Abstract

This text approaches the articulation between solidarity economy practices and the production of citizenship and autonomy among individuals in psychosocial suffering, through an artistic/cultural production. The confluence between public mental healthcare and associated work as an alternative to labor insertion for people suffering from mental disease is, although still challenging, very important in Brazil. We analyze two consolidated experiences, each extending over a period of two decades: The Suburban Madness group in the city of Rio de Janeiro, and GeraçãoPOA in Porto Alegre, both Brazilian capitals of the states of Rio de Janeiro and Rio Grande do Sul, respectively. The relevance of this research lies in showing the fruitful intersections between social movements, public health care, and arts, especially now that Brazil is facing a period of authoritarianism, which places at risk the democratic achievements of both public policies and social movements.

Keywords:
Arts/Culture; Solidarity economy; Mental health; Public Health

Resumo

Este texto aborda a articulação entre práticas de economia solidária e a produção de cidadania e autonomia entre indivíduos em sofrimento psicossocial, por meio da produção artística/cultural. A confluência entre a saúde mental pública e o trabalho associado como alternativa à inserção laboral para pessoas que sofrem de doença mental é, embora ainda desafiadora, muito importante no Brasil. São analisadas duas experiências consolidadas, cada uma com duração de duas décadas: o grupo Loucura Suburbana, na cidade do Rio de Janeiro, e o GeraçãoPOA, em Porto Alegre, ambas capitais brasileiras dos estados do Rio de Janeiro e Rio Grande do Sul, respectivamente. A relevância desta pesquisa reside em mostrar as interseções frutíferas entre movimentos sociais, serviços de saúde pública e artes, especialmente agora que o Brasil está enfrentando um período de autoritarismo que põe em risco as conquistas democráticas de políticas públicas e movimentos sociais.

Palavras-chave:
Artes/Cultura; Economia solidária; Saúde mental; Saúde Pública

Introduction

In the research that this article is based on, we were interested in knowledge and in social practices among mental healthcare system users who form groups to produce arts and sell their products. Considering knowledge, not as an exclusively cognitive, but fluid and dynamic instance which include affections and emotions, we look at it as the whole process of giving meanings to one’s world and assimilation of social practices (JOVCHELOVITCH, 2008JOVCHELOVITCH, S. Os contextos do saber: representações, comunidade e cultura. Petrópolis: Vozes, 2008.). It involves the worldviews, perceptions, and representations covering identity and sociocultural expressions of these subjects. Culture is thought of as a creative process and as a resource (YÚDICE, 2002YÚDICE, G. The Place of Culture After September 11. Revista Crítica de Ciências Sociais, v. 63, n. 1, p. 175-187, 2002. Available: https://journals.openedition.org/rccs/1273.
https://journals.openedition.org/rccs/12... ) to be used to generate income for people in social disadvantage. The study was conducted from February 2017 to July 2019.

The approach focuses on the articulation between solidarity economy practices and the production of citizenship and autonomy among individuals in psychosocial suffering through an artistic/cultural production. The confluence between public mental healthcare, and associated work as an alternative to labor insertion for people suffering from mental disease is, although still challenging, very important in Brazil (ANDRADE, 2013ANDRADE, M. C. et al. Loucura e trabalho no encontro entre saúde mental e economia solidária. Revista Psicologia Ciência e Profissão, v. 33, n. 1, p. 174-191, 2013. Available: https://www.scielo.br/scielo.php?pid=S1414-98932013000100014&script=sci_abstract&tlng=pt.
https://www.scielo.br/scielo.php?pid=S14... ; VILUTIS, 2011VILUTIS, L. Economia Viva: cultura e economia solidária no trabalho em rede dos pontos de cultura. Tese de doutorado em Cultura e Sociedade. Salvador: Universidade Federal da Bahia, 2015. Available: https://repositorio.ufba.br/ri/handle/ri/30703.
https://repositorio.ufba.br/ri/handle/ri... ). Methodologically, the perspective of participatory ethnographic registration was the alternative chosen for insertion in the research field. (BAUER; GASKELL, 2002BAUER, M.; GASKELL, G. Pesquisa qualitativa com texto, imagem e som. Petrópolis: Ed. Vozes, 2002.; DUBAR, 2005DUBAR, C. A socialização: construção das identidades sociais e profissionais. São Paulo: Martins Fontes, 2005.; JOVCHELOVITCH; PRIEGO-HERNANDEZ, 2013JOVCHELOVITCH, S.; PRIEGO-HERNANDEZ, J. Sociabilidades subterrâneas: identidade, cultura e resistência em favelas do Rio de Janeiro. UNESCO, Brasília, 2013.). The research team was formed by the coordinating researcher and three research assistants, a doctor and two undergraduate students. Two different Ethics Committees approved the study: the one from Unisinos University and the one from Porto Alegre City Hall, since GeraçãoPOA is part of the municipal public service (the project was registered at Plataforma Brasil, under number 2,171.36).

The relevance of this research lies in showing the fruitful intersections between social movements, public health care and arts, especially now that Brazil is facing a period of authoritarianism that places at risk the democratic achievements of both public policies and social movements.

The initiatives and its context: groups that produce art/culture through associativism

The individuals, in the scope of the Psychiatric Reform, look to achieve autonomy and broaden their citizenship, which was previously tutored and marked by segregation in mental institutions (AMARANTE, 1998AMARANTE, P. Loucos pela vida: a trajetória da reforma psiquiátrica no Brasil. Rio de Janeiro: SDE/ ENSP, 1988.; HESPANHA, 2013HESPANHA, P. A Reforma Psiquiátrica em Portugal: desafios e impasses. In: FONTES, B.; FONTE, E. Desinstitucionalização, redes sociais e saúde mental: análise de experiências da reforma psiquiátrica em Angola, Brasil e Portugal. Recife: Ed. UFPE, 2010. p. 137-162.). The Anti-Asylum Movement is a social movement that emerged in the 1980s in response to inhumane treatment in psychiatric institutions and contributed substantially to the implementation of the Psychiatric Reform within the scope of the Unified Health System (SUS being the acronym in Portuguese). It has the participation of health professionals, users of the mental health system and their families whose stance is expressed in the maxim: "For a society without asylums."

