefully bring up an analysis; which make appear, in a single blow, the ‘invisible’ institution […]”⁸8 Lourau R. René Lourau na UERJ: análise institucional e práticas de pesquisa. Rio de Janeiro: UERJ; 1993. (p. 35). Together with a permanent process of implication analysis¹¹11 Coimbra CM, Nascimento ML. Análise de implicações: desafiando nossas práticas de saber/poder. In: Geisler AR, Abrahão AL, Coimbra CM, organizadores. Subjetividades, violência e direitos humanos: produzindo novos dispositivos em saúde. Niterói: Eduff; 2008. p. 143-153., we intensively read the diaries and the transcriptions of the meeting records, producing a narrative from the experience in the field. This process produced two analytical displacements, making visible other elements which cross and affect the production of care.

This research meets the ethical and scientific requirements based on Resolutions no. 510, of April 7, 2016, and no. 466, 2012, of the National Health Council, which regulates research involving human beings. This project was submitted to the Ethics and Research Committee (CEP) and authorized via substantiated opinion number 2,906,748.

Violence in a CAPSad: a first look

The assessed CAPSad is in Pelourinho, a neighborhood in which we find, despite its architectural, historical, and cultural wealth, buildings falling apart, misery, and drug trafficking near its main streets. It is a territory permeated by centuries of slavery, inequalities, and violence¹²12 Fraga Filho W. Mendigos, moleques e vadios na Bahia do Século XIX. São Paulo: Hucitec, Edufba; 1995..

Many homeless inhabitants of the region, its main audience, access this CAPSad. Some have used it for years as a place to rest after a night on the streets, to safely use drugs, coexist, practice body hygiene, and feed themselves, which requires an intense presence of the care team.

Some engage in violence at the service, including verbal and physical aggression, threats, and depredation of the building structure, furniture or materials. Threats and aggressions include those among users and between workers and users.

Violence turns away some users from the CAPSad, many of which worry about the risk of a tragedy happening. Workers, often afraid and cornered, try to deal with these events in various ways.

The experience of violence in different intensities permeates these relationships, creating dynamics which cause suffering and disorganize the functioning of the service. Violence becomes a frequent theme of conversations, team meetings, assemblies, and meetings of the clinical-institutional supervision.

All construct explanations for what has been happening, many of which conflict with each other. The assumption that “violent behavior” is not a constitutive characteristic of the homeless and of intensive drug users lives together with the idea, common among users and workers, that one is to expect violence at a CAPSad.

A tension about workers’ notions about the “whys” and “hows” of violence gains centrality here, along with a sense of helplessness and uncertainty about how to deal with it. Some demand punitive measures for users involved in these situations, whereas others advocate investing in the construction of new rules of coexistence in the service. Although it failed to rigidly divide the group, this process illustrated doubts and insecurities which dialogue with both positions, often in the same worker.

From this tension, some question the measures imposed on users who cause scenes of violence – expulsion from the service at the time of the event, suspension for one or more weeks, and offer of care in the territory, among others – as “disciplinary measures”¹³13 Oliveira JAS, Barretto LD, Freire RC, Rosa GFS, Lima F, Dultra LS, et al. Desencontros entre a vista do ponto dos usuários e as formas de cuidar em saúde: reflexões sobre a produção do cuidado em uma região da cidade de Salvador-BA. In: Merhy EE, Baduy RS, Seixas CT, Almeida DES, Slomp Júnior H, organizadores. Avaliação compartilhada do cuidado em saúde. Surpreendendo o instituído nas redes. Rio de Janeiro: Hexis; 2016. p. 276-281.. Thus understood, such actions are considered as access-restricting punishment and in line with the outdated perspective of the mental asylum. Others understand these consequences as building “limits” for users. However, the care team often fails to support the construction of rules of coexistence, and it is common for some workers and users to assume a police and supervisory role toward those who fail to comply to them.

To consider the provision of care by a CAPSad outside its premises as restricting its access seems to point to a conception of care centered on the physical structure of the service, separate of the streets and life on them. This understanding brings a reflection on what care is and how it is produced.

Thus, we realized that the problem is more complex than the duality “mental asylum teams” and “anti-mental asylum teams.” We had to get out of this polarity to realize that we are all crossed by many established force and escape lines which produce different forms of care at each encounter. Other lenses and languages are needed to observe and discuss it.