The SUS is a free and universal public system, financed by Brazilian taxpayers. It was secured by the Federal Constitution of 1988, in a context of (re)democratization, at the end of the military dictatorship. Nowadays, in Brazil, there is great political pressure to privatize the health system with the radical adoption of neoliberal policies.

Some years ago, before it has been extinct, The Ministry of Culture in Brazil (MinC) operated with an expanded concept of culture, which seeks to activate elements of what was called the "three-dimensionality of culture", with the symbolic, citizen and economic dimensions defined by the MinC, such as:

The artistic-cultural projects constitute ways of resistance to neoliberal policies and political setbacks in the mental illness deinstitutionalization policy in the context of mental health care. It features a wide variety of forms of participation, social circulation, and citizenship expansion, which is the most important aspect in the current scenario for the users of the public health system who seek psychiatric help. The word “users” (“usuários”, in Portuguese) has, in this setting, a very positive sense: They are users of a public service to which they are entitled to. They are citizens exercising their right of access to public health services, which is a constitutional duty of the Brazilian State; they are not just “patients” or “the mentally ill”. They are proud to call themselves “users”.

In Brazil, in terms of a broader quantitative survey of solidarity-based enterprises aimed at promoting mental health linked to the Psychosocial Healthcare Network (RAPS being the acronym in Portuguese), the latest available data, released by the Ministry of Health, are from 2013, which identified over 1000 cooperative enterprises formed by mental health system users.

The Brazilian Psychiatric Reform has as its basic nucleus the recovery of citizenship, and it is observed that the practice of solidarity economy provides the expansion of the workers' capacities, which originates from the creation of access to cultural goods that may constitute products and services. Amarante (1998)AMARANTE, P. Loucos pela vida: a trajetória da reforma psiquiátrica no Brasil. Rio de Janeiro: SDE/ ENSP, 1988. tells us that within this active sociocultural dimension, important devices for transforming the social place of madness take place. There is a great complexity of the mental health care process, but all over the world “user movements are beginning to emerge demanding autonomy, full citizenship, empowerment, recovery and advocacy”, according to Desviat (2011DESVIAT, M. Panorama internacional de la reforma psiquiátrica. Ciência & Saúde Coletiva [online]. 2011, v. 16, n. 12], p. 4615-4622. Available: <https://doi.org/10.1590/S1413-81232011001300010> Access: 28 May 2021.
https://doi.org/10.1590/S1413-8123201100... , p. 4615). This same author, when reflecting on the situation of mental health care around the world, after the reform processes - which in each country have their own characteristics -, states that: “The current situation moves between the model of American liberal medicine, untouched after Obama's failure, which has turned community psychiatry into a program for the poor, maintaining universal coverage in Europe, beset by privatization tendencies that limit the most social benefits, and the participatory movement of mental health collective from Brazil” (DESVIAT, 2011DESVIAT, M. Panorama internacional de la reforma psiquiátrica. Ciência & Saúde Coletiva [online]. 2011, v. 16, n. 12], p. 4615-4622. Available: <https://doi.org/10.1590/S1413-81232011001300010> Access: 28 May 2021.
https://doi.org/10.1590/S1413-8123201100... , p. 1450).

The groups produce handicrafts of various kinds, as well as drawings, paintings, mosaics, poetry, photography, music, and carnival costumes for the parades. It was soon realized, through fieldwork, the importance of an artistic activity in the lives of the users/artists/workers (they use these three words when referring to themselves). Income complementation, learning a new trade and establishing new relationships with people of all walks of life, such as technicians and the surrounding community (companies, clients, visitors, etc.) are some of the observed benefits. And by doing, they broaden their network, socialize, attend spaces such as art galleries, cultural centers, and museums - usually restricted, in Brazil, to a middle-class audience - and move around the city and are thereby able to qualify their social participation.

The field of research: arts and mental health

The network of mental healthcare, RAPS, is constituted by some Psychosocial Rehabilitation Strategies, such as: Work and Income Generation Initiatives; Solidarity Enterprises and Social Cooperatives. In Brazil, the mental health policy changed its model of care, with the Psychiatric Reform (inspired by the Italian experience), reversing a strictly hospital centered care so that it would integrate different services in which solidarity economy and the production of autonomy would come to play a very important role.

In the 1960s and 70s, Italian psychiatry would influence Brazil in the deinstitutionalization of madness, with the process that Rotelli (2000ROTELLI, F. Empresa social: construindo sujeitos e direitos. In: AMARANTE, P. (Org.). Ensaios: subjetividade, saúde mental, sociedade. Rio de Janeiro: Editora FIOCRUZ, 2000. P. 301-306. (Loucura & Civilização collection). , p. 301) called a social enterprise. The author summarizes it stating that:

What he calls a social enterprise is a process that goes far beyond dehospitalization, it also means a cultural movement, the construction of a new scenario that goes beyond psychiatric labels and introduces complexity in understanding and caring for mental illness. According to Amarante (2018AMARANTE, P.; TORRE, E. H. G. “Back to the city, Mr. citizen!” - psychiatric reform and social participation: from institutional isolation to the anti-asylum movement. Rev. Adm. Pública [online], v. 52, n. 6, p. 1090-1107, 2018. Available: https://www.scielo.br/scielo.php?script=sci_abstract&pid=S0034-76122018000601090&lng=en&nrm=iso.
https://www.scielo.br/scielo.php?script=... , p. 2):

The Centers provided daily care and multiple activities, with beds in case of emergencies. Contrary to what many may think, the anti-asylum struggle is not against psychiatric admission; it is against institutionalization in models that segregate people permanently. Certainly, attention to the acute phases of the disease - psychotic break - is a strategic element for the care in freedom and services must be prepared for this. On this specific issue, Barbosa et al (2017BARBOSA, V. F. B. et al. The role of primary attention in health on the constitution of the network care in mental health. Revista de Pesquisa: Cuidado é Fundamental online, v. 9, n. 3, p. 659-668, 2017. Available: https://doi.org/10.9789/2175-5361.2017.v9i3.659-668.
https://doi.org/10.9789/2175-5361.2017.v... ), points out that the psychosocial care network in the municipalities sometimes presents structural and network problems between the different points of care, such as the difficulty of establishing a flow of reference and counter-reference that really works. Anyway, in the experiences followed in this study, users have access to specialized care in the care network in which they are inserted, if they need it.