Similarly, it is important to criticize the individualizing perspective of life production and the definition of “guilt” of each worker or homeless person experiencing violence at a CAPSad. The importance of recognizing the complexity of the production of workers and users in their multiplicities, as Dutra and Henriques point out¹⁴14 Dutra R, Arenari B. Orientações para as políticas públicas. In: Souza J, organizador. Crack e exclusão social. Brasília: Secretaria Nacional de Políticas sobre Drogas; 2016. p. 330-337., proved to be central in our investigation process.

First displacement: other views of the production of violence at a CAPSad

In health care relationships, we find a constitutive tension between the world of workers, with their rationalities and technologies, and that of service users, with their needs and ways of carrying their lives, perceiving themselves, and relating to these services¹⁵15 Merhy EE. Saúde: a cartografia do trabalho vivo. São Paulo: Hucitec; 2002.. These conflicts were expressed daily at the CAPSad. As Feuerwerker and Merhy¹⁶16 Feuerwerker LCM, Merhy EE. Como temos armado e efetivado nossos estudos, que fundamentalmente investigam políticas e práticas sociais de gestão e de saúde? In: Mattos RA, Baptista TWF, organizadores. Caminhos para análise das políticas de saúde. Porto Alegre: Rede Unida; 2015. p. 439-460. state

The team negatively perceives the notion that the dynamics of the streets would be invading the service. However, some workers and users claim that people who often disrupt the service behave completely differently on the streets. The phrase “Outside, everyone is really ‘chill;’ in here, everyone is brave!” is common.

They also often explain this difference in users’ behavior as a consequence of police violence on the streets, which imposes limits which are absent within the service: “Outside, if you walk out of line, the police will beat you up,” some say.

Our research began to denaturalize and displace the notion that violent situations are expected in a health service welcoming people under the influence of drugs or who are agitated, with abstinence syndrome or in withdrawal.

This finding dialogues with the analysis of Rodrigues et al.¹⁷17 Rodrigues JS, Lima AF, Holanda RB. Identidade, drogas e saúde mental: narrativas de pessoas em situação de rua. Psicol Cienc Prof. 2018; 38(3):424-436. Doi: https://doi.org/10.1590/1982-37030004912017.
https://doi.org/10.1590/1982-37030004912... , in their research with the homeless in Fortaleza. It deals with the difficulty of recognizing the homeless as holders of rights, reproducing stigmas resulting from normative and pathologizing conceptions which imprison the production of new ways of being in the world, inviting the reproduction of socially constructed expectations about this population.

In this perspective, Espinheira¹⁸18 Espinheira G. A casa e a rua. Cad CEAS. 1993; (145):24-38. points to a “learning of violence” as a kind of competence developed to survive on the streets. Once this is understood, it is necessary to deconstruct this hegemonic association between violence and intensively drug-using homeless people’ bodies; an association socially produced in the context of the war on drugs, permeating workers and users with implications which require analysis⁵5 Lourau R. Objeto e método da análise institucional. In: Altoé S, organizador. René Lourau: analista institucional em tempo integral. São Paulo: Hucitec; 2004. p. 66-86.. All these elements were revealed in the empirical material of this research, the result of meetings with the team and service users.

The denaturalization of what is experienced in meetings suggested that all are in constant production from various planes inside and outside the CAPSad. It indicates, thus, the inexistence of one user or one worker. Recognizing these multiple force lines crossing, affecting, and disputing the lives of each and every one is central. Looking at the micropolitics of care production brings to analysis the relationships built in society and the roles which are expected from health workers and users.

As expressed by a worker in one of the meetings with the team:

In this process, easy explanations no longer suffice, such as “users would walk ‘toe the line’ on the streets due to police repression.” What has no explanation or is not understood has become a clue to new visibilities, considering the micropolitics of living work and the production of health care in the encounter between workers and service users¹⁹19 Merhy EE. Em busca do tempo perdido: a micropolítica do trabalho vivo em saúde. In: Merhy EE, Onocko R, organizadores. Agir em saúde: um desafio para o público. São Paulo: Hucitec; 1997. p. 71-112.^,2020 Feuerwerker LCM. Micropolítica e saúde: produção do cuidado, gestão e formação. Porto Alegre: Rede Unida; 2014..