In Brazil, according to Coneglian, Cavalcante, and Leandro (2015CONEGLIAN, L. G.; CAVALCANTE, F. G.; LEANDRO, J. A. Reforma psiquiátrica e cidadania: considerações a partir de uma experiência. Trivium - Estudos Interdisciplinares, v. 7, n. 1, p. 127-133, 2015. Available: Available: http://pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=S2176-48912015000100012 . Access: 13 Jul 2020.
http://pepsic.bvsalud.org/scielo.php?scr... ), the Psychiatric Reform had as its basic core of its assumptions the recovery of citizenship of the users of the mental health system. It was not only a project of change in care services for those with mental disorders, but it was also a new way of looking at these individuals.

Prejudices and negative representations involving “madness” make mental illness take on a form of social categorization, reproducing inequalities. It places those who experience psychic suffering in certain social places, generally excluding them from the central instances of collective life. These stigmatizations serve to distinguish those who are labeled as half-wits, dangerous and disorderly from those who follow the patterns of "proper" social conduct. The “madmen” were eventually stripped of human character and animalized, as uncontrollable beings who must be contained, medicated, and removed from social life so as not to disturb the “normal” setting (MOSCOVICI, 1976MOSCOVICI, S. Homens domésticos, homens selvagens. Lisboa: Livraria Bertrand, 1976.).

Erving Goffman is a seminal author for understanding the category of ‘stigma’. According to him, stigma is a consequence of some characteristic considered socially undesirable, which carries a sense of an alterity difficult to be interpreted as “normal”. For this author, people build a ‘theory’ of stigma; an ideology to explain the ‘inferiority’ of other people. Thus, it would take care of the ‘danger’ it represents, rationalizing sometimes an animosity based on other differences, such as those of social class or type of behavior. People use specific terms of stigma like cripple, retarded, crazy, in his or her daily speech as a source of metaphor and representation, without thinking about its original meaning. Stigma disqualifies the subjects; causes social rejection, which can aggravate psychological suffering. (GOFFMAN, 1988GOFFMAN, E. Estigma: Notas Sobre a Manipulação da Identidade Deteriorada. Rio de Janeiro: Zahar, 1975.).

The term stigma originates from the Greek in the verb στίζω, which means ‘to sculpt, to mark as a sign of shame, punishment or disgrace’. The concept of stigma sheds light on the ways in which people with mental disorders are considered socially. Although the characteristics and behaviors considered stigmatizing are not the same in all societies, evidence indicates that stereotyped beliefs and discriminatory attitudes against people with mental illness are prevalent worldwide. Mental illness is still seen as an impediment to coexistence, work, a loving relationship, and the establishment of a family. (ECONOMOU; BECHRAKI; CHARITSI, 2020ECONOMOU, M.; BECHRAKI, A.; CHARITSI, M. The stigma of mental illness: Α historical overview and conceptual approaches. Psychiatric, v. 31, n. 1, p. 36-46, 2020. Available: Available: https://europepmc.org/article/med/32544075 . Access: 23 May 2021.
https://europepmc.org/article/med/325440... ).

Another theorizing of scientific interest is Thomas Scheff's ‘characterization theory’ or ‘label theory’. According to this theory, the rejection towards people who are different, or deviant does not depend on the latter's possibly altered behavior, but on the label previously assigned to them. Therefore, patients with mental illness would already be an object of stigma before they even demonstrated deviant behaviors. (SCHEFF, 1974SCHEFF, T. The Labelling Theory of Mental Illness. American Sociological Review, v. 39, n. 3. Jun, p. 444-452, 1974.).

According to Fontes (2009FONTES, B. Saúde Mental no Brasil. Revista IHU online, 2009. Available in: Available in: http://www.ihu.unisinos.br/noticias/noticias-arquivadas/23508-saude-mental-no-brasil . Access: 8 June 2019.
http://www.ihu.unisinos.br/noticias/noti... ), there is no “magic formula” to tackle the social exclusion and disqualification of those considered mad when one draws from sources charged with these negative representations of madness. Segregation results from representations of the other anchored in prejudices deeply rooted in people's mindsets. Prejudice and exclusion can only be dealt with when those who are the “target” of prejudice are introduced into social contact with other people, when they realize that many of their views of stigmatized people are not true. For example, the idea that the mad are violent and dangerous, that they cannot have a social life or that they are unable to work.

Thus, the Psychiatric Reform in Brazil proposed care in freedom, in local care services, within the scope of the Psychosocial Care Centers (CAPS being the acronym in Portuguese), based in communities and rescuing previously suppressed citizenship. The principle is to take care of patients in community-based, family-based, and artistic/cultural-based environments. This is the logic of the groups of users of the mental health services involved in artistic and cultural activities, because, as Fagundes Junior, Desviat and Silva (2015, p. 1450)FAGUNDES, H. M. , DESVIAT, M.; SILVA, P. R. F. Reforma Psiquiátrica no Rio de Janeiro: situação atual e perspectivas futuras. Ciência & Saúde Coletiva, v. 21, n. 5, p. 1449-1460, 2016. Available: <https://doi.org/10.1590/1413-81232015215.00872016>. Access: 23 May 2021.
https://doi.org/10.1590/1413-81232015215... points out, the everyday lives of de-institutionalized psychiatric patients change a lot. They are “able to walk the streets of the city and share their lives alongside their fellow citizens.” The work and the arts change their place in the subjects' experience, in these cases. It is not a question of leisure or therapy, but of social rights. And that leads us back to the issue of cultural policies and the importance of associating the dimensions of culture and arts with mental health care and reintegration practices.