This worker brings violence to the service as directed toward their own team, one which is produced in the relations of power at the service, highlighting the place workers occupy in organizations, though they, in some way, also represent the State and its violence toward intensively drug-using homeless people. On the other hand, users also expect the CAPSad to be a space of protection.

This account advances the idea of violence as a product of relations but preserves the notion that users are violent and are so because they transfer to workers the violence they have suffered, as if they were inactive in this production. It is a powerful account since it places the differences between the streets and the service as a problematic field to be explored: how much the service can dialogue with the production of life on the streets and how much the streets invade care.

Another account reinforces the externality of the streets in relation to CAPSad:

Statements referring to a certain caricature of “homeless people/drug users” who access CAPSad express a perspective in which the streets should be left out of the question, asking then with what CAPSad concerns itself. Thus, they question care and the worker which are produced when this perspective crosses the service. These are issues that always populated the field experience and the analysis of what was produced there.

However, at the end of this account, something important appears: the worker, hearing the user talking loudly (understood there as the language of the streets) talks even louder and, only from there, the user would react by reproducing the “violence of the streets.” In this account, the production of violence taking place in that encounter appears explicitly as the result of relationships.

How the streets cross the CAPSad and their meaning for workers and users illustrates the need for further development of what the CAPSad walls want to protect, what they want to contain from the streets to avoid the invasion of its daily life. The clinics on the streets which are made from the streets live with less tension in the relation care–service–street. Connection with production of life is the center of the care process for those who live on the streets and are strongly crossed by that link. As already reported, some users take into CAPSad everyday actions which are increasingly difficult outside it, such as a cozy space with some food in which they can sleep with both eyes closed and some protection. In these moments, it seems that CAPSad alone occupies the place which could be networked with other policies and services. Does this denounce a lack of other public policies? Are the streets invading the service? Is there a multiple production of life asking to be welcomed, forcing comfort in one of the few doors still open in the territory? Is life invading CAPSad?

What is the CAPSad when it goes to the streets to produce care where life happens, where it is better with those who cannot stay away from the streets inside its service walls? Is it not CAPSad anymore? Again, it questions what production of care is. Does it depend on the walls delimiting its space?

Thus, we leave aside the question “why do some users behave so differently at the CAPSad than on the streets?” and, questioning the encounters and divergences in the daily care of these users, we ask another question: “what, in these meetings, is produced, produces and makes emerge so strongly many forms of violence?” A shift in the look at the production of violence to the relationship between subjects, defocusing it from the individual. By leaving the role of interpreters of the “violence phenomenon” from our views of the point²¹21 Merhy EE. As vistas do ponto de vista, tensão dos programas de saúde da família que pedem medidas [Internet]. Rev Bras Saude Fam. 2014 [citado 5 Set 2020]; 14. Disponível em: http://189.28.128.100/dab/docs/portaldab/documentos/artigo_emerson_merhy.pdf
http://189.28.128.100/dab/docs/portaldab... , as expressed in the introduction, we changed the way we asked the question. The question would no longer be “why?” but “how does violence cross and affect the production of care?”

The experience of the many forms of violence within the CAPSad crosses bodies, producing affections, suffering, and displacement of certainties, questioning what is instituted. It may be an invitation to analyze the measures which go toward an “expulsion,” even if transitory, of users of the service, closing its doors and setting the CAPSad further apart from the streets. This displacement can also question what effects can be produced if the routine of this service would allow the streets to inhabit it. It is no longer the streets “invading” the CAPSad but the latter occupying the streets and, in them, mixing care with the lives they sew, embroider, and split. An invitation to bet on a form of care which is a shared production of life.

Second displacement: racism and social humiliation in encounters with the homeless

Violence is experiential and relational¹1 Minayo MCS. Um fenômeno de causalidade complexa. In: Minayo MCS. Violência e saúde [Internet]. Rio de Janeiro: Fiocruz; 2006 [citado 23 Abr 2021]. p. 12-23. Disponível em: https://static.scielo.org/scielobooks/y9sxc/pdf/minayo-9788575413807.pdf
https://static.scielo.org/scielobooks/y9... . In this health service, it was precisely in the subtlety of care relationships that some users felt it, though it remained “secret and accepted” or, at least, tolerated by the team.