Time has shown that art is one of the most potent tools in this field. In Brazil, Nise da Silveira's pioneering experience with arts is a source of inspiration for professionals and users of the health care network. Due to this pioneering spirit in relating the arts to personal expression and improvement in mental health disorders, she deserves a mention in this text. According to Pordeus (2018, p. 1)PORDEUS, V. Restoring the Art of Healing: A Transcultural Psychiatry Case Report. Journal of Psychology and Psychotherapy Research, 1, p. 47-49, 2014.:

Nise da Silveira understood the role of affections and images in psychiatric treatment, and she corresponded with Carl Gustav Jung, becoming an inspiring figure for mental health professionals in Brazil. Her instrument of approach was art. She believed that the contents of the unconsciousness were revealed in her patients' artistic work which contributed to the treatment. She used to say: “I like divers, people who study the inner world deeply. Most people are afraid of the unconsciousness, they stay on the surface. I need scuba divers. Whoever wants to study psychology, must get hold of a scuba diving gear and dive with the schizophrenic.”

Nise revolutionized occupational therapy and turned it into an effective treatment. By humanizing care for psychic suffering, her pioneering practice, left the interns free to create, exploring the senses through art. The bodies, previously confined, are set free, humanizing them, and allowing for healthier interactions. Nise even corresponded with Carl Gustav Jung, a Swiss psychoanalyst, who used important theoretical categories to access the unconscious through artistic expression. Decades later, these discoveries would be fundamental in the processes of psychiatric reform and in the cooperative experiences of producing artistic-cultural artifacts.

Since Nise da Silveira’s work which created the Museum of the Unconsciousness in Rio de Janeiro, a great deal has happened in Brazil and in the rest of the world, including the way in which culture and the arts are approached. This represents the importance of the changes that this pioneering professional introduced in mental health care in Brazil. Nise was the woman who refused to perpetuate violence in the hospital environment. Many of the paintings produced by patients are still of high value in the arts market.

For George Yúdice (2002YÚDICE, G. The Place of Culture After September 11. Revista Crítica de Ciências Sociais, v. 63, n. 1, p. 175-187, 2002. Available: https://journals.openedition.org/rccs/1273.
https://journals.openedition.org/rccs/12... ), culture has become a value, a central resource for economies worldwide. Culture is used as a means of socio-political and economic improvement, giving rise to various uses, and moving away from the notions of distinction and praise. However, the cultural sphere has acquired an importance and popularization perhaps never seen in history, which would characterize a cultural capitalism. UNESCO, the World Bank, Foundations and NGOs have transformed what we have come to understand as “culture,” making it a central aspect of development and a possibility of inversion (YÚDICE, 2002YÚDICE, G. The Place of Culture After September 11. Revista Crítica de Ciências Sociais, v. 63, n. 1, p. 175-187, 2002. Available: https://journals.openedition.org/rccs/1273.
https://journals.openedition.org/rccs/12... , p. 23).

The basic definition of YÚDICE's book "The Convenience of Culture," (2006YÚDICE, G. A conveniência da cultura: usos da cultura na era global. Belo Horizonte: Editora UFMG, 2006.) is that culture became a resource that generates and attracts investments whose distribution and use, whether for economic development or for the cultural industries, has shown to be an inexhaustible source. In this sense, culture assumes its management, a distinct perspective on the characteristics of high culture and everyday culture in the anthropological sense.

This legitimation based on the usefulness of culture would be linked to the processes of globalization, the transformation of the state’s role and world geopolitics in the post-Cold War period. Thus, in the 1990s, this process of creating a “cultural economy” or “creative economy” begins, globalizing and causing significant changes in many countries.

The author reveals his concern with the theme of co-optation of cultural initiatives; because they must negotiate with governments and markets, sociocultural enterprises run the risk of producing only what can be translated into commercial language that yields exchange value, or as he mentions: “corresponding to performative mandates which leave little space for an experience not translatable into the language of value development” (YÚDICE, 2002YÚDICE, G. The Place of Culture After September 11. Revista Crítica de Ciências Sociais, v. 63, n. 1, p. 175-187, 2002. Available: https://journals.openedition.org/rccs/1273.
https://journals.openedition.org/rccs/12... , p. 193). In the relationship between the artist and the market, State and society, there are many intentions and various social instances involved; but the negotiation processes to which Yúdice warns may turn out to be good since the act of producing culture is already transformative for the individual in psychological distress. A quote from a user-artist illustrates this aspect:

This brief mention of Yúdice's concept of culture is due to the author's approach to the precise theme of the policies of governmental and non-governmental organizations to promote the culture produced by minority groups. We will not, therefore, make a deeper incursion into the senses of the culture as a category, which are multiple in the humanities and social sciences.

The expressive and artistic activities make possible the (re)subjectivation and (re)singularization of the individuals. They are constituted as languages of flexible and plastic structure, allowing sharing experiences and facilitating communication among people, especially when the common language is insufficient to externalize unique experiences (CASTRO 2001CASTRO, E. D. et al. “Atividades humanas e Terapia Ocupacional”. In: PRADO, M. C.; BERTALOTTI, C. Terapia Ocupacional no Brasil: fundamentos e perspectivas. São Paulo: Plexus, 2001. p. 41-59.). According to Foucault (2005FOUCAULT, M. The Hermeneutics of the Self. Basingstoke: Palgrave Macmillan, 2005.) the subject is not universally granted, it it is in fact socially constructed through forms of knowledge and techniques of power.

Since solidary economy is based on the principle of the reproduction of life and not of capital, it is possible to generate financial income without exploitation of the labor force and with the appraisal of the results by the workers themselves, as became clear during the field research.

The "convenience" of using cultural products to promote social ends is analyzed by Yúdice in its complexity, not as good or bad per se, but as a constituent part of the issues of contemporary society. In any case, producing arts and marketing the products resulting from the work of the groups has been an important success factor in the field of resocialization of the mentally ill.

Solidarity economy and mental health: intersectoriality of the policies

In 2005, the Intersectoral Policy for Mental Health and Solidarity Economy was created, resulting from the articulation between the Ministry of Health and the National Secretariat for Solidarity Economy, at that time part of the Ministry of Labor and Employment and under the command of Professor Paul Singer (ANDRADE 2013ANDRADE, M. C. et al. Loucura e trabalho no encontro entre saúde mental e economia solidária. Revista Psicologia Ciência e Profissão, v. 33, n. 1, p. 174-191, 2013. Available: https://www.scielo.br/scielo.php?pid=S1414-98932013000100014&script=sci_abstract&tlng=pt.
https://www.scielo.br/scielo.php?pid=S14... ). Commenting on the changes that have occurred since 2001, Costa mentions that (2005COSTA, H. “Apresentação”. In: R. Martins. Saúde mental e economia solidária: inclusão social pelo trabalho. Brasília: Ministério da Saúde, Secretaria de Atenção à Saúde, 2005. p. 7-8., p. 8):

In the same book, Paul Singer (2005SINGER, P. Saúde Mental e Economia Solidária. In: MARTINS, R. Saúde mental e economia solidária: inclusão social pelo trabalho. Brasília: Ministério da Saúde, Secretaria de Atenção à Saúde , 2005. p. 11-12., p. 12) points out: “the solidarity economy and the anti-asylum movement are born from the same matrix - the fight against social and economic exclusion. Some are excluded (and locked up) because they are considered crazy, others because they are poor.” The experiences have been evaluated for financial sustainability, for the ability to generate income for users, to lead them to autonomy. But there are multiple dimensions through which they can be understood, in addition to this aspect, considering that the promotion of autonomy for users of mental health care network, in the social and institutional conditions that we have, will be relative and the income generated, still modest, but still important to them.

Work and income generation initiatives (solidarity enterprises and social cooperatives), as part of psychosocial rehabilitation strategies, end up producing a “market niche” with positive social impacts, involving multiple agents. They are constituted from the treatment of mental disorders and sometimes work through partnerships between the public health network, the third sector (NGOs), cooperatives and various associations, social movements and conventional companies, donors, or customers. Also noteworthy is the existence of a clientele made up of common citizens who attend the places where products are sold, or services are performed. It is an active socio-cultural and economic dimension, in which there are important devices for the transformation of the social place of ‘madness’ and the relationships between society and the representation of mental illness. Considering the impact and expression that the various artistic-cultural projects have been producing, it would be possible to state that there is a potential for scalar growth in this new artistic-cultural field and “niche” in the cultural market (AMARANTE 2012AMARANTE, P. et al. Da diversidade da loucura à identidade da cultura: o movimento social cultural no campo da reforma psiquiátrica. Cad. Bras. SaúdeMental, Rio de Janeiro, v. 4, n. 8, p. 125-132, 2012.).

According to reference studies (SINGER; SOUZA, 2000SINGER, P.; SOUZA, A. R. (Org.). A economia solidária no Brasil: a autogestão como resposta ao desemprego. São Paulo: Contexto , 2000.; GAIGER, 2004GAIGER, L. I. Sentidos e experiências da economia solidária no Brasil. Porto Alegre, Editora da UFRGS, 2004.; VERONESE, 2008VERONESE, M. Psicologia social e economia solidária. São Paulo: Ideias & Letras, 2008.; GAIGER; LAVILLE, 2009GAIGER, L. I.; LAVILLE, J. Economia plural. In: GAIGER, L. I. et al. (Org). Dicionário Internacional da Outra Economia. Coimbra: Almedina, 2009.), the priority of solidarity in these ventures is evident in their members’ involvement in day-to-day management, as well as in the socialization of productive resources and the adoption of equality principles. When extended to its surroundings, solidarity encourages broader reciprocity practices, where practical experience in managing the common good lends new value to the notions of justice and public interest. The collective action involved in the solidarity economy places new actors into the workplace, in class strategies and citizenship struggles, in response to concerns over welfare, recognition and a meaningful life.

Nowadays, the solidarity economy evokes a wide range of economic organizations, representative bodies, and civil society. Depending on the context, it can also refer to an economic sector, a social movement, or a field of political intervention. Solidarity economy experiences “tend to develop relationships that generate social bonds, in the opposite hand of the utilitarian and pragmatic exchanges that prohibit such developments and cut the universe of relationships, between people and groups, from the sphere of material exchanges.” (GAIGER, 2008GAIGER, L. I. A economia solidária e o valor das relações sociais vinculantes. Revista Katálysis, Florianópolis, v. 11, n. 1, p. 11-19, jun. 2008. , p. 12). In this sense, it is understood that the solidarity economy can intervene in many dimensions of human life, for instance in the political and social sphere in addition to an economic dimension. In other words, the solidarity economy presents itself as a form of expression, since it can metabolize “primary bonds and sociability, immersed in the practices of the popular economy and in the class experience of workers, arising from their common position within relations production” (GAIGER, 2008, p. 16GAIGER, L. I. A economia solidária e o valor das relações sociais vinculantes. Revista Katálysis, Florianópolis, v. 11, n. 1, p. 11-19, jun. 2008. ).

The income obtained by associate workers is important to assess the potential of a solidarity enterprise, of course. But sometimes, even if income is not compatible with minimum wage remuneration, it is particularly important. For subjects without any income at all from work, even with little money, the benefits of having their own income are significant.