Recognizing services as a space of disputes and tensions challenges and calls us to acknowledge the fields of forces which cross us, building processes of mutual subjectification permeated by diverse power relations and disputes from which singular realities and possibilities of care or neglect are elaborated. Collective visibility and invisibility fields are produced in this group processing.

We produce other lenses to see and other languages to talk about violence by interrogating violence in the service from the micropolitics of users and workers’ relationships. Thus, different forms of violence and tensions crossed our bodies in many encounters in health care, making visible the urgency of bringing life to these meetings. This displacement populates our cartographic diaries:

As the CAPSad seeks to separate life on the streets from life within it, it reproduces, in its daily life, the experience of invisibility permeating everyday life on the streets, in which people are seen only as transgressors who should be stopped and searched. The force lines crossing the production of life on the streets and in the CAPSad are intertwined and it is impossible to be in one without being also from the other. These force lines compete for more than care, disputing the value of people’s lives on the streets.

This scene in the cartographic diaries dialogues a lot with the violence which permeates care:

This scene opens two hegemonic value strands at the heart of structural racism and the war on drugs²²22 Fiorati RC, Xavier JJS, Lobato BC, Carretta RYD, Kebbe LM. Iniquidade e exclusão social: estudo com pessoas em situação de rua em Ribeirão Preto/SP. Rev Gest Saude (Brasília). 2015; 6 Supl 3:2120-2135.^,2323 Lancetti A. Contrafissura e plasticidade psíquica. São Paulo: Hucitec; 2015. (Políticas do desejo)., associating drug use with violence and Black bodies with danger²²22 Fiorati RC, Xavier JJS, Lobato BC, Carretta RYD, Kebbe LM. Iniquidade e exclusão social: estudo com pessoas em situação de rua em Ribeirão Preto/SP. Rev Gest Saude (Brasília). 2015; 6 Supl 3:2120-2135.^,2424 Rolnik R, Calil TG. Território e proibição: guerra às drogas ou guerra aos pretos e pobres [Internet]. São Paulo: Carta Capital; 2021 [citado 17 Jun 2021]. Disponível em: https://www.cartacapital.com.br/sociedade/territorio-e-proibicao-guerra-as-drogas-ou-guerra-aos-pretos-e-pobres/
https://www.cartacapital.com.br/sociedad... . A production sustaining the war on drugs legitimizes the genocide of Black people – most users of the assessed CAPSad are Black or brown – in so many territories. An authorization guided by necropolitics²⁵25 Mbembe A. Necropolítica: biopoder, soberania, estado de exceção, política de morte. Santini R, tradutor. 3a ed. São Paulo: N-1 edições; 2018. deciding who should live and who should die. This conception supports the social representation of Black bodies as threatening and drug users as unpredictable and potentially dangerous. The Covid-19 pandemic deepened further this abyssal inequality, exacerbating the effects of necropolitics in this population.

Peter Pál Pelbart²⁶26 Pelbart PP. Biopolítica. Sala Preta. 2007; 7:57-66. Doi: https://doi.org/10.11606/issn.2238-3867.v7i0p57-66.
https://doi.org/10.11606/issn.2238-3867.... questions what body is presented in this encounter:

Coming into contact with institutional, symbolic, and usually silenced forms of violence makes us reflect on these exhausted bodies – no longer standing the tameness imposed by the disciplines²⁶26 Pelbart PP. Biopolítica. Sala Preta. 2007; 7:57-66. Doi: https://doi.org/10.11606/issn.2238-3867.v7i0p57-66.
https://doi.org/10.11606/issn.2238-3867.... – which inhabit this place, as well as on what they speak, what is heard, and what is silenced. Recognizing this body reinforces violence as an analyzer and leads us to reflect on the effects produced in CAPSad encounters on how violence within this service questions the relation of our care with projects to tame bodies and on how the violence of life on the streets crosses users and workers’ bodies.

The violence experienced by users within CAPSad were understood, in dialogue with contemporary hegemonic cultural and social perspectives, as “criminal” or “delinquent,” making them intolerable since they hurt the fundamental morals of all cultures¹1 Minayo MCS. Um fenômeno de causalidade complexa. In: Minayo MCS. Violência e saúde [Internet]. Rio de Janeiro: Fiocruz; 2006 [citado 23 Abr 2021]. p. 12-23. Disponível em: https://static.scielo.org/scielobooks/y9sxc/pdf/minayo-9788575413807.pdf
https://static.scielo.org/scielobooks/y9... ^,2727 Toledo LM, Sabroza PC. Violência: orientações para profissionais da atenção básica de saúde. Rio de Janeiro: Fiocruz; 2013.^,2828 Santos JVT. A violência simbólica: o Estado e as práticas sociais. Rev Crit Cienc Soc. 2015; (108):183-190. Doi: https://doi.org/10.4000/rccs.6169.
https://doi.org/10.4000/rccs.6169... . Thus, regarding our research subjects, we noticed that these situations were not analyzed in light of care relationships, making visible only the acts of violence unilaterally inflicted against team members, which are already effortlessly visible.

According to Ladeia et al.²⁹29 Ladeia PSS, Mourão TT, Melo EM. O silêncio da violência institucional no Brasil. Rev Med Minas Gerais. 2016; 26(8):398-401. (p. 399), institutional violence is considered that which is “practiced by public agencies and agents which should be responsible for the care, protection, and defense of citizens.” It exists within institutions, especially through its rules, operation guidelines, and bureaucratic and political relations, reproducing unfair social structures¹1 Minayo MCS. Um fenômeno de causalidade complexa. In: Minayo MCS. Violência e saúde [Internet]. Rio de Janeiro: Fiocruz; 2006 [citado 23 Abr 2021]. p. 12-23. Disponível em: https://static.scielo.org/scielobooks/y9sxc/pdf/minayo-9788575413807.pdf
https://static.scielo.org/scielobooks/y9... , or “it also occurs in the way they are offered, denied, or neglected in public services”²2 Antoni C, Munhós AAR. As violências institucional e estrutural vivenciadas por moradoras de rua. Psicol Estud. 2016; 21(4):641-651. (p. 646). It manifests itself so naturally and silently that it is not even perceived as such, especially when it does not generate physical harm. In health, it presents itself as neglect, verbal aggression, rude treatment, reprimands, threats, physical violence (including the non-relief of pain), and sexual abuse²⁹29 Ladeia PSS, Mourão TT, Melo EM. O silêncio da violência institucional no Brasil. Rev Med Minas Gerais. 2016; 26(8):398-401.^,3030 D’Oliveira AFPL, Diniz CSG, Schraiber LB. Violence against women in health-care institutions: an emerging problem. Lancet. 2002; 359(9318):1681-1685..

Symbolic violence is invisible, inflicted and suffered in a poorly elaborate or perceptible way, exerted and experienced by the body, many without physical coercion, causing moral and psychological damage³¹31 Bourdieu P. Sur la télévision. Paris: Liber; 1996..

The scenes experienced and recorded showed the delicate articulation between institutional (in their non-physical and more subtle) and symbolic manifestations. Gonçalves Filho³²32 Gonçalves Filho JM. Humilhação social: humilhação política. In: Souza BP, organizador. Orientação à queixa escolar. São Paulo: Casa do Psicólogo; 2007. p. 187-221. claims that a person is humiliated when some trait of their humanity, such as liking something, loving or praying, is prevented from manifesting itself. He states that humiliation is always social (and political, relating to inequality in its fold to domination). It is “an impediment that is not natural or accidental but applied or sustained by other humans”³²32 Gonçalves Filho JM. Humilhação social: humilhação política. In: Souza BP, organizador. Orientação à queixa escolar. São Paulo: Casa do Psicólogo; 2007. p. 187-221. (p. 194).

These feelings of inferiority and inequality in the scene described above are collective and ancestral expressions which are updated in the body of that Black man when he perceives himself and is treated as inferior to a dog. Being prevented from feeling the same in relation to the other reinforces inequality, which ultimately has nothing to do with being different but with power relations and domination between humans³¹31 Bourdieu P. Sur la télévision. Paris: Liber; 1996..

The collective reflections in the service were not the most “subtle” violence practiced by the team in relation to users, sticking to these the invisibility imposed on those who suffer them. An invisibility of violence expressing institutional racism and lstructure³³33 Almeida SL. Racismo estrutural. São Paulo: Pólen; 2019..