In the cases analyzed in this text, for instance, the income that members receive is quite variable. In times of higher consumption, such as Christmas and Mother's Day, it can be quite significant, coming close to a national minimum wage. In normal times, the amount varies a lot, but however modest it is, it is a source of pride and satisfaction. Some of them have family support, others receive some type of state pension.

Methodological procedures

The perspective of participatory ethnographic record was the alternative for insertion in the field (BAUER; GASKELL, 2003BAUER, M.; GASKELL, G. Pesquisa qualitativa com texto, imagem e som. Petrópolis: Ed. Vozes, 2002., NUNES; TORRENTÉ, 2013). In the case of GeraçãoPOA, we made weekly visits for more than a year (fourteen months), staying the whole morning shift with them. On those occasions, we made participant observations on the work and income generation workshops. We also conducted individual interviews with 7 participants who wanted to grant them, four men and three women. Constant monitoring was carried out of the work and income generation workshops (the cooperative production itself). We also were there in the meetings of users and technicians to conduct decision-making processes about commercialization strategies. At cultural events we observed their relationship with the surroundings stakeholders, mapping the possibilities of dissemination and expansion. The team formed by the main researcher and three research assistants accompanied the group for more than a year, with frequent visits, field trips to produce or sell the products, participate in events in the psychosocial care network, including a municipal health conference. During these contacts, we generated written and oral records of the observations, which we shared and discussed; we also did narrative interviews that were transcribed and analyzed. We also conducted a workshop on solidarity economy, for the approximately 60 participants who circulate through the service. It was a way to contribute to the researched field, sharing knowledge with the subjects.

In the case of the Suburban Madness Carnival Parade, in Rio de Janeiro, there was no similar time to deepen the relationship, as was done in Porto Alegre. However, there were three field visits, two interviews with technicians and participation in two carnival parades. When we finally got the funding to deepen the fieldwork in Rio de Janeiro, the Covid-19 pandemic broke out and we had to postpone this stage of the research.

Showing two successful experiences: Bloco Carnavalesco Loucura Suburbana (Suburban Madness Carnival Parade) and GerAçãoPOA

The reasons for choosing these two projects are related to their longevity and success. They share some characteristics: community embeddedness, support from networks, trust from the communities where they operate. It was necessary to identify the positive factors, in order to disseminate qualified forms of sociolaboral insertion. Work is approached as a practice that promotes integration and socially legitimizes individuals and groups, favoring positive recognition in the communities of origin. It is also understood as a social right and the opportunity to return to work as a way of expanding the possibilities of social insertion and improving their mental health conditions. As for the binomial art / culture, is the device that allows the user to create and to construct itself as a subject. This is not about any kind of an alienating and sickening job. It is about meaningful work, cultural-artistic production carried out in groups. (AMARANTE, 2009AMARANTE, P. Reforma Psiquiátrica e Epistemologia. Cad. Bras. Saúde Mental, v. 1, n.1, jan-abr, 2009.).

Suburban Madness Carnival Parade

The suburb of Rio de Janeiro is situated in the city outskirts; it is a massive, densely populated area and has a rich cultural tradition related to the carnival. The Suburban Madness Carnival Parade emerges from the deinstitutionalization process of the Pedro II Psychiatric Center (CPPII), which was later renamed Nise da Silveira Health Care Municipal Institute (IMNS). Nise da Silveira, in addition to naming the Institute that houses the Loucura Suburbana project, is a constant source of inspiration for the participants.

The Institute holds the custody of the archives and bibliographical collections of the old hospital. The museum collection is the result of the pioneering work of psychiatrist Nise da Silveira, currently with 350,000 works, 128,642 of which are listed as Cultural Heritage of Humanity by the Institute of National, Historical and Artistic Heritage (IPHAN). Arts language is beyond any other form of communication; arts therapeutic workshops are a powerful means to communicate in a common language.

The Institute currently has three projects involving income generation and cultural production: “Espaço Travessia”, “Trilhos do Engenho” and “Suburban Madness”, the latter being the oldest and most structured of the institution, with a consolidated work of income generation, which is why we listed it for field research. Older and more rooted in the territory, the Suburban Madness brings together patients, families, employees, and residents of the neighborhood Engenho de Dentro and surrounding areas, making it a reference for a larger community.

In the parades of the carnival group, people dress up in costumes, colorful clothes and props. There is an arrangement among them to show placards and banners that carry the slogans of the anti-asylum struggle. The act is characterized by singing and playing. The carnival group mixes the fun side of the festivity with the demand for better living conditions and treatment

The carnival parade transposed the walls of the 'hospital', creating a movement of integration with the local community, motivated by Brazil’s largest popular festival, though the group no its activities are limited to the carnival. The people involved work all year long. The expansion of the project in 2001, based on the work of an art workshop at an outpatient clinic, was the beginning of the experience of greater community connection. Later it multiplied into other enterprises, with the founding of the Trilhos do Engenho Culture and Conviviality Center, which originated as a Culture Point. During the Lula era, we had in Brazil the National Program for Culture, Art and Citizenship, a national policy nicknamed "Cultura Viva". It congregates, in a warehouse, sewing and stationery workshop and other workshops. The School of Informatics and Citizenship (CDI) as well as the book publisher “EncantArte” were also created. The project, therefore, is a great space for learning and for cultural and musical production for people with mental problems and participants in general. (TORRE, 2018TORRE, E. G. Saúde Mental, Loucura e Diversidade Cultural: inovação e ruptura nas experiências de arte-cultura da Reforma Psiquiátrica e do campo da Saúde Mental no Brasil. Tese (Doutorado) - Programa de Pós-Graduação em Saúde Pública, Escola Nacional de Saúde Pública Sergio Arouca, Fiocruz, Rio de Janeiro, 2018.).