Grada Kilomba³⁴34 Kilomba G. Memórias da plantação: episódios de racismo cotidiano. Oliveira J, tradutor. Rio de Janeiro: Cobogó; 2019. states that the “white subject,” in the process of splitting his psyche, creates this “Other” who always antagonizes the “I.” Thus, only the “good” part of their ego (welcoming and benevolent) is recognized and experienced as the “I.” The rest, the “bad” part, is rejected and projected onto the “Other.” Whiteness is the positive part of oneself and not the negative one, which is deposited in this Other, the “Black subject.” Therefore,

A social construction which reinforces the idea about who is considered violent, unpredictable or potentially dangerous: Black men, “junkies,” and “loonies.” But not just any loony, Black person or junkie; someone who, in addition to all this, is homeless, with all the constructions in the social imaginary about what it is to be in this position: a delinquent, vagabond, rascal, unreliable, zombie, non-human, a probable crack user²³23 Lancetti A. Contrafissura e plasticidade psíquica. São Paulo: Hucitec; 2015. (Políticas do desejo).^,3535 Merhy EE. Anormais do desejo: os novos não humanos? Os sinais que vêm da vida cotidiana e da rua. In: Conselho Federal de Psicologia. Grupo de Trabalho de Álcool e outras Drogas. Drogas e cidadania: em debate. Brasília: Conselho Federal de Psicologia; 2012. p. 9-18..

Bringing to the scene the multiple produced forms of violence crossing relationships, the encounters between workers and users interrogate and help us break with simplistic responses categorizing them from what is hegemonically given.

Final considerations

Research processing produced visibilities and sayabilities for the multiple dimensions of violence and its expressions in a CAPSad. One such visibility is that the homeless who use this service, in addition to the many forms of violence they already suffer, are also crossed by the institutional and symbolic violence produced in care relations, which are well known and studied, but little recognized by health workers. Violence whose production involves workers who are affected by the strength of organizations and institutions and by the stigmas attributed to the population they serve, manifested itself daily as certain discursive and communicational practices.

Another important visibility was realizing that the stigmas and the violence surrounding the homeless are social constructs active in workers and users’ subjectification, produced in CAPSad and present in their daily lives. This visualization helps us to overcome the idea of violence as constitutive of the homeless and drug users and to deconstruct these people’s individual responsibility for the violence occurring in the service, understanding them as relational and social co-productions.

On the other hand, it helps us visualize the structural and institutional racism which workers and health services inhabit, especially those accessed by people in vulnerable situations. Thus, this research joins other studies questioning the power relations, disputes, and tensions present in the encounters producing life and care.

By bringing violence as a social and relational production, centering the debate on the production of health care and work around structural and institutional racism and building languages to discuss it, this study implicates health workers and points to the need for these themes to be raw materials of their training, as provided for in the general guidelines of the National Policy of Integral Health of the Black Population³⁶36 Brasil. Ministério da Saúde. Secretaria de Gestão Estratégica e Participativa. Departamento de Apoio à Gestão Participativa. Política Nacional de Saúde Integral da População Negra: uma política para o SUS. Brasília: Ministério da Saúde; 2013.. This study reinforces the importance of building permanent education strategies which take daily life, with all these elements, as a trigger of formative processes which interrogate and enable the processing of the effects which violence and racism produce on health services. It reinforces the perception that care is actively produced, thus requiring permanent support strategies.

Letting these concerns take shape and giving voice to what interrogates us invites us to further develop what can be the care of intensively drug-using homeless people who produce their lives in connection with the streets. How to create care within a service which is intertwined with care on the streets, the spaces of the territory in which these lives take place. It also centralizes the need for a network of public policies which would take CAPSad out of its loneliness, another expression of state violence which has dismantled the network of protection and guarantee of rights.

The visibilities and sayabilities on violence at CAPSad in its different dimensions contributed to the deepening of the always unfinished look on health care. It centralizes the connection with affections, the production of life, and the inventions constituting this care with the homeless (but not only with them), enhancing the many intensities which cross lives on the streets and their expressions in the service.

Acknowledgements

We would like to thank all who are part of the teams at CAPSad Gregório de Matos and the Clinic on Pelourinho street for their indispensable presence in this research.

References

Publication Dates

History