The “Madness”, as it is affectionately called by the participants (MACHADO, 2010MACHADO, A. L. O. S. “10 anos de Loucura Suburbana: cidade e loucura como enredo para o carnaval carioca. VI ENECULT, Salvador-BA, 25 a 27 de maio, 2010. Available: http://www.cult.ufba.br/worpress/24247.pdf.
http://www.cult.ufba.br/worpress/24247.p... ), opens the carnival of Engenho de Dentro, recovering the neighborhood street party and promoting changes in the community itself. People participate in its annual parade, and one can see prejudice against madness thawing into feelings of empathy.

It is a matter of moving from a symbolic death of subjectivity (the asylum, the incarceration) to an active life, a life of a citizen occupying their public space. The production of culture has precisely this power of bringing the individuals to the active life of the city. It could very well be considered a job, since there is the production and trade of goods which generate income, but one that produces political activity as well, as Hannah ArendtARENDT, H. The human condition. Chicago and London: University of Chicago Press, 1988. would state, it places individuals interacting in public spaces, and within this action and discourse produces the public sphere which is common to each and everyone (AMARANTE, 2018AMARANTE, P.; TORRE, E. H. G. “Back to the city, Mr. citizen!” - psychiatric reform and social participation: from institutional isolation to the anti-asylum movement. Rev. Adm. Pública [online], v. 52, n. 6, p. 1090-1107, 2018. Available: https://www.scielo.br/scielo.php?script=sci_abstract&pid=S0034-76122018000601090&lng=en&nrm=iso.
https://www.scielo.br/scielo.php?script=... ).

In carnival groups there is the possibility to dance, choreograph and interact with others. They take to the streets expressing their emotions through their bodies: painted, dressed up and free. Here there is a fine line between wanting to be in the carnival fantasy and confusing fantasy as a manifestation of madness. Since both tend to blend, the “abnormal” takes on a new contour, which is extended and soothed. The faces are painted, and the disguises allow for so many others. There is no need to have a 'matching' outfit. Makeup does not need refined features. The shirt may be purposely buttoned upside down. All the creation of the difference is accepted in the carnival game.

From observing the parade, one image and meaning came to my mind: free bodies. What a change, from incarceration to a free party in the streets, freely fraternizing with people from the community, tourists, and sympathizers. Foucault’s idea that the body is a cultural construct rather than a natural phenomenon is very important to think about the liberation of the individuals’ bodies. The history of the body cannot be separated from the devices of construction of bio-power. The body is a socially constructed text, a living archive of its social construction history. It may very well be considered the place where culture and arts stem from. Bodies placed on the margins of the humanly acceptable are produced absences, which can (re)emerge as potency, as long as they are given favorable social and institutional conditions (SANTOS; MENEZES, 2009SANTOS, B. S.; MENESES, M. P. Epistemologias do Sul. Coimbra: Almedina , 2009.).

In relation to work practices, there are many activities, which can generate income. The group paints and sells t-shirts, create carnival costumes to sell, there is a Free Music Workshop open to public, a Percussion Workshop, a Paper Workshop, the Encantarte book publisher, Computer School and monthly Samba workshops.

GerAção POA

The Workshop of Health and Work GerAção-POA is a service that belongs to the municipal RAPS of Porto Alegre, the capital of the southernmost state of Brazil - Rio Grande do Sul. Its health promotion actions include work as a central axis, as an organizer of users' lives, contributing to their social and labor integration. The main area of activity is the solidary economy.

The users-workers-artists (“patients” is not a term that is used) work in their store a few shifts of the week, selling the products themselves. From the old concept of occupying time and driving away laziness, the role of work in social rehabilitation shifts to the field of rights, powers, and capacities of people who, in doing so, realize themselves as citizens, promoting greater autonomy in their lives (AMARANTE 2011AMARANTE, P. et al. Da diversidade da loucura à identidade da cultura: o movimento social cultural no campo da reforma psiquiátrica. Cad. Bras. SaúdeMental, Rio de Janeiro, v. 4, n. 8, p. 125-132, 2012.).

The Workshop is a place of passage, where the user-worker-artist performs real work experiences, with its organization, its rules, and the creation of bonds among the participants. It is about learning, producing, selling, managing, and building meaningful relationships that promote solidarity, cooperation, and autonomy (FERREIRA; BARFKNECHT; BERTHUOL, 2004FERREIRA, C.; BARFKNECHT, K.; BERTUOL, M. Geração POA. Saúde em Porto Alegre, v. 1, n. 1, p. 35-40, 2004., p. 28).

The great importance of artistic and economic activities in the lives of the subjects becomes evident during observations. Some have worked in solidarity economy for over ten years, complementing their income and learning new trades, maintaining affective as well as workplace relationships, practicing mutual help with other users, network technicians and the surrounding community (clients, visitors, etc.). They broaden their network, socialize, visit art venues such as galleries, cultural centers, and museums - usually restricted, in Brazil, to a middle-class public - they move around the city and thus come close to what common sense calls 'normal life', which has been denied to them for so long (AMARANTE; TORRE, 2018TORRE, E. G. Saúde Mental, Loucura e Diversidade Cultural: inovação e ruptura nas experiências de arte-cultura da Reforma Psiquiátrica e do campo da Saúde Mental no Brasil. Tese (Doutorado) - Programa de Pós-Graduação em Saúde Pública, Escola Nacional de Saúde Pública Sergio Arouca, Fiocruz, Rio de Janeiro, 2018.).

They work daily in the production workshops at the headquarters of GeraçãoPOA. The first activity in the morning is a meeting in which they make decisions about the production of that day and check the schedule for the fairs and shops and organize who will work that week. Sometimes there are also seminars, visits, and other kinds of events in which they relate to an audience from outside the service.

When producing manual activities, the members sit around a table where the work materials are. In this space, while they create handicrafts, they interact with each other. In a dynamic of integration, they exchange their experiences, sensations, and feelings. These groups were the subject of participant observation in this research for more than a year.

We also witnessed surprise and admiration from the people who buy the products. The users-artists get in touch with clients in fairs and retail outlets. Customers marvel at the quality of the products and are surprised that they were made by “mad people”. From the interviews and observations in the fieldwork, it can be inferred they conclude that “crazy people can be talented and productive” and that “SUS, after all, does good things…”, changing their mindsets about madness and about the public system at the same time (Field Diary, January 2019). This is precisely why this recognition is so important. For those who not acquainted with Brazil’s current reality, it should be clarified that the mass media has been campaigning against the SUS. In Brazil, the media companies are private corporations that hold government concessions; thus, their interests are those of the private health insurance corporations and not those of the citizens who need good public services.

When interacting with customers, there is a table that serves to display products. Those who sell are on one side and those who buy on the other. People interested in the crafts go through the product stalls. In this activity, they can explain how the product was made, what materials were used and what it symbolizes. This exercise of expressing oneself with someone from outside the group allows them to improve their forms of communication and other cognitive skills. It is precisely the act of occupying the city, obtaining the right to mobility, to work with meaning and to exchange with a range of different social actors that provides an expansion of the subjects' psychosocial skills. Professional activity with the arts goes far beyond the scope of the clinic, even the expanded clinic. Being an artist and worker - being remunerated for craftsmanship - is part of the rescue of citizenship previously suppressed by inactivity and supposed incapacity.

First conclusions and discussion

In the field of health, the current context points to enormous challenges for the realization of the universal public system policies. The dispute between the two major antagonistic projects in health - the private and the public free health - is unbalanced, with the election of a hyper-conservative government that is openly leaning towards privatization. The conflict between the model of health policies based on humanized care/universal free accessversusa commodity to be marketed like any other product is constant in Brazil. The SUS implementation and consolidation, based on the principles of Integrality, Equity and Universality has always faced politic and economic resistances in Brazil. The system is underfunded and boycotted by the private insurance lobby. Since the 1990´s we have a scenario of restriction of the state’s role and the strengthening of the market through neoliberal policies.

That is the reason why we believe these experiences embedded in their communities can help to sustain the model of health care in freedom and at the same time engage citizens. People can engage in the idea, as consumers, supporters, and stakeholders, strengthening the initiatives and the bonds of civil society. Both experiments have in common the fact of being strongly rooted in the surrounding community. Therefore, we believe it is so important that social actors from civil society can engage in projects of solidarity economy, arts/culture, and mental health promotion. As the state withdraws from financing, other alternatives need to be available, making it necessary to broaden the client base. Community support and networking are actions that protect groups from weakening or even disappearing.

The individual’s worldview changes substantially after they join the workshop groups and the community activities. They report relearning how to live in a community and become more active, participative, and self-assured. The income is something relevant to them, as well as occupying the city and developing new skills in crafts and arts. Most of them report a significant change in their lives.

These institutional arrangements partially funded by the State but promoted through the solidarity economy, represent social innovations (FERRARINI, 2016FERRARINI, A. O Ethos da Inovação Social: implicações ético-políticas para o estudo de práticas produzidas em diferentes ambientes. Revista Contemporânea, v. 6, n. 2, 2016. Available: Available: http://www.contemporanea.ufscar.br/index.php/contemporanea/article/view/430 . Access: 23 Jan 2021.
http://www.contemporanea.ufscar.br/index... ). For a future study, we could propose to ourselves the challenge of expanding the literature review on the concept of social innovation - something we have not done in this text - and applying it to the understanding of these experiences. Social innovation is something that can stem from socio-community relations, through which new institutional relations may emerge, such as the expansion of the consumption of cultural products made by solidarity economy, which foster new enterprises. It would be an excellent idea to replicate these experiences in other health services, expanding the reach of successful experiences.

The challenge is to expand the scale of action, legitimizing the existence of the enterprises and strengthening institutional strategies of mental health care in freedom. The political scenario in Brazil today is hostile to both social movements and State social investments. Cuts in public spending limit funding-dependent actions. Therefore, the insertion in alternative commercial circuits, through cooperative production practices, is a potent means to diversify the sources of income.

The relationship between human subjectivity and political economy must be considered. From the collaborative artistic workshops, the users-workers-artists emerge as new social actors, with new expectations, but have difficulties to express it in their own terms. They still need care but a kind of care that promotes autonomy, not one that restricts it. We have a perspective of contributing to the field, researching with and not about the individuals.

Because of that, being in the field, thinking together and discussing with them is crucial. One must address the differences in thinking, feeling, acting, and saying that exist between neurotypical individuals (individuals of typical intellectual and cognitive abilities) and neurodiverse individuals (anybody who is neurologically different from the general standard). As Berk-Clark and Pyles (2011)BERK-CLARK, C.; PYLES, L. Deconstructing Neoliberal Community Development Approaches and a Case for the Solidarity Economy. Journal of Progressive Human Services, v. 23, n. 1, p. 1-17, 2012. Available: Available: https://www.researchgate.net/publication/239950460_Deconstructing_Neoliberal_Community_Development_Approaches_and_a_Case_for_the_Solidarity_Economy . Access: 18 Mar 2020.
https://www.researchgate.net/publication... affirm, it is the job of evidence-based practitioners and researchers to point out inequality issues, to analyze the ways that economic structures affect communities and individuals, and present alternative actions, policies, and programs.

There are many possibilities in a society characterized by relational matrices that amplify exchanges and correspondences among individuals (YÚDICE, 2006YÚDICE, G. A conveniência da cultura: usos da cultura na era global. Belo Horizonte: Editora UFMG, 2006.). The transformation of political culture, the cultural democratization, represent important steps for innovation in social policies and consequently in social life; State and Civil Society can do it together and solidarity economy plays an important role in this process.¹1M. V. Veronese e J. Salvagni were responsible for the construction of the article, consolidation of bibliographic data from a theoretical review, compilation and analysis of the data collected and for the final writing of the document.

References

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